HOSPITAL GUIDELINES FOR BIRTH INJURIES (PERINEAL TRAUMA)
The following is an example of typical guidelines prepared by NHS Trusts which their maternity units are obliged to follow. If a Trust prepares guidelines and they are not followed then the Trust will have breached its own policy which will normally amount to a breach of duty to the patient.
Classification of perineal trauma is as follows:-
- 1st degree - Injury to skin only.
- 2nd degree - Injury to the perineal muscles but not the anal sphincter.
- 3rd degree - Injury involving the anal sphincter complex.
- 3a - Less than 50% external anal sphincter torn.
- 3b - More than 50% of external anal sphincter torn.
- 3c - Internal anal sphincter torn.
Following delivery all women should undergo an initial examination in the immediate period following birth to assess for genital trauma. The assessment should be carried out after explaining to the woman what needs to be done and why. The patient should be offered analgesia and there should be good lighting. She should be positioned so that she is comfortable.
If trauma is identified, further systematic assessment should be carried out after explanation to the patient of what the healthcare professional plans to do and why.
The timing of this assessment should not interfere with the mother/infant bonding unless the mother has bleeding and requires urgent attention.
Further assessment should be in the lithotomy position (the patient has the knees bent and lies on her back and the legs are raised above the hip level, with the feet put through stirrups) to allow adequate visual assessment of the degree of trauma and for the repair.
Visual inspection of the extent of perineal trauma should include the structures involved, the apex of the injury and assessment of any bleeding.
A rectal examination must be performed to assess whether there has been damage to the external or internal anal sphincter or if there is any suspicion that the perineal muscles are damaged.
The patient should be referred to a more experienced healthcare professional if there is any doubt as to the nature or extent of the trauma.
Repair of Trauma
Women should be advised that in the case of 2nd degree trauma the wound should be sutured to improve healing, unless the edges are well opposed. In the case of 1st degree trauma it is not necessary to repair the wound unless there is bleeding.
The repair should be undertaken as soon as possible to minimise the risk of infection and blood loss.
General Technique for Repair of 1st and 2nd Degree Tears
There should be tested and effective analgesia in place with either local infiltration of up to 20ml of 1% Lidocaine or topping up of the epidural.
Aseptic technique should be used throughout. Equipment should be checked and swabs and needles counted before and after the procedure. A rapid-absorption synthetic material should be used throughout. There should be good lighting. Difficult trauma should be repaired by an experienced practitioner in theatre under regional or general anaesthesia. The apex of the tear should be identified and a continuous non-locking suture used to approximate the vagina and the perineal muscle.
If the skin is opposed after suturing of the muscle in 2nd degree trauma there is no need to suture it.
When the skin does require suturing a continuous subcuticular technique should be used. Good anatomical alignment should be achieved and consideration given to the cosmetic result.
Repair of 3rd and 4th Degree Tears
All repairs must be conducted in theatre with general or regional anaesthesia. The repair should only be undertaken by a consultant or an experienced registrar who has been certified as independently competent.
In a 4th degree tear the torn mucosa should be repaired with interrupted Vicryl or Polysorb 2/0 sutures. If the internal sphincter is torn this should be repaired by an end to end repair using interrupted Polysorb 2/0.
The external sphincter should be repaired using either 3/0 PDS sutures or 2/0 Polysorb. The overlap repair may be superior to the end to end technique when more than 50% of the external sphincter is disrupted. All women should have prophylactic antibiotics (1.2g augmentin intravenously during repair. If allergic to augmentin use 1.5g cefuroxime intravenously and 500mg of Metronidazole intravenously during repair).
Care Immediately after Repair
All swabs and needles should be counted. Documentation of notes should include the classification and extent of the perineal trauma aided by a diagram where needed. The pro forma for 3rd and 4th degree tears should be used (see end of article).
Rectal nonsteroidal anti-inflammatory drugs should be offered provided there is no contraindication. Women who have sustained a 3rd or 4th degree tear can have a rectal NSAID at the time of the repair but subsequent analgesia should be oral.
Information should be given to the woman regarding the extent of trauma. They should be advised that topical cold therapy such as crushed ice or gel pads are effective methods of pain relief. They should be advised of the importance of hygiene including frequent changing of sanitary pads, washing hands before and after doing this and daily bathing or showering to keep their perineum clean. They should also be given information on the importance of pelvic floor exercises.
Women who have sustained a 3rd or 4th degree tear should be given sufficient lactulose to maintain soft stools for 10 days. Routine prescription of stool bulking agents should be avoided as incontinence in the immediate postnatal period is more common.
The Trust's leaflet on perineal tears should be given to women who have had a 3rd or 4th degree tear.
Standards for Record Keeping in relation to all Perineal Trauma
Clear notes should be written of the type of perineal trauma sustained and the repair. This should be documented in the obstetric records and on the maternity information system. A pro forma for 3rd and 4th degree tears should be completed and signed by the practitioner undertaking the repair and filed in the obstetric records for all of these cases. Notes should be legible, detailed and clear and include discussion, plan and follow-up.
A clinical incident form should be completed for all women who sustain a 3rd or 4th degree tear and the incident form number documented in the maternity records.
Further Care
Following delivery enquiries should be made about perineal healing and perineal pain.
If perineal pain is present the perineum should be assessed. Signs and symptoms of infection, inadequate repair and wound break down should be evaluated urgently. A risk management form should be completed for all women who require re-suturing of the perineum or who are readmitted with perineal infection requiring intravenous antibiotics.
Resumption of sexual relations should be discussed 2 – 6 weeks after delivery. If the woman is experiencing dyspareunia (pain during intercourse) the perineum should be assessed.
Women who have sustained a 3rd degree tear should be offered a follow up appointment in the antenatal clinic at 6 – 12 weeks postpartum. At this visit they should be reviewed with their antenatal and postnatal notes by a consultant or experienced registrar.
At the postnatal visit women should be advised about future deliveries. Asymptomatic women can be reassured that there is no contraindication to vaginal delivery. Women with continuing symptoms may wish to consider elective caesarean section, but they should be advised that it is not completely protective against faecal incontinence.
A risk management form should be completed and returned to the risk management midwife for all women who are referred to a consultant gynaecologist with problems related to perineal repair.
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