Fascia covering the muscles Transverse perineal branches of pudendal vessels& nerves Subcutaneous tissue & skin.
3:Perineal Repair Repair is done soon after the expulsion of the placenta.
Purpose of RepairTo control bleeding To prevent infection To assist wound healing byprimary intention.
The most common suture type polyglactin 910 suture: Coated Vicryl, Vicryl RAPIDE (> 70%) polyglycolic acid: Safil, Safil Quick, Dexon II (12%) Traditional sutures : catgut, chromic catgut) (10%).
Preliminaries : The patient is placed in lithotomy positionA good light source from behind is needed to find the apex first.
The perineum &the wound area is cleaned with antiseptics Blood clots are removed from the vagina & the wound area
The patient is drapped properly &repair should be done under strict aseptic precautionA vaginal pack is inserted & is placed high up.
Principles in suturing Close all dead space –ensure haemostasis and prevent infection
Cotton balls must not be used. Handle tissue gently using nontoothed forceps.Ensure good anatomical restorationand alignment to facilitate healing.
• Use minimal amount of suturematerial, and do not over tighten suturethis may impede healing.• Following the repair a rectal examinationshould be performed to ensure no suturematerial has been inserted through therectal mucosa.
Step 1 Suturing the vagina• Identify the apex.• Insert the anchoring suture 0.5 cmabove the apex.• Repair the vaginal wall with acontinuous non-locking stitch withapproximately 0.5 cm between eachstitch.
Step 2 Suturing the perinealmuscle Check the depth of the trauma. Repair the perineal muscles in one or two layers with the same continuous stitch. Ensure the muscle edges are apposed carefully leaving no dead space.
On completion of the muscle layer, the skin edges should align so that they can be brought together without tension.
Step 3 Suturing the skin• Reposition the needle at the inferiorend of the wound commence.• Stitches are placed below the surfaceof the skin,
• The point of the needle should be repositioned between each side,• So that it faces the skin edge being sutured.• Continue taking bites of tissue from each side until the superior wound edge is reached.
Immediate care• Inspect the repair to check that haemostasis has been achieved• Remove the vaginal tampon, if used,• Account for all instruments, swabs and needles• Discard sharps safely
Apply sterile pad following thoroughperineal washWait for minimum one hour to shift thepatient to wardCheck for bleeding & urine output