Care of the perineum in labour including episiotomy and suturing
In the UK, it is estimated that 85% of women will experience some degree of perineal trauma during vaginal delivery. This may be caused by spontaneous or surgical incision (episiotomy). Some women who experience perineal trauma will suffer from complications such as persistent pain, wound breakdown, wound infection, poor anatomical alignment, dyspareunia, urinary and faecal incontinence during the postnatal period. It is therefore important to explore what action could be taken by midwives during labour to minimise postpartum morbidity. It is crucial that every midwife is skilled in perineal trauma assessment and repair.
There are different approaches employed by midwives to minimise the risk of perineal trauma. Providing continuous support, communicating effectively and working in partnership with women during labour can prevent perineal trauma.
Kneeling, upright and all fours position during the second stage of labour have been found to increase the chances of intact perineum, although there is no evidence to suggest that these positions prevent labia tears. The lateral position has also been associated with lower rates of perineal trauma and pain postnatally. Sitting, squatting and birth stools are known to have the highest incident of perineal trauma.
There is conflicting evidence when it comes to perineal protection. The hands-on or hands poised (HOOPS) trial was the first study that compared the hands-on versus hands-poised approach during the second stage. The study found no difference in perineal trauma between the two groups. Since then, researchers have either reported significantly higher incidence of perineal laceration with the hands-on technique or argued that the hands-on approaches could be beneficial in minimising the rate and degree of perineal injuries.
Supporting the perineum with the thumb and index finger has been found to be effective in reducing the tension of the perineal tissue, and subsequently preventing trauma. Similarly, application of warm compresses (Figure 30.1) and slow delivery of the head during the second stage is known to reduce perineal trauma. Both hands-on and hands-poised approaches can be used to facilitate spontaneous birth. It is important that midwives inform women about methods of preventing perineal trauma, to enable them to make informed decisions. Box 30.1 provides the classifications of perineal tears.
Episiotomy is the surgical incision of the perineum during childbirth to enlarge the birth canal. The main types are the midline and mediolateral incision. The latter is most commonly used in the UK. The incision begins at the posterior fourchette and is made at an angle of 45–60 degrees, avoiding damage to the Bartholin’s gland.
Indications for episiotomy are:
- Suspected fetal compromise
- Instrumental birth
- Shoulder dystocia (assess if episiotomy is needed)
- Breech delivery (assess if episiotomy is needed).
Before performing episiotomy:
- Seek consent and document.
- Use an aseptic technique to avoid introducing infection.
- Insert two fingers between the fetal head and perineum to protect fetal tissues.
- Infiltrate along the mediolateral line with lidocaine 1% (Figure 30.2).
- Avoid damage to Bartholin’s duct and gland.
- Allow the perineum to thin before the incision, to reduce the risk of bleeding.
When and how to perform the incision (Figure 30.3):
- Best after infiltration
- Perineum should be thin and 3–4 cm long
- During a contraction
- Cut between the two fingers to protect the baby’s head.
The continuous suturing technique is associated with less short-term pain. This is a three-stage technique using absorbable suture material, for example 2-0 Vicryl Rapide™. The first knot is secured approximately 1 cm above the apex of the wound (Figure 30.4). The vaginal wound is sutured up to the posterior fourchette (Figure 30.5). The needle is then introduced into the perineal wound to suture the perineal muscle (Figures 30.6 and 30.7). The skin is repaired using subcuticular technique (Figure 30.8), finishing with the Aberdeen knot at the posterior fourchette (Figure 30.9). The National Institute for Health and Care Excellence recommends this method.
Preparing for suturing:
- Ensure privacy and dignity
- Explain the procedure and seek consent
- Offer inhalational analgesia if the woman has no working epidural.
- Wash hands, wear a gown and sterile gloves prior to the assessment to minimise the risk of infection.
- Check with the woman to ensure that local or regional analgesia is effective.
- Carry out a visual assessment of structures involved in the trauma.
- Identify the apex before suturing is commenced.
- Perform vaginal and rectal examination before the repair to establish full extent of the injury. This should be carried out for all women who have had vaginal delivery, even those with intact perineum, to rule out anal sphincter injury and button-hole tear. Change gloves afterwards.
- Assess the amount of blood loss throughout.
- Swabs, instruments and needles should be checked and signed by two people.
- Ensure that the tissues are correctly aligned anatomically throughout the procedure.
- Avoid the routine use of a tampon, as women who have no regional analgesia may find it uncomfortable. If the use of the tampon is required, remember to secure the tail with an artery forceps.
- Perform rectal examination after repair, to ensure that no sutures have been inserted into the rectum.
- Rectal non-steroidal anti-inflammatory drug (Diclofenac suppository) should be offered routinely unless contraindicated.
- Document in records.
- Draw a diagram illustrating the extent of the trauma.
The aftercare discussion should include:
- Perineal hygiene
- Dietary advice
- Pelvic floor exercise.