PERINEAL TEAR

1. PRESENTED BY: MRS. DEEPTI KUKRETI
PG NURSING TUTOR
OBSTETRICS & GYNAECOLOGY

2. Genital tract injuries also known as perineal trauma
occurs either spontaneously with vaginal delivery or
secondarily as an extension to an episiotomy.
Several perineal trauma can involve damage to the
anal sphincter and anal masses. Obstetric anal
sphincter injuries(OASIS) include third and fourth
degree perineal tear.
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3. ANATOMICAL CLASSIFICATION:
1. Injuries to bony parts
- Injury to symphysis pubis
- Injury to sacro-coccygeal joint
- Injury to sacro-iliac joint.
2. Injuries to soft tissue
- Injury to vulva
- Perineal tears
- Laceration of vagina and cervix
- Rupture of uterus.
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4. First degree Injury to perineal skin only
Second degree Injury to perineal muscles but not involving the anal sphincter
Third degree Injury to perinem involving the anal sphincter complex
CLASSIFICATION OF OASIS: ( RCOG, 2015 and SOGC, 2015)

6. Lacerations of the vulval skin posteriorly and the
paraurethral tear on the inner aspect of the labia minora
are the common sites. Paraurethral tear may be
associated with brisk haemorrhage and should be
repaired by interrupted catgut sutures, preferably after
introduction of a rubber catheter into the bladder to
prevent injury of the urethra.
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7. While minor injury is quite common, especially during first birth,
gross injury ( third and fourth degree) is invariably a result of
mismanaged second stage of labor.
Causes:
Perineal injury mainly the third and fourth degree results from:
- Overstretching of the perineum
- Rapid stretching of the perineum, especially when the perineum is
inelastic ( elderly primigravida, perineal scar.)
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9. Proper conduct in the second stage of labor taking due care
of the perineum when it is likely to be damaged is essential.
Some of the important steps to prevent perineal tears are:
- Delivery by early extension is to be avoided.
- Spontaneous forcible delivery of the head is to be avoided.
- To deliver the head in between contractions.
- To perform timely episiotomy.
- To take care during delivery of the shoulders.
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10. Recent tear should be repaired immediately following the
delivery of the placenta. This reduces the chance of
infection and minimizes the blood loss. In case of delay
beyond 24 hours, the repair is to be withheld. Antibiotics
should be started to prevent infection. The complete tear
should be repaired after 3 months if delayed beyond 24
hours.
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11. Isolated vaginal tears or lacerations without involvement of
the perineum or cervix are common. These are usually seen
following instrumental or manipulative delivery. In such cases,
the tears are extensive and often associated with brisk
haemorrhage.
Tears associated with brisk haemorrhage require exploration
under general anesthesia with a good light.
In case of extensive lacerations, in addition to sutures,
hemostasis may be achieved by intravaginal plugging by roller
gauze soaked with glycerine and acriflavine. The plug should
be removed after 24 hours. Selective arterial embolization
may be done if bleeding persists.
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12. Minor degree of cervical tear is invariable during first
delivery and requires no treatment. Extensive cervical tear
is rare. It is the commonest cause of traumatic postpartum
haemorrhage. Left lateral tear is the most common.
DIAGNOSIS:
Excessive vaginal bleeding immediately following delivery
in presence of a hard and contracted uterus raises the
suspicion of a traumatic bleeding. Exploration of the
uterovaginal canal under good light not only confirms the
diagnosis but also helps to know the extent of the tear.
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13. Only deep cervical tear associated with bleeding should be
repaired soon after delivery of the placenta. Repair should
be done under general anesthesia, in lithotomy position with
a good light. The pre-requisites are- Sim’s posterior vaginal
speculum, vaginal wall retractors, at least two sponge
holding forceps and an assistant.
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14. Disruption in the continuity of all uterine layers
(endomatrium, myometrium and serosa) anytime beyond
28 weeks of pregnancy is called rupture of the uterus.
INCIDENCE:
The prevalence of widely varies from 1 in 2,000 to 1 in
200 deliveries.
ETIOLOGY:
- Spontaneous rupture
- Scar rupture
- Iatrogenic rupture
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15. Prophylaxis:
The following guidelines are helpful to prevent or to detect at the
earliest the tragic occurrence of rupture uterus-
- The at-risk mothers, likely to rupture, should have mandatory hospital
delivery.
- General anaesthesia should not be used to give undue force in
external version.
- Undue delay in the progress of labor in a multipara with previous
uneventful delivery should be viewed with concern and the cause
should be sought for.
- Judicious selection of cases with previous history of caesarean for
vaginal delivery.

16. Vesico vaginal fistula is an abnormal opening between the
bladder and the vagina that results in continuous and
unremitting urinary incontinence.
CAUSES:
It can be congenital or acquired.
Congenital are very rare and associated with other urogenital
malformations.
Acquired can be due to obstetrical and surgical related.
In developing world, 90% of the fistulas are of obstetrical causes.
In industrialized world, >75% of the fistulas are of gynaecological and
surgical causes.
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17. A recto vaginal fistula is the abnormal connection between
the rectum and urinary bladder. Stool or gas may leak or
passed through the bladder as a result of this connection.
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