SDMS ID: P2010/0488-001 2.

5-08WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported:

Perineal Repair
Episiotomy and Perineal Repair Protocol 2.5 Suturing of perineal lacerations and/or episiotomy Midwifery and Medical Staff, Queen Victoria Maternity Unit Suture, perineal repair, accreditation

P2010/0308-001 Management of Third and Fourth Degree Tears P2010/0488-001LGH QVMU Perineal Repair Learning Package

Purpose: Perineal repair is a surgical procedure and should only be undertaken by credentialed medical and midwifery personnel who have undertaken additional education in repair of the perineum, or by those undergoing supervised practice. Where the extent of the repair is beyond the skill level of an individual, assistance should be sought from a more experience operator. The repair of third and fourth degree perineal tears should only be undertaken by an experienced registrar or consultant. Definition: First degree tear involves fourchette, hymen, labia, skin, vaginal mucosa. Second degree tear involves the pelvic floor, perineal muscle, vaginal mucosa. Third degree tear involves the external anal sphincter (EAS) and internal anal sphincter (IAS). 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn Fourth degree tear involves the anal sphincter (EAS and IAS) and rectal mucosa. Equipment Suture pack Gloves and gown Suture material and needles Local anaesthetic 1% lignocaine Syringe 20ml Needles 19 FG drawing up and 22FG infiltration needle Antiseptic solution Stool Light source Lubricant Sanitary pad
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Procedure Repair of the perineal tear or episiotomy should be carried out as soon as is practicable after the birth. Explain the procedure to the woman prior to commencing the repair. Place the woman appropriately and ensure good lighting. Ensure the area to be suture is adequately anaesthetised by: o offering the woman N2O & O2 prior to and during preparation and infiltration of the area or o offering the woman an epidural top up if there is one in progress. o allow time for the anaesthetic to take full effect before continuing. Infiltrated the perineum using 1% lignocaine with the maximum dose not exceeding 20ml (in accordance with the General Orders for Midwives). Clean the perineal area with a warm antiseptic solution. Adhere to a strict aseptic technique. Insert a vaginal tampon and record its insertion. Assess the full extent of the trauma. Observe for excessive blood loss during and following the procedure. Repair the episiotomy and /or any genital lacerations in layers ensuring correct apposition: o Insert an initial knot 1 cm beyond the apex of the vaginal wall. o Using a continuous suture, repair the vaginal epithelium first followed by perineal muscles and finally the skin. o Ensure sutures are not over tightened, clots are removed from the wound, dead spaces are not left behind and hymen remnants are not sutured. Remove the vaginal tampon on completion of the repair and records its removal. Perform a vaginal and rectal examination. Consider 100mg Diclofenac suppository rectally, if no known allergy and no history of asthma. Clean the area. Apply intermittent cold therapy, eg an ice pad for up to 30 minutes, with half hourly to hourly intervals between applications. Avoid direct application of any cooling device to the skin. Gently and simultaneously remove the womans legs from the lithotomy position (if used). Ensure the woman is clean, dry and comfortable. Instruct the woman about the nature of the injury sustained, the absorption time of the sutures and care of the perineum. Check swabs, needles and instruments are correct and dispose of "sharps" as per infection control procedures. Document the perineal repair in the womans notes.

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Attachments
Attachment 1 Attachment 2 Background Information References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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APPENDIX 1 Background Information: The use of more rapidly absorbed form of polyglactin 910 (Vicryl Rapide) for repair of perineal trauma is associated with a significant reduction in pain and a reduction in suture removal when compared with standard absorbable synthetic material. The use of a continuous subcuticular technique for the perineal skin closure is associated with less short-term pain than techniques employing interrupted sutures. A loose, continuous non-locking suturing technique used to oppose each layer (vaginal tissue, perineal muscle and skin) is associated with less short-term pain compared with the traditional interrupted method (RCOG Guideline No. 23 Methods and materials used in perineal repair 2004). A vaginal tampon is inserted to prevent uterine blood oozing onto the wound and obscuring the area. It also reduces the risk of further trauma and bleeding which may be caused by repeated swabbing or dabbing (King Edward Memorial Hospital Guideline No. B 5. 15.1.Suturing an episiotomy/genital laceration). Rectal analgesia can reduce pain from perineal trauma following childbirth experienced by women and the intensity of any pain within the first 24 hours after birth. Women use less additional analgesia within the first 48 hours after birth when analgesic rectal suppositories are used.

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APPENDIX 2 REFERENCES Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD 003931. DOI: 10.1002/14651858.CD003931. Joanna Briggs Institute 2005 Suturing episiotomy/genital laceration. Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php King Edward Memorial Hospital Clinical Guidelines 2003 Suturing an episiotomy/genital laceration. Online: http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. Cochrane Database of Systematic Reviews 1998, Issue 1. Art. No.: CD000947. DOI: 10.1002/14651858.CD000947. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000006. DOI: 10.1002/14651858.CD000006. Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Royal College of Obstetricians and Gynaecologist Guideline No 23 2004 Methods and materials used in perineal repair. Online: http://www.rcog.org.uk/index.asp?PageID=525 Royal Womens Hospital Clinical Practice Guidelines 2006 Perineal trauma: assessment and repair. Online: http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918 Royal Womens Hospital Clinical Practice Guidelines 2006 Perineal repair: procedure. Online: http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=9407

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