Chapter 11. Perineal repair
Introduction
Perineal pain is a source of significant morbidity for many women following childbirth, not only in the immediate postnatal period but also in the longer term (Grant et al 2001). The skill and techniques employed by the midwife or doctor who assesses and cares for the woman following perineal trauma can have a significant impact on her recovery.
Classification of perineal and genital trauma
The perineum and genital tract are inspected for trauma as outlined in Chapter 9.
Trauma to the genital tract can be anterior (involving the labia, urethra, clitoris or anterior vaginal wall) or posterior (involving the posterior vaginal wall, perineal muscles or anal sphincters). For definitions of perineal or genital trauma see Table 11.1.
| Classification of trauma | Description |
|---|---|
| First degree | Injury to the skin only |
| Second degree | Injury to the skin and perineal muscle but not the anal sphincter |
| Third degree | Injury to the perineum involving the anal sphincter complex: 3a – less than 50% of external anal sphincter (EAS) torn 3b – more than 50% of EAS torn 3c – internal anal sphincter (IAS) torn |
| Fourth degree | Injury to the perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium |
Precise classification is particularly useful for communication between attending practitioners and for audit of incidence of trauma and recovery success.
Although student midwives receive initiation into perineal suturing during their pre-registration programme (NMC 2004a), not until their competence has been verified are they able to undertake this role without supervision. Achieving competence requires careful observation of skilled practitioners and close supervised practice. There are many visual aids available to complement this process, including videos and lifelike models. Competence, once gained, requires maintenance, and midwives have a duty to keep up-to-date with new techniques and research evidence (NMC 2004b).
In ideal circumstances, the practitioner who assisted at the birth should be the person to undertake the suturing, as this enhances continuity of carer (Dahlen & Homer 2008). In most maternity units there is a programme of training supporting midwives in the development of their suturing skills. However, as not all midwives work in the labour suite setting it is not appropriate that midwives who would not use this technique regularly should be expected to gain competence.
House officers working on the labour suite will already be proficient at a wide range of suturing. However, when they are allocated to the labour suite they will need to learn the specific skills and issues related to caring for women during such an intimate procedure. Midwives and doctors have much to learn from each other, and this aspect of care provides many opportunities for inter-professional learning (Dahlen & Homer 2008).
If a midwife feels that a repair of a perineal wound is beyond her expertise, she should refer to a senior obstetrician rather than to a house officer. All complicated tears (third or fourth degree) or extended episiotomies should be referred, with an honest explanation given to the woman.
Inspection of the perineum
It is usual practice to inspect the perineum for damage following delivery of the placenta and membranes. However, if an episiotomy has been performed or a large tear is evident, it would be unkind and uneccesary to spend time exploring the wound without analgesia, as suturing is inevitable. Further inspection can be made when the person undertaking the repair is ready to start the procedure. If, however, it is unclear if suturing is required, a quick but thorough inspection is indicated.
It is important to examine the vaginal wall even if the perineum appears intact. The woman should be informed of what to expect and verbal consent gained. The midwife should use two cotton wool balls in her non-dominant hand to stem any blood flow from the cervix. Then using two cotton wool balls in her dominant hand she identifies the apex of any trauma, by inserting her two fingers high into the vagina and then working her way down to the introitus. Just after birth the vaginal wall is lax and it is possible to explore the lateral and posterior walls systematically, using the cotton wool to remove any blood that may be obscuring visability. The labia and clitoris also need to be inspected for tears and grazes. If there are bilateral grazes, it may be necessary to suture at least one side to avoid the two grazes healing together. The woman should be informed of your findings and the implications discussed with her.
To suture or not?
If examination of the perineum after the birth revealed that suturing was required, this observation should be discussed with the woman. It may be felt that a small first- or second-degree tear may not require suturing if it is not bleeding and the edges of the wounds fall closely together. However, the woman’s choice and individual preference should be carefully considered. This can be a difficult time to obtain ‘informed consent’. There is limited evidence about whether or not to suture perineal wounds, and women need to know this. It would be relatively easy for a midwife who preferred not to suture to convince a woman that she did not need stitches. The woman is unlikely to insist on this procedure and will probably take the midwife’s advice. One Scottish trial, comparing suturing versus non-suturing of first- and second-degree tears in primigravidae (Fleming et al 2003), found no difference between the groups regarding perineal pain but found that women who were sutured had better wound approximation 6 weeks after the birth.
An alternative is to suture the muscle layer and leave the skin layer to heal naturally. This technique was explored in a large randomized controlled trial in the UK (Gordon et al 1998) and more recently in Nigeria (Oboro et al 2003). Although both trials found significantly more wound gaping up to 10 days after the birth when the skin was unsutured, they also concurred that there was significantly less dyspareunia (pain during intercourse) three months postnatally in this group.
If the wound is bleeding and/or the muscle edges do not appose then suturing is the most appropriate course of action. This should be started as soon after birth as is practical, while not interfering too much with the parents’ adoration of their new baby.
Procedure for perineal repair
This is a sterile procedure and as such involves opening packs and draping the woman’s legs and abdomen in sterile sheets. (Full details are provided in Box 11.1.) It is not essential for the person undertaking this procedure to require the woman to be in a lithotomy position, although it does enable the perineum to be clearly visualized. The NICE intrapartum care guidelines (NICE 2007) suggest that women should usually be in the lithotomy position for suturing, but this position should not be used for longer than is necessary. It is possible to suture without resorting to the lithotomy, as happens when a woman needs stitches following a home birth.The woman can position her bottom at the edge of the bed and her legs can be supported on two stools; the midwife sitting between them.
Box 11.1
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Procedure for perineal repair
• Explain what the procedure will involve and obtain verbal consent
Rationale To involve the woman in her care. To seek permission to undertake procedure
• Ensure bedding is clean and dry
Rationale To ensure maternal comfort and reduce the risk of skin abrasion
• Ensure emergency drugs are in the room and check their expiry date
Rationale To facilitate rapid response in the event of accidental administration of intraveous lignocaine
• Identify a stable surface near the woman, on which sterile pack can be opened
Rationale To create a sterile field that can be reached easily while suturing
• Identify and test a light source
Rationale To enhance visualization of the perineum
• Wash hands carefully
Rationale To minimize the risk of cross infection
• Open sterile packs (which include the equipment listed inbox 11.2) onto stable surface
Rationale To ensure all necessary equipment is available for use
Box 11.2
Equipment for perineal suturing
■ Good light source
■ Stable table or trolley
■ Sterile suture pack (contents: 2 bowls for water and lubricant, cotton wool, sanitary pad, sterile drapes, tampon, swabs, toothed forceps, scissors, needle holder)
■ 20ml syringe, needle; 20ml 1% lignocaine, sharps box
■ Warm tap water, lubricant
■ Sterile gloves
■ Waste bag
• Pour warm water into a large bowl
Rationale To prepare to swab the perineum
• Pour obstetric cream into gallipot
Rationale To prepare for lubrication of tampon
• Scrub hands
Rationale To prepare for sterile procedure
• Don sterile gloves, attach needle to syringe, draw up and check (with assistant) 1% lignocaine
Rationale To prepare for administration of local anaesthetic, before exposing the woman’s perineum
• Count swabs, check and organize equipment. attach needle to needle holder
Rationale To confirm the number of swabs in use and that all necessary instruments are present, correct and ready for use
• Assistant(s) helps woman into a position with her legs apart, covering them with a modesty sheet
Rationale To prepare for clear visualization of the perineum, while maintaining the woman’s dignity
• Cover the woman’s legs with sterile drapes (ask assistant to remove modesty sheet), place waterproof paper under her bottom and sterile drape across her abdomen
Rationale To create a sterile field and reduce the risk of contamination
• Swab perineum with cotton wool soaked in warm water (from anterior to posterior) using a new swab for each labia majora, then labia minor and finally the introitus
Rationale To enable clear visualization of the perineal trauma and reduce the risk of wound contamination
• Infiltrate the perineum (seebox 11.3)
Rationale To ensure adequate anaesthesia, enabling the woman to relax and not feel any discomfort
• Dip the tampon in obstetric cream and insert gently into vault of vagina
Rationale To prevent uterine blood loss from obscuring the perineal wound
• Secure the tape of the tampon to the edge of the drape across the abdomen
Rationale To ensure that the tampon remains visible and is therefore removed following the procedure
• Using forceps, gently approximate the edges of the wound, including hymenal remnants, perineal skin, etc.
Rationale To visualize how the repair will look when finished. To assess that the repair is within the capabilities of the practitioner
• Identify the apex of the wound and insert an anchoring stitch approximately 0.5–1.0cm above this point
Rationale To ensure that all of the wound has been visualized and that approximation of the vaginal mucosa is accurate
• Using a loose, continuous, non-locking stitch, work down the vaginal mucosa to the hymen, continue with the deep then superficial perineal muscle, and finish with subcuticular sutures to the skin if required
Rationale This technique is associated with less short-term pain than locking or interrupted sutures
• Remove vaginal tampon and check that haemostasis has been achieved and that all wound edges are accurately apposed
