How To Repair A Fourth Degree
Repair of Obstetric Perineal Lacerations
Am Fam Doc. 2003 Oct xv;68(8):1585-1590.
A more contempo article on prevention and repair of obstetric lacerations is bachelor.
Article Sections
- Abstract
- Perineal Beefcake
- Surgical Principles
- Repair of 2d-Degree Perineal Lacerations
- Repair of Quaternary-Degree Perineal Lacerations
- Postpartum Intendance
- Prevention
- References
Family physicians who evangelize babies must frequently repair perineal lacerations after episiotomy or spontaneous obstetric tears. Effective repair requires a knowledge of perineal anatomy and surgical technique. Perineal lacerations are classified co-ordinate to their depth. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. With lacerations involving the anal sphincter complex, particular attention must exist given to anatomy and surgical technique because of the high incidence of poor functional outcomes later on repair. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is being investigated to make up one's mind if it might decrease the incidence of anal incontinence. Minimizing the utilize of episiotomy and forceps deliveries can subtract the occurrence of severe perineal lacerations.
Perineal repair after episiotomy or spontaneous obstetric laceration is one of the most mutual surgical procedures. Potential sequelae of obstetric perineal lacerations include chronic perineal hurting,ane dyspareunia,2 and urinary and fecal incontinence.3–5 Few studies of laceration repair techniques exist to support the development of an evidence-based approach to perineal repair. This article discusses a repair method that emphasizes anatomic detail, with the expectation that an anatomically right perineal repair may result in a better long-term functional outcome.
Perineal Anatomy
- Abstract
- Perineal Anatomy
- Surgical Principles
- Repair of Second-Caste Perineal Lacerations
- Repair of Fourth-Degree Perineal Lacerations
- Postpartum Intendance
- Prevention
- References
The perineal trunk, located between the vagina and the rectum, is formed predominantly past the bulbocavernosus and transverse perineal muscles (Figure 1). The puborectalis musculus and the external anal sphincter contribute additional musculus fibers.
FIGURE 1.
Muscles of perineal body.
Used with permission from Ciné-Med, Inc., 127 Main St. N, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
The anal sphincter complex lies inferior to the perineal torso (Figure 2). The external anal sphincter is equanimous of skeletal muscle. The internal anal sphincter, which overlaps and lies superior to the external anal sphincter, is composed of smooth muscle and is continuous with the smooth musculus of the colon. The anal sphincter complex extends for a distance of 3 to 4 cm.6
FIGURE 2.
Anal sphincter complex (cadaver dissection).
The internal anal sphincter provides near of the resting anal tone that is essential for maintaining continence. Laceration of this sphincter is associated with anal incontinence.4 Interestingly, repair of the internal anal sphincter is not described in standard obstetric textbooks.7,8
Surgical Principles
- Abstruse
- Perineal Beefcake
- Surgical Principles
- Repair of Second-Degree Perineal Lacerations
- Repair of 4th-Degree Perineal Lacerations
- Postpartum Care
- Prevention
- References
Obstetric perineal lacerations are classified as beginning to fourth degree, depending on their depth. A rectal exam is helpful in determining the extent of injury and ensuring that a tertiary- or fourth-degree laceration is non overlooked.
Repair of the perineum requires proficient lighting and visualization, proper surgical instruments and suture material, and adequate analgesia (Table one). Compared with surgical repair using catgut or chromic suture, repair using 3-0 polyglactin 910 (Vicryl) suture results in decreased wound dehiscence and less postpartum perineal pain.9–12 [ Reference9—Evidence level A, randomized controlled trial (RCT); Reference10—Prove level B, uncontrolled trial; Reference11—Bear witness level A, meta-analysis; Reference12—Bear witness level B—systematic review of RCTs] Utilize of speedily absorbed polyglactin 910 (Vicryl Rapide) suture decreases the need for postpartum suture removal after repair of second-caste lacerations.thirteen
TABLE one
Equipment for Repair of Obstetric Perineal Lacerations
| Sterile drapes and gloves |
| Irrigation solution |
| Needle holder |
| Metzenbaum scissors |
| Suture scissors |
| Forceps with teeth |
| Allis clamps |
| Gelpi or Deaver retractor (for use in visualizing tertiary- or fourth-degree perineal lacerations, or deep vaginal lacerations) |
| 10-mL syringe with 22-gauge needle |
| one% lidocaine (Xylocaine) |
| three-0 polyglactin 910 (Vicryl) suture on CT-ane needle (for vaginal mucosa sutures) |
| 3-0 polyglactin 910 suture on CT-ane needle (for perineal musculus sutures) |
| 4-0 polyglactin 910 suture on SH needle (for peel sutures) |
| 2-0 polydioxanone sulfate (PDS) suture on CT-ane needle (for external anal sphincter sutures) |
Local anesthesia can be used for repair of most perineal lacerations. Withal, general or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization for surgical repair of severe or complex lacerations.
Severe perineal lacerations involving the anal sphincter complex pose a surgical challenge. Recent studies3,14 have demonstrated a 20 to l percent incidence of anal incontinence or rectal urgency after repair of third-degree obstetric perineal lacerations. These injuries practise non crave immediate repair; hence, an inexperienced md can delay the procedure for a few hours until appropriate support staff are available.
With astringent perineal lacerations involving the anal sphincter complex, we irrigate copiously to better visualization and reduce the incidence of wound infection. Because these lacerations are contaminated past stool, a unmarried dose of a second- or third-generation cephalosporin may be given intravenously before the procedure is started.
Repair of 2d-Degree Perineal Lacerations
- Abstract
- Perineal Anatomy
- Surgical Principles
- Repair of Second-Degree Perineal Lacerations
- Repair of 4th-Degree Perineal Lacerations
- Postpartum Care
- Prevention
- References
Repair of a second-degree laceration (Figure 3) requires approximation of the vaginal tissues, muscles of the perineal body, and perineal peel. The steps in the procedure are as follows:
Figure iii.
2d-degree perineal laceration.
Used with permission from Ciné-Med, Inc., 127 Main St. North, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
The apex of the vaginal laceration is identified. For lacerations extending deep into the vagina, a Gelpi or Deaver retractor facilitates visualization.
An anchoring suture is placed 1 cm in a higher place the noon of the laceration, and the vaginal mucosa and underlying rectovaginal fascia are airtight using a running unlocked 3-0 polyglactin 910 suture. If the apex is too far into the vagina to exist seen, the anchoring suture is placed at the well-nigh distally visible area of laceration, and traction is applied on the suture to bring the apex into view. The running suture can be locked for hemostasis, if needed.
The sutures must include the rectovaginal fascia (Effigy 4), which provides support to the posterior vagina. The running suture is carried to the hymenal ring and tied proximal to the ring, completing closure of the vaginal mucosa and rectovaginal fascia.
Figure 4.
Vaginal mucosa and underlying rectovaginal fascia.
Used with permission from Ciné-Med, Inc., 127 Main St. North, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
The muscles of the perineal body are identified on each side of the perineal laceration (Effigy 5). The ends of the transverse perineal muscles are reapproximated with ane or two transverse interrupted iii-0 polyglactin 910 sutures (Effigy vi)
FIGURE 5.
Second-degree perineal laceration with underlying muscles exposed.
Used with permission from University of New Mexico School of Medicine, Section of Family and Customs Medicine, Albuquerque, Northward.M.
FIGURE six.
Repair of transverse perineal muscles with single interrupted suture.
Used with permission from Academy of New Mexico School of Medicine, Department of Family and Customs Medicine, Albuquerque, North.M.
A unmarried interrupted 3-0 polyglactin 910 suture is then placed through the bulbocavernosus musculus (Figure vii). The torn ends of the bulbocavernosus muscle are frequently retracted posteriorly and superiorly. Utilize of a big needle facilitates proper suture placement.
FIGURE 7.
Repair of bulbocavernosus muscle with single interrupted suture.
Used with permission from University of New Mexico School of Medicine, Department of Family and Community Medicine, Albuquerque, N.M.
If the laceration has separated the rectovaginal fascia from the perineal body, the fascia is reattached to the perineal body with ii vertical interrupted three-0 polyglactin 910 sutures (Figure eight)
FIGURE 8.
Reattachment of rectovaginal septum to muscles of perineal body.
Used with permission from University of New Mexico School of Medicine, Department of Family and Community Medicine, Albuquerque, Northward.Chiliad.
When the perineal muscles are repaired anatomically as described higher up, the overlying peel is usually well approximated, and skin sutures by and large are not required. Pare sutures have been shown to increase the incidence of perineal pain at three months later on delivery.xv [Evidence level B, uncontrolled trial] If the skin requires suturing, running subcuticular sutures have been shown to exist superior to interrupted transcutaneous sutures.sixteen The 4-0 polyglactin 910 sutures should first at the posterior apex of the pare laceration and should be placed approximately 3 mm from the edge of the pare.
An alternative arroyo to repair of the perineal body muscles is a running suture that is continued from the vaginal mucosa repair and brought underneath the hymenal ring. Withal, we prefer the interrupted approach because it facilitates a more anatomic repair, allowing reapproximation of the bulbocavernosus muscle and reattachment of the vaginal septum with minimal utilise of sutures.
Repair of Fourth-Caste Perineal Lacerations
- Abstruse
- Perineal Anatomy
- Surgical Principles
- Repair of Second-Degree Perineal Lacerations
- Repair of Quaternary-Degree Perineal Lacerations
- Postpartum Care
- Prevention
- References
Repair of a fourth-caste laceration requires approximation of the rectal mucosa, internal anal sphincter, and external anal sphincter (Effigy 9)
Figure nine.
Fourth-degree perineal laceration.
Used with permission from Ciné-Med, Inc., 127 Main St. Due north, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
A Gelpi retractor is used to separate the vaginal sidewalls to allow visualization of the rectal mucosa and anal sphincters. The noon of the rectal mucosa is identified, and the mucosa is approximated using closely spaced interrupted or running 4-0 polyglactin 910 sutures (Figure 10). Traditional recommendations emphasize that sutures should non penetrate the complete thickness of the mucosa into the anal canal, to avoid promoting fistula formation. The sutures are continued to the anal verge (i.e., onto the perineal pare).
FIGURE ten.
Repair of rectal mucosa.
Used with permission from Rogers RG, Kammerer-Doak DN. Obstetric anal sphincter lacerations, function ii. Female Patient 2002;27(v):31–half dozen.
The internal anal sphincter is identified as a glistening, white, fibrous structure between the rectal mucosa and the external anal sphincter (Figure 11). The sphincter may be retracted laterally, and placement of Allis clamps on the muscle ends facilitates repair. The internal anal sphincter is closed with continuous 2-0 polyglactin 910 sutures.
FIGURE 11.
Internal anal sphincter and external anal sphincter.
Used with permission from Rogers RG, Kammerer-Doak DN. Obstetric anal sphincter lacerations, role two. Female person Patient 2002;27(5):31–6.
The external anal sphincter appears every bit a band of skeletal musculus with a fibrous capsule. Traditionally, an terminate-to-stop technique is used to bring the ends of the sphincter together at each quadrant (12, 3, half dozen, and 9 o'clock) using interrupted sutures placed through the capsule and muscle (Figure 12). Allis clamps are placed on each end of the external anal sphincter. We use two-0 polydioxanone sulfate (PDS), a delayed absorbable monofilament suture, to allow the sphincter ends adequate time to scar together. Contempo evidence suggests that stop-to-end repairs have poorer anatomic and functional outcomes than was previously believed.3,4 [ Reference3 —Bear witness level B, descriptive study; Reference4 —Evidence level B, prospective cohort study]
Figure 12.
End-to-end technique for repairing external anal sphincter.
Used with permission from Ciné-Med, Inc., 127 Main St. North, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
An culling technique is overlapping repair of the external anal sphincter. Colorectal surgeons prefer to use this method when they repair the sphincter remote from commitment.14,17 The overlapping technique brings together the ends of the sphincter with mattress sutures (Figure 13) and results in a larger area of tissue contact between the two torn ends. Dissection of the external anal sphincter from the surrounding tissue with Metzenbaum pair of scissors may exist required to reach acceptable length for the overlapping of the muscles. The suture is passed from top to bottom through the superior and inferior flaps, and so from lesser to top through the inferior and superior flaps. The proximal terminate of the superior flap overlies the distal portion of the inferior flap. Two more sutures are placed in the aforementioned manner. Afterwards all iii sutures are placed, they are each tied snugly, but without strangulation. When tied, the knots are on the top of the overlapped sphincter ends. Care must be taken to incorporate the muscle capsule in the closure.
FIGURE xiii.
Overlapping technique for repairing external anal sphincter.
Used with permission from Ciné-Med, Inc., 127 Chief St. North, Woodbury, CT 06798-2915. Copyright © Ciné-Med, Inc.
Postpartum Care
- Abstract
- Perineal Anatomy
- Surgical Principles
- Repair of 2d-Caste Perineal Lacerations
- Repair of Fourth-Degree Perineal Lacerations
- Postpartum Care
- Prevention
- References
The literature contains little information on patient intendance after the repair of perineal lacerations. We recommend the use of sitz baths and an analgesic such equally ibuprofen. If a woman has excessive pain in the days subsequently a repair, she should be examined immediately because pain is a frequent sign of infection in the perineal surface area. After repair of a third- or fourth-degree laceration, we include several weeks of therapy with a stool softener, such as docusate sodium (Colace), to minimize the potential for repair breakdown from straining during defecation.
The perineal muscles, vaginal mucosa, and skin are repaired using the aforementioned techniques described for the repair of second-degree lacerations.
Prevention
- Abstract
- Perineal Anatomy
- Surgical Principles
- Repair of Second-Degree Perineal Lacerations
- Repair of Fourth-Degree Perineal Lacerations
- Postpartum Care
- Prevention
- References
The incidence of severe perineal trauma tin exist decreased by minimizing the use of episiotomy and operative vaginal commitment. A Cochrane review demonstrated that liberal use of episiotomy does non reduce the incidence of anal sphincter lacerations and is associated with increased perineal trauma.18 [Evidence level A, systematic review of RCTs] A meta-analysis of eight randomized trials of vacuum extraction versus forceps delivery demonstrated that one sphincter tear would be prevented for every 18 women delivered with vacuum rather than forceps.19 [Evidence level B, systematic review of lower quality RCTs]
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Figure 2 supplied by Janet Yagoda Shagam, Ph.D.
REFERENCES
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ane. Albers Fifty, Garcia J, Renfrew G, McCandlish R, Elbourne D. Distribution of genital tract trauma in childbirth and related postnatal pain. Birth. 1999;26:11–7. ...
2. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol. 2001;184:881–8.
3. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308:877–91.
4. Kammerer-Doak DN, Wesol AB, Rogers RG, Dominguez CE, Dorin MH. A prospective cohort study of women after primary repair of obstetric anal sphincter laceration. Am J Obstet Gynecol. 1999;181:1317–22.
5. Viktrup 50, Lose G. The gamble of stress incontinence 5 years after kickoff commitment. Am J Obstet Gynecol. 2001;185:82–7.
6. Delancey JO, Toglia MR, Perucchini D. Internal and external anal sphincter beefcake every bit it relates to midline obstetric lacerations. Obstet Gynecol. 1997;xc:924–7.
7. Benedetti TJ. Obstetric hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, et al., eds. Obstetrics: normal and trouble pregnancies. 4th ed. New York: Churchill Livingstone, 2002:503–xxx.
eight. Cunningham FG, et al., eds. Williams Obstetrics. 21st ed. New York: McGraw-Hill, 2001:328.
9. Mahomed One thousand, Grant A, Ashurst H, James D. The Southmead perineal suture written report. A randomized comparing of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol. 1989;96:1272–eighty.
ten. Mackrodt C, Gordon B, Fern E, Ayers South, Truesdale A, Grant A. The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. Br J Obstet Gynaecol. 1998;105:441–5.
11. Grant A. The choice of suture materials and techniques for repair of perineal trauma: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1989;96:1281–9.
12. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database Syst Rev. 2003;(1):CD000006
thirteen. Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or quickly captivated sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet. 2002;359:2217–23.
fourteen. Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. A randomized clinical trial comparison master overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol. 2000;183:1220–4.
15. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich Childbirth Study: one. A randomised evaluation of ii stage postpartum perineal repair leaving the peel unsutured. Br J Obstet Gynaecol. 1998;105:435–40.
16. Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. Cochrane Database Syst Rev. 2003;(1):CD000947
17. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol. 1999;106:318–23.
eighteen. Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2003;(1):CD000081
19. Eason E, Labrecque K, Wells Thousand, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol. 2000;95:464–71.
This article is one in a series of "Office Procedures" manufactures on obstetrics and gynecology coordinated by Brett Johnson, M.D.
Copyright © 2003 by the American Academy of Family unit Physicians.
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