Perineal Tears
Perineal Tears
Perineal Tears
TEAR
BY
Dr.D.V.RATNAM
Perineum
Diamond shaped area between the thighs.
It is bounded by the pubic symphysis anteriorly,
ischiopubic rami and ischial tuberosities anterolaterally,
sacrotuberous ligaments posterolaterally, and coccyx
posteriorly.
Anterior Triangle
This superficial
pouch contains
several
important
structures, which
include the
Bartholin glands,
vestibular bulbs,
clitoral body and
crura, branches
of the pudendal
vessels and
nerve, and the
ischiocavernosus
,
bulbocavernosus,
Posterior Triangle
This triangle contains the ischioanal
fossae, anal canal, and anal sphincter
complex, which consists of the
internal anal sphincter, external anal
sphincter, and puborectalis muscle.
Branches of the pudendal nerve and
internal pudendal vessels are also
found within this triangle.
Ischioanal Fossae
Also known as ischiorectal fossae,
These two fat-filled wedge-shaped spaces are found on
either side of the anal canal and comprise the bulk of the
posterior triangle.
PERINEAL TEARS
The following classification described
by Sultan has been adopted by the
International Consultation on
Incontinence and the RCOG:
Bulbocavernos
us m.
Superficial
transverse
perineal m.
External
anal
sphincter
External
anal
sphincter
Internal anal
sphincter
Rectal
mucosa
Risk factors
1. BW > 4.0 kg
2. Persistent OP position
3. Nulliparity
4. Asian ethnicity
5.
6.
7.
8.
9.
Epidural analgesia
Prolonged second stage ( > 1 hour)
Shoulder dystocia
Midline episiotomy
Forceps delivery
Symptomatology:
Immediate:
Bleeding Traumatic PPH - hemorrhagic
shock.
Perineal Pain
Perineal hematoma
Urinary retention due to painful
perineum
Urinary incontinence
Anorectal dysfunctions like fecal
incontinence
Delayed:
1. Infected perineum- perineal abscess
2. Uterovaginal prolapse
3. Urinary incontinence (stress and urinary
fistula)
4. Fecal incontinence ( rectovaginal
fistula)
5. Dyspareunia
6. Feeling of slack vagina during coitus
How to recognize:
Put the patient in extended lithotomy position.
Arrange proper spottless bright light.
Arrange for vaginal pads, instruments like ant.
and post. vaginal retractors , urinary cathter,
sponge holders, curved and straight artery
clamps.
Vulva should be examined stepwise right from
clitoris to the anus downwards, laterally
paraclitoral, paraurethral, paravaginal and
pararectal skin and muscles in every case
after delivery.
End-to-end technique
Approximation of the
anorectal mucosa and
submucosa in a running or
interrupted fashion using
fine absorbable suture such
as 30 or 40 chromic or
Vicryl.
During this suturing, the
superior
extent of the anterior anal
laceration is identified, and
the sutures are placed
through the submucosa of
the anorectum
In overview, with
traditional end to-end
approximation of the
EAS, a suture is placed
through the EAS
muscle, and four to six
simple interrupted 20
or 30 Vicryl sutures
are placed at the 3, 6,
9, and 12 oclock
positions through the
connective tissue
capsule of the
sphincter.
Sutures to
reapproximate the
anterior and superior
walls of the EAS
capsule.
The remainder of the
repair is similar to that
described for a midline
episiotomy.
Postoperative management
The use of broad-spectrum antibiotics is
recommended following repair of OASIS to
reduce the risk of postoperative infections
and wound dehiscence.
A single dose of a second-generation
cephalosporin is suitable, or clindamycin
for penicillin-allergic women.
The use of postoperative laxatives is
recommended to reduce the risk of wound
dehiscence.
Prognosis
Good prognosis following EAS repair
60 - 80% asymptomatic at 12 months
Complications if left
untreated:
Infection
Hemorrhagic Shock
Cosmetic disadvantage
3rd and 4th degree tears if left untreated
may lead to fecal incontinence.
THANK YOU