Third and Fourth Degree Tears - Management

Transcription

1 1. Purpse This dcument utlines the guideline r prcedure details fr the management f wmen wh sustain third r furth degree perianal tears during childbirth at the Wmen s. Up t 57% f wmen with third r furth degree perineal tears during childbirth suffer frm sme kind f altered anal symptms which include faecal urgency and incntinence f flatus, liquid stl and slid stl. This cnditin may als present in wmen withut bvius anal sphincter tears during labur and delivery (ccult injury). This guideline (CPG) aims t supprt clinical decisin making fr 3rd/4th degree tears, in preventin, diagnsis, initial management, nging management and management f the subsequent birth. 2. Definitins Secnd degree tear: invlves the perineal muscles nly. Obstetric anal sphincter injury: applies t bth third- and furth-degree tears. Third degree tear: injury t the perineum invlving partial r cmplete disruptin f the anal sphincter cmplex (external [EAS] and internal [IAS]). Classificatin f a third degree tear is dependent upn the degree f disruptin as fllws: 3a <50% f external sphincter trn 1 3b >50% f external sphincter trn 1 3c internal sphincter trn. Furth degree tear: invlves anal sphincter and rectal mucsa. 3. Respnsibilities Obstetric medical staff and midwifery staff are respnsible fr the clinical care f the wman. Physitherapists are respnsible fr the physitherapy management f the wman. Dietitians are respnsible fr the dietetic management f the wman. CNC Urgynaeclgy is respnsible fr initiating fllw up care and referral t the Perineal Clinic Team. Perineal Clinic Team: are respnsible fr fllw-up care and nging management f the wman. This team cmprises experts in urgynaeclgy, clrectal, dietetics, midwifery / cntinence nursing, physitherapy and sexual cunselling. The Perineal Clinic ffers a multidisciplinary, best practice apprach t the management and fllw-up f anal sphincter injury with the aim t prevent/minimise lng term cmplicatins. 4. Guideline 4.1 Risk factrs The fllwing risk factrs have been assciated with wmen sustaining an bstetric anal sphincter injury: nulliparity Asian r indian sub-cntinent ethnicity wman has Female Genital Mutilatin (FGM) baby is large in relatin t maternal size (> 4kg) previus histry f perineal trauma requiring repair previus histry f bstetric anal sphincter injury precipitate r faster than expected secnd stage instrumental birth active secnd stage lnger than 1 hur inapprpriate maternal psitin (e.g. lithtmy psitin) midline episitmy r an inadequately angled medilateral episitmy which functins like a mid-line. Uncntrlled dcument when printed Publicatin date (08/05/2013) Page 1 f 5

2 4.2 Predictin and preventin Obstetric anal sphincter injury is unpredictable but there are clinical practices which are knwn t reduce the risk. Fr this reasn all wmen attempting a vaginal birth shuld be assessed fr their risk f bstetric anal sphincter injury using the Risk Assessment Frm cntained with the Clinical Infrmatin system and management f birth managed accrdingly. Clinicians must be aware f the risk factrs fr bstetric anal sphincter injury, but als recgnise that knwn risk factrs d nt readily allw predictin/preventin f such an injury Where episitmy is indicated, the medilateral technique is recmmended, with careful attentin t the angle cut away frm the midline All clinical staff shuld fllw best practice techniques when making a decisin t perfrm an episitmy and t perfrm an episitmy. Guidance n episitmy technique has been develped and can be accessed via the Birth Centre Resurces page. 4.3 Classificatin It is recmmended that the classificatin utlined in the definitins sectin f this CPG be used when describing any bstetric anal sphincter injury. 1 If in dubt abut the grade f third degree tear, it is advisable t classify it t the higher degree Recgnitin/identificatin It is the respnsibility f the accucheur r supervising accucheur t thrughly examine the perineum after childbirth. Guidance n best practice technique has been develped and can be accessed via the Birth Centre Resurces page. All wmen shuld be examined t assess degree f perineal/vaginal/rectal injury after vaginal birth as fllws: The external anal sphincter shuld be palpated between tw fingers ne vaginal, ne rectal All wmen wh have an instrumental birth, r wh have extensive perineal injury shuld be examined by a cnsultant r registrar trained in recgnitin and management f perineal tears Repair technique fr third/furth degree tears Extensive tears and all third and furth degree tears shuld be repaired under general r reginal analgesia (ptimally in the perating theatre). 1 Muscle relaxatin is required t retrieve and verlap the retracted ends f the muscle withut tensin Unless repaired under general anaesthesia, a midwife shuld remain with the wman during the repair t prvide emtinal supprt 2 A cnsultant/senir level trainee experienced in third/furth degree tear repair shuld be present. 1 Repair shuld nt be attempted by JMS withut apprpriate supervisin 2 A single dse f a brad spectrum prphylactic antibitic shuld be administered at the time f repair A repeat examinatin shuld be perfrmed in theatre t adequately grade the tear A trn anal epithelium is repaired using interrupted 2-0 Vicryl (plyglactin) sutures with the knts tied in the anal lumen Trn ends f the external anal sphincter shuld be fully mbilized and repaired using an verlap technique. If the sphincter is nly partially trn (<50%) then repair using an end-t-end technique with interrupted mattress sutures is acceptable. 2-0 PDSII (Plydixanne) is the preferred suture material. Avid using figure-f-eight sutures unless fr haemstasis, as end-t-end technique may be mre vulnerable t ischaemia due t retractin f appsed sphincter muscles 1 The internal anal sphincter shuld be identified and if trn, shuld be repaired separately with interrupted 2-0 PDSII (Plydixanne) sutures using end-t-end r verlap technique If the rectal mucsa is disrupted then this shuld be repaired using 2-0 Vicryl (plyglactin) sutures fr interrupted sutures, r 2-0 PDSII (Plydixanne) if submucsal cntinuus sutures are used Uncntrlled dcument when printed Publicatin date (08/05/2013) Page 2 f 5

3 The perineal muscles and subcutaneus tissue shuld be repaired with 2-0 Vicryl (plyglactin). The perineal muscles must be recnstructed with care in rder t prvide supprt t the sphincter repair. A shrt, deficient perineum will increase the risk f further damage in a subsequent vaginal birth. Ensure that the knts are cmpletely buried t avid suture migratin 2 The perineal skin is apprximated with a subcuticular r interrupted plyglactin suture Perfrm a rectal examinatin at the end t ensure the repair is intact. 4.6 Pst-perative/pstnatal management Prir t discharge frm hspital the wman shuld be: fully infrmed abut the nature f her injury and benefits t her f fllw-up prvided with written cnsumer infrmatin seen by a physitherapist t recmmend an individualised prgram fr cmmencing a pelvic flr muscle rehabilitatin prgram as sn as cmfrtable, usually at abut 3 days pst birth/delivery seen by a dietician and cmmenced n a lw residue diet fr 7-10 days with a stl sftening laxative. The purpse f this is t have a delayed, then sft and easy t pass stl referred t CNC Urgynaeclgy t ensure fllw up in the Wmen's Perineal Clinic 3 mnths pst birth/delivery. 4.7 Medicine/analgesia measures include: Ice therapy, t decrease swelling fr the first hurs. Apply an ice pack in a sanitary pad t the perineum fr 20 minutes every 3-4 hurs Adequate analgesia such as nn-steridal anti-inflammatry analgesia, plus ral paracetaml. Avid cdeine cntaining analgesics as they may cause cnstipatin Avid rectal analgesia Laxatives r stl sfteners (e.g. lactulse +/- fybgel) are advisable fr 7-10 days t avid cnstipatin and reduce the incidence f wund dehiscence Adequate fluid intake (1.5-2L per day) especially if taking lactulse. 4.8 Subsequent management Cmmence pelvic flr muscle exercise regime in apprximately 4-6 weeks. This will ensure the ability t recruit pelvic flr muscles fr lng term pelvic flr rehabilitatin At 12 weeks all wmen shuld be assessed with regard t sphincter integrity by endanal ultrasund (Perineal Clinic Wednesday Urgynaeclgy). Digital examinatin has nly a 43% sensitivity rate fr the identificatin f external anal sphincter defects cmpared with ultrasund. Sme wmen may need nging treatment All wmen shuld be reviewed as fllws: 6 weeks pst birth Perineal Clinic Dctr and 12 weeks pst birth Perineal Clinic 26 weeks pst birth. 4.9 Planning the next birth All wmen wh sustained an bstetric anal sphincter injury in a previus pregnancy shuld be cunselled at the bking visit regarding the mde f birth and this shuld be clearly dcumented in the ntes. All wmen wh sustained a third/furth degree tear in a previus pregnancy shuld be cunselled abut the risk f develping anal incntinence r wrsening symptms with subsequent vaginal birth/delivery 1. They shuld be als be advised that there is n evidence t supprt the rle f prphylactic episitmy in subsequent pregnancies. 1 Uncntrlled dcument when printed Publicatin date (08/05/2013) Page 3 f 5

4 4.10 The rle f learners (accucheurs) and wmen with previus sphincter injury All wmen wh sustained a third/furth degree tear in a previus pregnancy wh are eligible fr a vaginal birth, shuld be cared fr and supprted during birth by an experienced midwife. It is especially imprtant that the accucheur prvides apprpriate cntrl f the emerging fetal head. It is inapprpriate fr the accucheur t be a student, a graduate midwife r a junir medical fficer, even under supervisin. 5. Evaluatin, mnitring and reprting f cmpliance t this guideline Cmpliance t this guideline r prcedure will be mnitred, evaluated and reprted thrugh clinical incident reprting. 6. References 1. Ryal Cllege f Obstetricians and Gynaeclgists (RCOG). Green-tp Guideline N. 29: The management f third- and furth-degree perineal tears pp Sultan AH (2005) Management f 3rd & 4th degree tears: Labur Ward Guidelines. Mayday Urgynaeclgy and Pelvic Flr Recnstructin Unit, Mayday University Hspital, UK Legislatin/Regulatins related t this guideline Nt applicable. 8. Appendices Appendix 1: Third and Furth Degree Tears: Risk Assessment Tl Refer t the Wmen's cnsumer fact sheet: Anal sphincter tears in childbirth. PGP Disclaimer Statement The Ryal Wmen's Hspital Clinical Guidelines present statements f 'Best Practice' based n thrugh evaluatin f evidence and are intended fr health prfessinals nly. Fr practitiners utside the Wmen s this material is made available in gd faith as a resurce fr use by health prfessinals t draw n in develping their wn prtcls, guided by published medical evidence. In ding s, practitiners shuld themselves be familiar with the literature and make their wn interpretatins f it. Whilst appreciable care has been taken in the preparatin f clinical guidelines which appear n this web page, the Ryal Wmen's Hspital prvides these as a service nly and des nt warrant the accuracy f these guidelines. Any representatin implied r expressed cncerning the efficacy, apprpriateness r suitability f any treatment r prduct is expressly negated In view f the pssibility f human errr and / r advances in medical knwledge, the Ryal Wmen's Hspital cannt and des nt warrant that the infrmatin cntained in the guidelines is in every respect accurate r cmplete. Accrdingly, the Ryal Wmen's Hspital will nt be held respnsible r liable fr any errrs r missins that may be fund in any f the infrmatin at this site. Yu are encuraged t cnsult ther surces in rder t cnfirm the infrmatin cntained in any f the guidelines and, in the event that medical treatment is required, t take prfessinal, expert advice frm a legally qualified and apprpriately experienced medical practitiner. NOTE: Care shuld be taken when printing any clinical guideline frm this site. Updates t these guidelines will take place as necessary. It is therefre advised that regular visits t this site will be needed t access the mst current versin f these guidelines. Uncntrlled dcument when printed Publicatin date (08/05/2013) Page 4 f 5

5 THE ROYAL WOMEN'S HOSPITAL Third/Furth Degree Tear: (Affix Label Here) Risk Assessment Tl Instructins: Please cmplete this frm fr all wmen prir t birth, except thse having an elective caesarean. Place cmpleted frm in bx prvided. D nt file in wman s medical recrd. Criteria fr scring: Yes N 1 pint fr yes answers, 0 pints fr n answers Nulliparus/primiparus /first vaginal birth (includes VBAC) Asian r Indian (r sub-cntinent) backgrund FGM Baby large in relatin t maternal size Previus histry f perineal trauma requiring repair r third/furth degree tear Sub-ttal Precipitate r faster than expected secnd stage Prlnged active secnd stage (> 1.5 hurs) Instrumental birth Ttal scre: Management f secnd stage: A ttal scre >4 means the wman has an increased risk fr third/furth degree tear. The fllwing clinical practices knwn t decrease the risk are recmmended. Yes N N/A Encurage pen-glttis pushing technique (nt Valsalva maneuvre) Encurage a nn-supine psitin fr active secnd stage and birth Discurage the use f lithtmy psitin r ft plates If epidural in situ, encurage lateral psitin ver semi-recumbent If episitmy required, ensure crrect length and angle is bserved If birth is unassisted: If previus third degree tear, accucheur is t be an experienced midwife Hands n, cntrlled, slw birth f the head Birth the head between cntractins Birth the psterir shulder first r if unable t d s, lift the psterir shulder as sn as anterir shulder brn t avid tensin n the perineum In what psitin did the birth ccur? If instrumental birth: If wman Asian r Indian, accucheur shuld be Level 2+ and credentialed in frceps birth Lithtmy psitin nly nce decisin has been made If episitmy required, ensure crrect length and angle is bserved Cntrlled, slw birth f the head Lift the psterir shulder as sn as anterir shulder brn t avid tensin n the perineum After the birth: Thrughly inspect the genital tract fr trauma as per CPG Any genital tract trauma must be repaired by a suitably credentialed clinician r a trainee under supervisin by same Third / furth degree tears must be repaired under apprpriate analgesia, preferably in the OTS. Third / furth degree tears must be repaired by an apprpriately trained, credentialed medical practitiner r a trainee supervised by same. A cnsultant shuld be present at the repair f all furth degree tears Frm cmpleted by: Signature Print name Published: 21 May 2010 Data entered Uncntrlled dcument when printed Publicatin date (18/10/2013) Page 5 f 5