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
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. 1 4.4 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. 1 4.5 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
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 48-72 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: Physitherapist @ 6 weeks pst birth Perineal Clinic Dctr and physitherapist @ 12 weeks pst birth Perineal Clinic Dctr @ 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
4.10 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. 2007. pp.1-11. http://www.rcg.rg.uk/wmens-health/clinical-guidance/management-third-and-furth-degree-perinealtears-green-tp-29 2. Sultan AH (2005) Management f 3rd & 4th degree tears: Labur Ward Guidelines. Mayday Urgynaeclgy and Pelvic Flr Recnstructin Unit, Mayday University Hspital, UK. 2009. 7. 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
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