PERINEAL INJURY AND EPISIOTOMY
OUTLINE OF PRESENTATION
• ANATOMY OF PERINEUM
• FIRST AND SECOND DEGREE TEAR – REPAIR
• THIRD AND FOURTH DEGREE TEAR - REP...
PERINEUM
• Diamond shaped area between the thigh
• Perineal body:
– mass of interlocking muscular, fascial, and fibrous
co...
Anterior triangle: superficial compartment
• bounded deeply by the perineal membrane and
superficially by Colles fascia
• closed compartment  infection or bleeding ...
Anterior triangle: deep compartment
Posterior triangle
• Contents:
– Ischiorectal fossa
– Anal canal
– Sphincter complex
ANORECTUM
External anal sphincter
Internal anal sphincter
CLASSIFICATION OF PERINEAL INJURY
RCOG GREEN TOP GUIDELINE
• Risk factors (for 3rd degree tear):
1.
2.
3.
4.
5.
6.
7.
8.
9.

BW > 4.0 kg
Persistent OP posit...
• Prognosis:
– Good prognosis following EAS repair
– 60 - 80% asymptomatic at 12 months
– Those with symptoms: flatus inco...
• Future deliveries (for those who sustained obstetrics
anal sphincter injury):
– should be counselled about the risk of d...
Perineal injury and episiotomy
Perineal injury and episiotomy
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Perineal injury and episiotomy

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  • continuous superiorly with the pelvic cavity  any collection can spread up to pelvic cavity
  • Most of the risk factors identified cannot readily be used to prevent or predict the occurrence of a
    third- and fourth-degree tear.20 Studies are required to investigate the effect of interventions to
    prevent third-degree tears in women with risk factors
  • Perineal injury and episiotomy

    1. 1. PERINEAL INJURY AND EPISIOTOMY
    2. 2. OUTLINE OF PRESENTATION • ANATOMY OF PERINEUM • FIRST AND SECOND DEGREE TEAR – REPAIR • THIRD AND FOURTH DEGREE TEAR - REPAIR
    3. 3. PERINEUM • Diamond shaped area between the thigh • Perineal body: – mass of interlocking muscular, fascial, and fibrous components lying between the vagina and anorectum – attachment point for components of the urinary and fecal continence mechanisms, which are commonly damaged during vaginal childbirth • Anterior and posterior triangle
    4. 4. Anterior triangle: superficial compartment
    5. 5. • bounded deeply by the perineal membrane and superficially by Colles fascia • closed compartment  infection or bleeding within it remains contained • Contains muscles that are cut during episiotomy: – Bulbospongiosus – Transverse perineal
    6. 6. Anterior triangle: deep compartment
    7. 7. Posterior triangle • Contents: – Ischiorectal fossa – Anal canal – Sphincter complex
    8. 8. ANORECTUM
    9. 9. External anal sphincter
    10. 10. Internal anal sphincter
    11. 11. CLASSIFICATION OF PERINEAL INJURY
    12. 12. RCOG GREEN TOP GUIDELINE • Risk factors (for 3rd degree tear): 1. 2. 3. 4. 5. 6. 7. 8. 9. BW > 4.0 kg Persistent OP position Nulliparity IOL Epidural analgesia Prolonged second stage ( > 1 hour) Shoulder dystocia Midline episiotomy Forceps delivery
    13. 13. • Prognosis: – Good prognosis following EAS repair – 60 - 80% asymptomatic at 12 months – Those with symptoms: flatus incontinence or faecal urgency – Endoanal ultrasound as part of follow-up  persistent defects in 54–88% of women after primary repair of recognised thirddegree tears
    14. 14. • Future deliveries (for those who sustained obstetrics anal sphincter injury): – should be counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery – no evidence to support the role of prophylactic episiotomy in subsequent pregnancies – Those who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should have the option of elective caesarean birth

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