Clinical Protocols and Guidelines CPMA127

Maternity (all sites) Perineal trauma management Guideline

Perineal trauma management guideline

To be read in conjunction with relevant maternity clinical competencies as referenced.

1. Classification of perineal trauma

Southern Health recommends the following classifications adopted by the International

Consultation on Incontinence and the Royal College of Obstetricians and Gynaecologists.3

First degree Injury to perineal skin only.

Second degree Injury to perineum involving perineal muscles but not involving the anal
sphincter.

Third degree Injury to perineum involving the anal sphincter complex:

3a: less than 50% of external anal sphincter thickness torn.

3b: more than 50% of external anal sphincter thickness torn.

3c: internal anal sphincter torn.

Fourth degree Injury to perineum involving the anal sphincter complex (EAS and IAS)
and anal epithelium.

Buttonhole tear If the tear involves only anal mucosa with intact anal sphincter complex
this has to be documented as a separate entity.

2. Risk reduction

While it might be useful to identify risk factors for major perineal trauma, recognising known
risk factors does not readily allow prediction or prevention.3

Where an episiotomy is indicated, the recommended technique is a 45-60 degree angle

mediolateral episiotomy originating at the vaginal fourchette.13 A 50% relative reduction in
third degree tears has been associated with every 6 degrees away from the midline.2

3. Identification of anal sphincter injury

All women having a vaginal birth are to be examined systematically post birth by a
midwife or doctor trained and competent in the identification and classification of perineal
trauma.4,13,14,15 The timing of the examination should not interrupt mother infant bonding
unless the woman has bleeding requiring urgent action.13 It is prudent to defer the woman
from oral intake until the examination has taken place, particularly if there is no epidural in
situ and/or major perineal trauma is suspected.

Prior to suturing, where any degree of trauma requiring repair is identified, a rectal
examination should be carried out to exclude an anal sphincter tear. The external anal
sphincter should be palpated between two fingers - one in the vagina and one in the rectum.

If there is any degree of uncertainty consider assessment by a more senior midwife or

doctor.

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4. Repair of first and second degree tears

Principles

A midwife or doctor with the required competency14 should perform suturing as soon as
possible after the birth to reduce bleeding and risk of infection.3 Simple trauma should be
repaired using aseptic technique once effective anaesthesia is in place. Ensure good lighting
to visualise and identify the structures involved.

The practice of leaving first and second degree tears unsutured is associated with poorer
wound healing and non significant differences in short term discomfort.3 Women should be
advised that only in first degree trauma where the skin edges are well opposed, may suturing
not be required.13

Method and materials: refer 6 below.

5. Repair of third and fourth degree tears

Principles
For repair of the external anal sphincter, either an overlapping or end to-end (approximation)
method can be used, with equivalent outcome.4,5,6

Extensive tears and all third degree tears should be repaired with operating theatre
conditions under adequate analgesia.

All fourth degree tears should be repaired in the operating theatre under regional or general
anaesthesia. General or regional anaesthesia is important to allow adequate muscle
relaxation to retrieve retracted torn sphincter muscle and enable repair without tension.7

A consultant or senior level trainee competent in third and fourth degree tear repair should be
present.15

Intraoperative and postoperative broad-spectrum antibiotics should be administered to

prevent infection and risk of subsequent complications such as: anal incontinence and fistula
formation in the event of breakdown of the anal sphincter repair.7,8 The recommended
regimen is : 2 gram cephalosporin and 500mg metronidazole intravenous (IV) stat.
Followed by: 5 days of oral Augmentin Duo Forte 1 tablet twice a day.

Note: alternative antibiotics will be required for women who have known antibiotic allergies.

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6. Technique and suture materials

Anal epithelium

The torn anal epithelium should be repaired with interrupted sutures preferably using Syneture
Polysorb 3-0, 26mm taper round bodied needle V-20, GL-122; with the knots tied in the anal
lumen.6

Internal anal sphincter

The IAS should be repaired separately with interrupted sutures using end-to-end or overlap
technique. It is advisable to repair in the operating theatre with colorectal or senior obstetric
consultation.

The recommended sutures include fine 3-0 PDS or 2-0 Polysorb as it may cause less irritation
and discomfort.

External anal sphincter

The torn ends of the EAS should be fully mobilized and repaired using either an overlap or end-to-
end technique. Burying of surgical knots beneath the superficial perineal muscles is
recommended to prevent knot migration to the skin.

The recommended sutures 4 include: Ethicon PDS*II 2-0, 26mm 1/2c taper round bodied needle
CT-2, Z333; or Syneture Polysorb 2-0, 27mm 1/2c taper round bodied needle GS-22, CLS-88; or
Syneture Maxon* *2-0, 27mm 1/2c taper round bodied needle GS-22.

Note: Vicryl rapide should NOT be used as it is too quickly absorbed.

Perineal muscle

Care must be exercised with extensive tears in reconstructing the perineal muscles to provide
support to the sphincter repair. The anal sphincter is more likely to be traumatised during a
subsequent vaginal birth in the presence of a short deficient perineum.6

Repair preferably using a continuous non- locked suturing technique.3,13

The recommended material for muscular repair is a *2.0* delayed absorbable suture such as 2.0
Polysorb (GS-21, CL-843 - 37mm 1/2c taper round bodied needle).

Perineal skin

Skin closure preferably using a continuous subcuticular technique.3,13

Preferred suture is undyed braided absorbable suture (Ethicon Vicryl rapide (polyglactin 910) 2-
0, 36mm tapercut needle.

Perform a rectal examination at the end of the procedure to ensure the repair is intact
and exclude inadvertent suture penetration of the rectum.

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7. Documentation
Detail the perineal repair on :
- Birth Suite Operative Report (MRG33) if repair is done in birth suite. Two
signatures are mandatory.
- Operation Report (MRG17(i) if repair occurs in the Operating Theatre.

In the Operating Theatre the needle and pack count will be checked with the surgeon and
documented by theatre nurses on the Operation Register (MRG21(i).

8. Post repair management

Rest, ice, compression and exercise/elevation (RICE) underpin postpartum management.

Rest: advise regular lying down rest periods during the day over the first six weeks to assist in
reduction of perineal descent, pain and swelling. Avoid prolonged standing.

Ice: apply an ice pack for 20 minutes every 2 4 hours for the first 24 - 48 hours to assist in
reduction of swelling.

Compression: suggest wearing 23 pads for extra perineal support and firm fitting
underwear.

Exercise: commence pelvic floor exercises after 2-3 days or when comfortable to aid in
recovery.

Avoid straining on the toilet.

Analgesia: ensure adequate pain relief, such as a non steroidal anti-inflammatory analgesic,
plus oral paracetamol. Avoid constipating analgesics if possible. Rectal analgesia should be
avoided with 3rd and 4th degree tear repairs.

Laxatives or stool softeners: recommended with 3rd degree tears post-operatively for
about 7-10 days to maintain soft stool and avoid constipation (such as lactulose +/- fybogel).

With 4th degree tears, post-operative laxatives are delayed because of the rectal mucosal
injury. These patients are to be referred to the dietician, and commenced on a low residue diet
for approximately 7 days. The purpose of this is to have a delayed bowel motion with a soft
stool that is easy to pass.

After a regional anaesthetic the urinary catheter should remain insitu on free drainage for
at least 12 hours after the last epidural top up dose.

9. Referrals

A referral to the dietitian should be made for all women who have sustained 3rd or 4th
degree perineal trauma.

A referral to the physiotherapist must be made for all women who have sustained 3rd or 4th
degree perineal trauma, and the woman reviewed by the physiotherapist prior to discharge /or
soon post discharge. A pelvic floor muscle rehabilitation program should be commenced as
soon as comfortable, usually at about 2-3 days post birth. An individualised program can be
recommended by the physiotherapist. The physiotherapist will arrange a follow up outpatient
physiotherapy appointment at approximately 7 weeks at the campus or continence service
closest to the womans home.

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Obstetric follow-up MUST be arranged at 6 weeks.

All women with a third or fourth degree perineal tear should be offered a follow-up appointment at
three (3) months in the Pelvic Floor Clinic, Moorabbin Campus.

If a woman is experiencing incontinence or pain at follow-up, referral to a specialist

gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal
manometry should be considered.

10. Prognosis with third and fourth degree tears

Women should be advised that the prognosis following external anal sphincter repair is good, with
6080% asymptomatic at 12 months.3 Most women who remain symptomatic describe
incontinence of flatus or faecal urgency.

11. Future births

All women who sustain an anal sphincter injury during birth should be counselled about the
possibility of developing anal incontinence or worsening symptoms with subsequent vaginal
births.

There are no systematic reviews or randomised controlled trials to suggest the best method of
birth following anal sphincter injury.

Two groups of women have been recognised as having increased risk of worsening anal
incontinence following a second vaginal birth.10

1. Women who have transient anal incontinence following their first birth (i.e. 6-12 weeks post-
partum) and/or into their second pregnancy. These women should be counselled and offered
a caesarean section for the subsequent pregnancy.

2. Women who have had a delayed secondary anal sphincter repair or fistula repair should also
be advised to have a caesarean section for the subsequent pregnancy.

All other woman should be advised by their midwife/doctor they have no greater risk of worsening
anal incontinence.

There is a risk of recurrent anal sphincter laceration in a subsequent vaginal birth of 6-7%. The
main risk factors are forceps birth, birth weight > 4kg and midline episiotomy.10

There is no evidence that prophylactic episiotomy prevents a recurrence of sphincter rupture and
therefore should only be performed for the usual clinical indications.6

All women who have suffered an anal sphincter injury are to be counselled at the medical booking
visit regarding the mode of birth and episiotomy. This discussion should be clearly documented in
the womans medical record.

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12. Third and fourth degree tear perineal repair pack instruments

kidney dishes (2)

tooth forceps
needle holder
Allis forceps (2)
artery forceps (4)
McIndoe scissors
suture cutting scissors
Sims speculum
lateral vaginal wall retractors (2)
self-retaining retractor eg. Weislanders retractor
sponge holding forceps (4)
large swabs.

If an adverse event (actual or near miss) is associated with this guideline document
details in the health record and complete an incident report.

1. Faltin DL, Boulvain M, Irion O, Bretones S, Stan C, Weil A. Diagnosis of anal sphincter

tears by postpartum endosonography to predict faecal incontinence Obstet Gynecol
2000;95:6437.
2. Eogan M, Daly L, OConnell PR, OHerlihy C. Does the angle of episiotomy affect the
incidence of anal sphincter injury? BJOG 2006;113:1904.
3. Royal College of Obstetricians and Gynaecologists. Methods and materials used in
perineal repair. Guideline .no23 London; RCOG, June 2004
4. Royal College of Obstetricians and Gynaecologists. Management of third- and fourth-
degree perineal tears following vaginal delivery. Guideline No. 29, 2007
5. Goh J, Carey M, Tjandra J. Direct end-to-end or overlapping delayed anal sphincter
repair for anal incontinence: long term results of prospective randomised study.
Neurourol Urodyn 2004;23:41214.
6. Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric
anal sphincter laceration: A randomized trial of two surgical techniques. Am J Obstet
Gynecol 2005;192:1697701.
7. Sultan AH, Monga AK, Devinder K, Stanton SL. Primary repair of obstetric anal
sphincter rupture using the overlap technique. BJOG 1999;106: 318-323
8. Fernando R, Sultan AH, Kettle C, Radley S, Jones P, O'Brien P. Repair techniques for
obstetric anal sphincter injuries: A randomized controlled trial. Obstet Gynecol
2006;107(6): 1261-1268
9. Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA,Richmond DH. How to
repair an anal sphincter injury after vaginal delivery: results of a randomised controlled
trial. BJOG 2006;113:2017.
10. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Longterm results of
overlapping anterior anal sphincter repair for obstetric trauma. Lancet 2000;355:2605.
11. Fitzpatrick M, Behan M, OConnell R, OHerlihy C. A randomisedclinical trial comparing
primary overlap with approximation repair of third degree tears. Am J Obstet Gynaecol
2000:183: 12204.

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12. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, OBrien S. Repair techniques
for obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol
2006; 107:12618.
13. Collaborating Centre for Women and Childrens Health. Intrapartum Care: Care of
Healthy Women and Their Babies During Childbirth London: RCOG Press, September
2007 (www.nice.org.uk/guidence/cg55).
14. Southern Health (2008), Clinical Competency in perineal suturing (CP-MA47) Clinical
Protocols and Guidelines, Maternity.
15. Southern Health (2008), Clinical Competency in third degree/fourth degree perineal
repair/haematoma (CP-MA109) Clinical Protocols and Guidelines, Maternity.

SH Policy Patient Care ACHS Clinical

Reviewer Urogynae Team (Rosamilia, Edwards,Chao) Last review date September 2010
Women s Health Physiotherapists
Acute Dietetic Managers
Maternity Guideline Development Group
Authoriser Maternity Executive Committee Next review date April 2012

If this is a hard copy it might not be the latest version of this document. Please see the
Southern Health site for current policies, protocols and guidelines.

Disclaimer
These clinical practice guidelines and protocols have been developed having regard to general circumstances. It is the
responsibility of every clinician to take account of both the particular circumstances of each case and the application of these
guidelines. In particular, clinical management must always be responsive to the needs of the individual woman and particular
circumstances of each pregnancy.
These guidelines have been developed in light of information available to the authors at the time of preparation. It is the
responsibility of each clinician to have regard to relevant information, research or material which may have been published or
become available subsequently. Please check this site regularly for the most current version.

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