RUPTURE PERINEUM

Prepared by :
Christine Surbakti - 406147010
Marcelly Raymando - 406147011
Melani Sugiarti Wijaya Kangmartono 4060147014

OBSTETRI AND GYNECOLOGY CLERKSHIP

TARUMANAGARA UNIVERSITY
RSUD CIAWI, BOGOR
Period 29 th December 2014 s/d 7th March 2015

Definition
Lacerations of perineum are the result of
overstreching or too rapid streching of the
tissue especially if they are poorly
extensile or rigid. Laceration of the
perineum is a wound or irregular tear of
the perineal tissues during childbirth.

ANATOMY
Perineum
Perineum is a diamond-shaped space
that lies below the pelvic floor.
Is bounded by :
Superiorly : Pelvic floor
Laterally : the pelvic outlet consisting of
subpubic angle, ischiopubic rami, ischial
tuberosities, sacrotuberous ligaments and
coccyx
Inferiorly : skin and fascia

 This area is divided into two triangles

by transverse muscles of perineum
and base of urogenital diaphragm :
Anterior triangle
Posterior triangle

Most of the support of perineum is

provided by pelvic floor and
urogenital diaphragm

ETIOLOGI
Tear in perineum commonly occur at
childbirth :
Malpresentations such as breech
The head of the fetus is born too
soon
Labor is not headed properly
Previously on peineum there is a lot
of scar tissue

RISK FACTOR
Risk Factor for more complex laceration include :
Midline Episiotomy
Nulliparity ( Primigravida )
Longer second-stage labor
Precipitous delivery
Persistent occiput posterior postition
Operative vaginal delivery
Asian Race
Increasing Fetal birthweight

EPIDEMIOLOGY
One in three women occurring
spontaneous laceration in the first
childbirth.
Seven in ten women reported using
episiotomy in their first childbirth
It estimates that 85% of women who
have a vaginal delivery will have
some degree of perineal trauma and
that 60-70% will require suturing.

CLASSIFICATION
Degrees of Perineal Rupture :
First-degree lacerations involve the fourchette,
perineal skin, and vaginal mucous membrane but
not the underlying fascia and muscle. These
included periurethral lacerations, which may
bleed profusely.

 Second-degree lacerations involve, in

addition, the fascia and muscles of the perineal
body but not the anal sphincter. These tears may
be midline, but often extend upward on one or
both sides of the vagina, forming an irregular
triangle.

 Third-degree lacerations extend

farther to involve the external anal
sphincter.

 Fourth-degree lacerations extend completely

through the rectal mucosa to expose its lumen
and thus involves disruption of both the external
and internal anal sphincters.

SIGN AND SYMPTOMS

Bleeding in a State where the placenta is born, uterine
contractions and well, it is certain that the bleeding
wounds of the street comes from the birth. Signs that
threatens to tear the perineum, among others:
1. the perineum Skin started flaring and tense.
2. the perineum Skin colored pale and shiny
3. there is bleeding out of the holes of the vulva, is an
indication of a tear in the vaginal mucosa.
4. when the skin of the perineum at the midline
begins to tear, among the fourchette and the
sphincter ani.

EPISIOTOMY
episiotomy is incision of the pudendumthe
external genital organs.
The incision maybe made in the midline, creating
a median or midline episiotomy. It may also begin
off the midline and directed laterally and
downward away from the rectum, termed a
mediolateral episiotomy.

Episiotomy should be considered for indications

such as
shoulder dystocia,
breech delivery,
macrosomic fetuses,
operative vaginal deliveries,
persistent occiput posterior positions,
and other instances in which failure to perform an
episiotomy will result in significant perineal
rupture

EXAMINATION
1. Routine Examination
Almost all clinicians examine perineum area after childbirth
process to detect tears can be appear. Some clinicians also
recommend having all labor, followed by routine rectal
examination and inspection of the walls of the vagina and
cervix. Routine examination of the rectal to detect the septal
aims on mucosa recta, anal sphincter, and perineum by using
one finger into the rectum.
2. Peri-rule
Is a standard tool for assessing the perineum tear stadium two
objectively made of plastic scale.

MANAGEMENT
Lacerations should be repaired
immadietly if possible, and certainly
within hours of delivery
First step is to define the limits of the
lacerations, which includes vagina as
well as perineum
As accurate an approximation as
possible of all tissues should be
secured and no dead spaces are left

There are many ways to repair a perineal

lacerations, but the concept is still the same:
The suture material commonly used is 20
chromic catgut.
For shallow wound it can be repair with
one stitch; for deep wound it can be repair
with two or more.
Each stitch should be reach to the base of
the wound
Third degree laceration need a special
technique.

 Initially the walls of the rectum is sewn

inverted with simple gut. The needle
cannot be penetrate the rectum wall and
into the rectum lumen then the layer is
closed with fascia stitch on it. After that,
the end of the sphincter ani is searched
and connected with two or three stitch
using chromic cat gut. Finally it is sewn
like second degree laceration

Fourth-Degree Laceration Repair

Education in patients also need to be provided, can be :

Clean the wound after defecation/urination
Avoid the use of toilet paper, perfume, or powder on the
genital area
Rest the pelvic area with no sexual intercourse, inserting
tampon
Check if pain increases or settled more than 1 week.
Check if excessive bleeding occurs
Specifically for III and IV degree tears, avoid constipation,
as well as consume a diet low in fiber, low residue, as well
as a stool softener.
In 6 weeks post partum, if the tear heal normally, physical
examination on perineum indicated normal then the
patient can continues her sexual activity.

Post operative treatment

Administering of antibiotics given to
patients with ruptured perineum
Control of pain in the days after birth,
usually by administering NSAID
Maintain hygiene perineum

PREVENTION
The incidence of severe perineal
trauma can be decreased by
minimizing the use of episiotomy and
operative vaginal delivery
Proper support of perineum at the
time of crowning and expulsion of
head

COMPLICATIONS
Infection
Cosmetic disadvantage
3 and 4 degree tears if left untreated
may lead to fecal incontinence

PROGNOSIS
The majority of patients with an episiotomy or
tear will heal very well, with the disappearance of
pain 6 weeks after delivery and minimal scarring,
however the stool incontinence may occur in the
short term and long term on 10% of patients with
fourth degree laceration, although already done
well handling. If there are no complications, no
required care and monitoring for long a period of
time