Genital tract trauma and repair

March 2016
Learning outcomes

• To review the principles of perineal repair

• To practice perineal repair

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Definition of Tear

It is essential to be able to recognise degree of

tear to ensure appropriate repair

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General Principles of Repair

• Informed consent
• Use universal precautions
• Aseptic techniques and sterile equipment
• Use needle holder and dissecting forceps
• Local anaesthesia with 0.5% Lignocaine
• Ensure good exposure and good lighting
• Start suturing above the apex of the tear

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 General Principles of Repair

• Minimal use of suture materials

• Reduce number of knots
• Recommended continuous non-locking suture
• Ensure haemostasis - close dead space
• Ensure alignment of the hymenal remnant and fourchette
• Rectal examination to ensure no damage to the internal or
external anal sphincters or perineal muscle
• Change gloves afterwards

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1st and 2nd degree perineal laceration

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Repair of perineal lacerations

Note the vaginal tampon

that protects the field from
local exudate is only used
if necessary and must be
accounted for after

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Repair

• Suture the vaginal

laceration from above
downwards

• It is important to repair
the hymenal ring

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Repair

• Repair vaginal skin from

just above the apex
• Use continuous suture
• Knot under the skin

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Repair

Repair of Muscle Layer Repair of Skin Layer

• Continuous • Sub cuticular

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Repair

Repair of perineal
skin – preferably
subcutaneous
Knot into vaginal or
Aberdeen knot

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 Third Degree Tear

• Should be done within 24 hours of event

• Theatre, anaesthesia and by most senior surgeon

• Ideal suture material:

• Anal epithelium: Vicryl 3-0, round bodied needle
• External sphincter: PDS 3-0, round bodied needle
• Perineal muscle and skin: Vicryl rapide taper cut needle

If suture type of choice not available use any absorbable

suture of appropriate size

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Third degree perineal tear

Complete laceration
of the perineum
involving rupture of
the anal sphincter

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Fourth degree perineal tear

Complete laceration of
the perineum (rupture of
the anal sphincter and
rectal mucosa)

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Suturing- Good Practice
• Examine carefully and administer pain relief
• Using one continuous suture (PGA or Vicryl)
• Suture vagina
• Suture muscle layer
• Suture perineal skin

• Re-examine
• Index finger in vagina
• Middle finger in rectum
• Exclude sutures in rectum

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Post procedure
• Remove any vaginal packs
• Clean perineum
• Explain procedure to woman
• Analgesics
• Antibiotics & laxatives for 3rd & 4th degree tears
• Encourage good perineal hygiene / good hydration
• Physio
• Follow up (3rd & 4th degree tears)
• Write up notes
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?

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Recap

• Recognition of degree of perineal tear

• Principles of management

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