007 laceration of the birth canal

1. DR NIPON POOMTHANAWIT

3. Fourth degree
Third degree
Second degree
First degree
Lacerations of the Birth Canal
involves skin and vaginal mucosa
but not underlying fascia and muscle
involves fascia and muscles of the
perineal body but not the anal sphincter
involves the anal sphincter but does
not extend through it
extends through the anal sphincter
into the rectal lumen

4.  Involve the fourchette, perineal skin, and vaginal mucous membrane but
not the underlying fascia and muscle
 These included periurethral lacerations
Lacerations of the Birth Canal
First-degree lacerations

5.  Involve, in addition, the fascia and muscles of the perineal body but
not the anal sphincter. These tears usually extend upward on one or
both sides of the vagina, forming an irregular triangular injury.
Second-degree lacerations

6.  Extend farther to involve the anal sphincter
Third-degree lacerations

7.  Extends through the rectum's mucosa to expose its
lumen.
Fourth-degree lacerations

8.  Factors associated with an increased risk of third- and
fourth-degree lacerations
 Midline episiotomy
 Nulliparity
 Second stage arrest of labor
 Persistent occiput posterior position
 Forceps delivery
 Use of local anesthetic
 Asian race
Laceration Risks and Morbidity

9.  Morbidity rates rise as laceration severity increases.
 Repair of perineal lacerations is virtually the same as
that of episiotomy incisions, sometimes less
satisfactory because of tear irregularities

10.  Episiotomy is incision of the pudenda.
 Perineotomy is incision of the perineum
 The term episiotomy often is used synonymously with
perineotomy
Episiotomy
: The external genital organs of a human being;
especially : the external genitals of a woman : vulva—
usually used in plural

11.  Straight surgical incision, which was easier to repair, for
the ragged laceration
 Postoperative pain is less and healing improved with an
episiotomy compared with a tear
 It prevented pelvic floor complications that is, vaginal
wall support defects and incontinence
Purposes of Episiotomy

12.  Although still a common obstetrical procedure, the
use of episiotomy has decreased remarkably over the
past 25 years
 Carroli and Mignini (2009) reviewed the Cochrane
Pregnancy and Childbirth Group trials registry
 Lower rates of posterior perineal trauma, surgical repair,
and healing complications in the restricted-use group
 The incidence of anterior perineal trauma was lower in
the routine-use group.

13.  Episiotomy did not protect the perineal body and
contributed to anal sphincter incontinence by
increasing the risk of third- and fourth-degree tears

14.  For all of these reasons, the American College of
Obstetricians and Gynecologists (2006) has concluded
that restricted use of episiotomy is preferred to routine
use
 Shoulder dystocia
 breech delivery
 Forceps or vacuum extraction

15.  Typically, episiotomy is completed when the head is
visible during a contraction to a diameter of 3 to 4 cm
 When used in conjunction with forceps delivery, most
perform an episiotomy after application of the blades
 Performed too early, bleeding from the episiotomy may
be considerable
 Performed too late, lacerations will not be prevented.
Timing of Episiotomy

16.  Median episiotomy
 Mediolateral episiotomy
 Right (RML)
 Left (LML)
Type of episiotomy

17. 

18. 

20.  Usually done after delivery of the placenta
 Hemostasis and anatomical restoration without
excessive suturing
 Adequate analgesia
 Prefer blunt needle
 Chromic catgut 2-0
 Rapidly absorbed synthetic sutures
 Slowly absorbed sutures may require removal due to
pain or dyspareunia
 Continuous or interrupted suture
Episiotomy repair

21. A. Disruption of the hymenal ring and bulbocavernosus and superficial
transverse perineal muscle are seen within the diamond-shaped incision
following episiotomy...
Repair of midline episiotomy.

22. B. Absorbable 2-0 or 3-0 suture is used for
continuous closure of the vaginal mucosa and
submucosa

23. C. After closing the vaginal incision and reapproximating the
cut margins of the hymenal ring, the needle and suture are
positioned to close the perineal incision

24. D. A continuous closure with absorbable 2-0 or 3-0 suture is
used to close the fascia and muscles of the incised perineum. E.
The continuous suture is then carried upward as a subcuticular
stitch. The final knot it, tied proximally to the hymenal ring.

25. E. The continuous suture is then carried upward as a
subcuticular stitch. The final knot it, tied proximally to the
hymenal ring.

26. A. Approximation of the anorectal mucosa and submucosa in a running or interrupted
fashion using fine absorbable suture such as 3-0 or 4-0 chromic or Vicryl. During this
suturing, the superior extent of the anterior anal laceration is identified, and the
sutures are placed through the submucosa of the anorectum approximately 0.5 cm
apart down to the anal verge
Layered repair of a fourth-degree perineal laceration

27. B. A second layer is placed through the rectal muscularis using 3-0 Vicryl suture in a running or interrupted
fashion. This "reinforcing layer" should incorporate the torn ends of the internal anal sphincter, which is
identified as the thickening of the circular smooth muscle layer at the distal 2 to 3 cm of the anal canal. It can be
identified as the glistening white fibrous structure lying between the anal canal submucosa and the fibers of the
external anal sphincter (EAS). In many cases, the internal sphincter retracts laterally and must be sought and
retrieved for repair. In overview, with traditional end-to-end approximation of the EAS, a suture is placed
through the EAS muscle, and four to six simple interrupted 2-0 or 3-0 Vicryl sutures are placed at the 3, 6, 9,
and 12 o'clock positions through the EAS muscle's connective tissue capsule. The sutures through the inferior
and posterior portions of the sphincter should be placed first and tied last to aid this part of the repair. Initially
with closure, the disrupted ends of the striated (EAS) muscle and capsule are identified and grasped with Allis
clamps

28. C. Suture through the posterior wall of the external anal sphincter
(EAS) capsule.

29. D. Sutures through the EAS (blue suture) and inferior
capsule wall.

30. E. Sutures to reapproximate the anterior and superior
walls of the EAS capsule. The remainder of the repair is
similar to that described for a midline episiotomy .

34.  Pudendal block analgesia will help to relieve perineal pain
postoperatively
 Application of ice packs helps to reduce swelling and allay
discomfort
 Topical application of 5-percent lidocaine ointment was
not effective in relieving episiotomy or perineal laceration
discomfort
 Analgesics such as codeine give considerable relief
Pain after Episiotomy

35.  Because pain may be a signal of
 Vulvar, paravaginal, or ischiorectal hematoma
 Perineal cellulitis
 It is essential to examine these sites carefully if pain is
severe or persistent