REPAIR OF VAGINAL AND PERINEAL TEARS

Four degrees of tear can occur during delivery:

Repair of first and second degree tears

Most first degree tears close spontaneously without sutures.

1	Use local infiltration with lidocaine. If necessary, use a pudendal block. Anaesthetize early to provide sufficient time for it to take effect.
2	Ask an assistant to massage the uterus and provide fundal pressure.
3	Carefully examine the vagina, perineum and cervix (Figure 12.16). If the tear is long and deep through the perineum, inspect to be sure there is no third or fourth degree tear: • Place a gloved finger in the anus • Gently lift the finger and identify the sphincter • Feel for the tone or tightness of the sphincter • Change to clean, sterile gloves.
Figure 12.16
4	If the sphincter is injured, see pages 12–27 to 12–28 on the repair of third and fourth degree tears.
5	If the sphincter is not injured, proceed with repair.
6	Repair the vaginal mucosa using a continuous 2-0 suture (Figure 12.17): • Start the repair about 1 cm above the apex (top) of the vaginal tear, continuing the suture to the level of the vaginal opening • At the opening of the vagina, bring together the cut edges of the vaginal opening • Bring the needle under the vaginal opening and out through the perineal tear and tie.
Figure 12.17
7	Repair the perineal muscles using interrupted 2-0 suture (Figure 12.18). If the tear is deep, place a second layer of the same stitch to close the space.
Figure 12.18
8	Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening (Figure 12.19). If the tear was deep, perform a rectal examination. Make sure no stitches are in the rectum.
Figure 12.19

Repair of third and fourth degree perineal tears

The woman may suffer loss of control over bowel movements and gas if a torn anal sphincter is not repaired correctly. If a tear in the rectum is not
repaired, the woman can suffer from infection and rectovaginal fistula.

Repair the tear in the operating room.

1	If you cannot see all edges of the tear, use regional or general anaesthesia. If you can see all edges of the tear use local infiltration with lidocaine.
2	Ask an assistant to massage the uterus and provide fundal pressure.
3	Examine the vagina, cervix, perineum and rectum. To see if the anal sphincter is torn: • Place a gloved finger in the anus and lift slightly • Identify the sphincter, or lack of it • Feel the surface of the rectum and look carefully for a tear.
4	Change to sterile gloves, apply antiseptic solution to the tear and remove any faecal material, if present.
5	Repair the rectum using interrupted 3-0 or 4-0 sutures 0.5 cm apart to bring together the mucosa (Figure 12.20). Place the suture through the muscularis (not all the way through the mucosa).
Figure 12.20
6	Cover the muscularis layer by bringing together the fascial layer with interrupted sutures.
7	Apply antiseptic solution to the area frequently.
8	Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening (Figure 12.19). If the tear was deep, perform a rectal examination. Make sure no stitches are in the rectum.
Figure 12.19
9	If the sphincter is torn, grasp each end of the sphincter with an Allis clamp (the sphincter retracts when torn). The sphincter is strong and will not tear when pulling with the clamp. Repair the sphincter with two or three interrupted stitches of 2-0 suture (Figure 12.21).
Figure 12.21
10	Apply antiseptic solution to the area again. Examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter. Then change to clean, sterile gloves. Repair the vaginal mucosa, perineal muscles and skin.

Post-procedure care

Management of neglected cases

A perineal tear is always contaminated with faecal material. If closure is delayed more than 12 hours, infection is inevitable. Delayed primary closure is
indicated in such cases.

Complications
If a haematoma is observed, open and drain it. If there are no signs of infection and the bleeding has stopped, the wound can be reclosed.

If there are signs of infection, open and drain the wound. Remove infected sutures and debride the wound.

If the infection is mild, antibiotics are not required.

If the infection is severe but does not involve deep tissues, give a combination of antibiotics:

If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give a combination of antibiotics until necrotic tissue has been removed and the woman is fever-free for 48 hours:

Once the woman is fever-free for 48 hours, give:

Necrotizing fasciitis requires wide surgical debridement. Perform secondary closure in 2–4 weeks, depending on resolution of infection.

Faecal incontinence may result from complete sphincter transection. Many women are able to maintain control of defaecation by the use of other perineal muscles. When incontinence persists, reconstructive surgery must be undertaken 3 months or more after delivery.

Rectovaginal fistula requires reconstructive surgery three months or more postpartum.