5.9 Perineal repair


During delivery the perineum can tear causing different degrees of vulvovaginal lacerations: superficial (first-degree tear), or deeper, affecting the muscle tissue (second-degree tear, equivalent to an episiotomy).

All genital mutilations – that is, clitoral circumcision (Type I mutilation), clitoral circumcision with removal of the labia minora (Type II mutilation), and infibulation (Type III mutilation, Section 5.10) – are associated with a risk of perineal tears during expulsion.

Two adjacent tissues may also be damaged:
– The anal sphincter muscle, which is red and fleshy. A tear in this sphincter can be recognized by the loss of the anus' radial appearance (third-degree tear). Repair of the muscle is essential to prevent faecal incontinence.
– The rectal mucosa, which is smooth and whitish, extending from the anus. A tear in rectal mucosa (fourth-degree tear) must be sutured to prevent anal fistula with incontinence and infection.

5.9.1 Equipment

– Suture set containing sterile scissors, dissecting forceps and needle holder
– 10% polyvidone iodine
– Local anaesthesia (1% lidocaine)
– One or two Dec3 (2/0) absorbable sutures
– A rapidly absorbable suture for closing the skin or, if not available, a non-absorbable Dec3 (2/0) suture
– Sterile drape and gloves
– If needed, make a tampon from sterile compresses tied together with a thick thread; this is inserted into the vagina to absorb the endo-uterine bleeding (Figure 5.24). The pull string, visible at the vulva, prevents forgetting the tampon when the procedure is over. Ordinary compresses may be used in place of this tampon.
– Good lighting

Figure 5.24 - Tampon made of compresses tied together with a pull string

5.9.2 Technique

The perineum should not be sutured until after the placenta is delivered.

– Swab the perineum and vagina with polyvidone iodine 10%.
– Position a sterile aperture drape.
– Assess the size and number of tears. If episiotomy was performed, check to make sure it did not tear further, and look for other tears. If necessary, use vaginal retractors to expose the entire vaginal wall.
– Use local anaesthesia (lidocaine 1%) in all the involved tissues except the rectal mucosa.
For complex and/or third- or fourth-degree tears, do not hesitate to do the suturing in the operating room under general or spinal anaesthesia.

Superficial vulvar tears (first-degree)

– If they are not bleeding and confined to the area near the vaginal opening: basic care, no suturing.
– If they are bleeding or deep: continuous simple or simple interrupted suture using absorbable suture material.

Episiotomy or simple second-degree perineal tears

– Locate the apex of the cut/tear and place a first stitch there if necessary.
– Suture the vaginal mucosa going from the inside out, to just behind the hymenal remnants, using a continuous or interrupted figure-of-eight absorbable suture; stitches should be close enough to prevent lodging of lochia in the following days, but not too deep, to avoid going into the rectum (Figure 5.25).
– Next, suture the muscle layer with two or three absorbable figure-of-eight sutures (Figure 5.26).
– Close the skin with rapidly absorbable or non-absorbable suture material, using interrupted (simple or vertical mattress) stitches; begin by placing the first stitch, without tying it, on the posterior commissure (Figure 5.27). Because the tissues will be oedematous in the days following the birth, avoid tying the knots too tight. Do a rectal examination to make sure that no stitches can be felt in the rectum. Remove compresses from inside the vagina.

Figure 5.25 - Suturing the mucosa

Figure 5.26 - Suturing the muscle

Figure 5.27 - Suturing the skin

Rupture of the anal sphincter

– A tear in the muscular ring can result in retraction of the two torn ends of the muscle, now hidden in the tissues. Insert a finger into the rectum to locate the two ends.
– Suture the sphincter with two or three absorbable figure-of-eight or horizontal mattress sutures (Figure 5.28).
– Continue in the same sequence as in the preceding case.

Figure 5.28 - Suturing the anal sphincter

Tear in the rectal mucosa

– Protect the wound from faecal material by placing a compress in the rectum (as with the vaginal tampon, do not forget to remove it).
– Swab with polyvidone iodine 10%.
– Suture the rectal mucosa, going from high to low, using absorbable, interrupted stitches knotted on the rectal surface (Figures 5.29).
– Continue in the same sequence as in the preceding case.

Figures 5.29 - Suturing the rectal mucosa
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5.9.3 Post-operative care

– In all cases, the vulva should be cleansed with soap and water and dried when the patient urinates or defecates, at least twice daily.
– For nonabsorbable sutures: remove the stitches between the 5th and 8th day.
– Routine analgesia: paracetamol and/or ibuprofen (especially if there is perineal oedema). A short course of ibuprofen can be prescribed in breastfeeding women (maximum 5 days).
– For third- and especially fourth-degree tears, recommend a fibre-free diet (no fruits or vegetables) for two weeks, if possible. If necessary, give a laxative to prevent passage of hard stools over the sutured rectal mucosa.
– No antibiotics are needed for an episiotomy or perineal tear. For fourth-degree tears, administer metronidazole PO: 1.5 g/day in 3 divided doses for 5 days.

5.9.4 Management of complications

Haematoma

– Remove the stitches and drain.
– If there are no signs of infection and the bleeding has stopped, re-suture the episiotomy either completely or partially (to allow spontaneous drainage), or leave a drain in place.

Infection

– Remove the stitches, drain and, if necessary, remove non-viable tissues
– Minor infection: no antibiotic; drainage is enough.
– Severe infection: antibiotic therapy for 5 days (amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divided doses).