CHHS15/059

Canberra Hospital and Health Services

Clinical Procedure
Perineal Care- Maternity
Contents

Contents......................................................................................................................................1
Purpose.......................................................................................................................................2
Alerts...........................................................................................................................................2
Scope...........................................................................................................................................2
Background.................................................................................................................................2
Section 1 – Warm Compresses for use on the perineum...........................................................3
Section 2 – Episiotomy................................................................................................................4
Section 3 – First and second degree genital tract repair............................................................5
Section 4 – Third and fourth degree genital tract repair............................................................6
Section 5 – Postpartum management of genital tract trauma...................................................8
Implementation..........................................................................................................................9
Related Policies, Procedures, Guidelines and Legislation..........................................................9
References..................................................................................................................................9
Definition of Terms...................................................................................................................10
Search Terms.............................................................................................................................11

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Purpose

Using best practice to optimise perineal outcomes following vaginal birth, women
who are labouring are offered warm compresses to the perineum to increase
comfort, reduce pain and genital tract trauma.

To ensure that episiotomies and genital tract repairs are done by appropriately skilled
midwives or doctors in appropriate situations as defined by evidence, and that all
women with genital tract trauma have appropriate postnatal perineal care,
management and follow up.
Scope

Alerts

 Midline episiotomies are not recommended unless absolutely necessary and are to be
done by experienced midwives or doctors only. A midline episiotomy increases the
chances of the cut extending through to the anus and causing a 3rd or 4th degree tear.
Scope

 Doctors and Medical Students under the direct supervision of a skilled medical
officer
 Midwives and student midwives (who have undertaken the accredited
competency through the Maternity Unit, Woman and Babies, CHWC or under
the direct supervision of an accredited midwife or doctor,).
Background

Perineal injury is the most common maternal morbidity associated with vaginal birth. Anal
sphincter injury is a major complication that can significantly affect women’s quality of life.
Although risk factors have been identified it is difficult to predict the occurrence of severe perineal
trauma.

Risk factors for anal sphincter injury

Knowledge of anal sphincter injury risk factors is not generally useful in the prevention or
prediction of anal sphincter injury. Risk factors for third and fourth degree tears include:
 birth weight over 4 kg
 persistent occipitoposterior position
 nulliparity
 induction of labour
 epidural analgesia
 second stage longer than 1 hour
 shoulder dystocia
 midline episiotomy
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 forceps delivery

Intrapartum interventions to reduce perineal trauma

 Either the 'hands on' (guarding the perineum and flexing the baby's head) or
the 'hands poised' (with hands off the perineum and baby's head but in
readiness) technique can be used to facilitate spontaneous birth
 Warm Compresses to the perineum should be applied
 Women should be encouraged to adopt upright positions which she finds comfortable
 Women should be encouraged with physiological pushing rather than directed pushing in
the second stage of labour
 Do not perform perineal massage in the second stage of labour
 Do not carry out a routine episiotomy during spontaneous vaginal birth

Section 1 – Warm Compresses for use on the perineum

Warm compresses to the perineum during the second stage of labour have been identified
in studies to increase comfort, reduce pain to the perineum and to reduce third and fourth
degree tears.

Physiology literature supports the potential beneficial effects of warm packs in dilating blood
vessels, increasing bloods flow, influencing transmission of pain by reducing the level of
nociceptive stimulation, and increasing collagen extensibility (Dahlen et al, 2007)

Procedure
 Obtain consent from the woman for use of warm compresses to her perineum and
document in her clinical record
 Ensure the woman is able to discriminate between cold by applying a cool pack or ice
first, if ok you can proceed with warm compresses
 Fill a sterile bowl with warm water, to ensure that it is a safe temperature add 300mls of
boiling water to 300mls of cold tap water. Replacing the whole bowl of water every 15
mins. Do not “top up” or add hot water as this increases the risk of burning
 Soak a perineal pad in the warm water; wring out the water before placing the warm
compress to the perineum. The pad is resoaked to maintain warmth between
contractions
 Apply lightly without pressure and check skin after each application
 Do not use when skin has reduced thermal sensitivity (e.g. epidural)
 Discontinue or modify practice as directed by the woman
 Be aware that this may be a suitable pain relief option for some women who prefer to
use non-pharmacological pain relief

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Section 2 – Episiotomy
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An episiotomy is a surgical enlargement of the vaginal orifice by an incision of the perineum

during the last part of the second stage of labour or delivery, routine episiotomy does not
protect the perineum from severe injury.

It is used to facilitate birth

 if there is a non-reassuring Cardiotocograph (CTG) or
 if there are non-reassuring fetal heart sounds birth if the
 if birth of the fetal head is being prevented by a tight perineum
 to aid a difficult delivery
 with instrumental deliveries where necessary

Equipment
1. Curved mayo scissors
2. 1% lignocaine
3. 20ml syringe and 23g needle

Process
 Discuss with the woman why you are recommending an episiotomy is needed, explain
procedure and gain verbal, informed consent. Document in clinical notes
 Utilise local anaesthetic if the perineum is not already anaesthetised (e.g.:
epidural/spinal anaesthesia)
 Elevate the perineum from the presenting part by inserting 2 fingers (usually of the left
hand) into the woman's vagina. Using curved mayo scissors, placed at a 45 0 angle from
the midline of fourchette, make a single incision to form a medio-lateral episiotomy.

Note: control the presenting part as the episiotomy is done to prevent a precipitous birth.
Midline episiotomies are not recommended unless absolutely necessary and are performed
by experienced midwives or doctors only

Female genital mutilation

If a women is identified as having Female genital mutilation (FGM) refer to an obstetrician in
the antenatal period for assessment and discussion on management. Refer to the Female
genital mutilation guideline on sharepoint for further information.
http://inhealth/PPR/Pages/PPRSearchResults.aspx?k=fgm

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Section 3 – First and second degree genital tract repair

Women who sustain a first and second degree genital tract tear may require genital tract
repair. Women who sustain a second degree tear will always require a repair.

 First degree : Injury to perineal skin, includes the fourchette, the hymen, labia and
vaginal epithelium
 Second degree : Injury to perineum involving perineal muscles but not involving the anal
sphincter

Equipment

 2/0 Vicryl round bodied needle

 2/0 or 3/0 Vicryl Rapide (absorbable suture material) cutting needle
 light source
 sterile drapes
 dressing pack
 sterile gloves
 Local anaesthetic (if regional block is not in place)
 Syringe and needle for local infiltration

Procedure
 Staff performing the repair must be accredited through the competency through the
Maternity Unit, Woman and Babies, CHWC (Junior medical staff and midwives who are
not accredited to perform repairs will be supervised by a senior colleague)
 Ascertain the degree of injury and the need for repair – including significant anatomical
disruption, poor tissue alignment and/or bleeding. Some first degree tears, labial
lacerations or vaginal wall tears may not require suturing
 Obtain consent from the woman Document ij clinical record
 Position the woman comfortably with optimal light and exposure for the practitioner
completing the repair
 Document the time if the woman is placed in lithotomy with leg supports being careful
to note that prolonged placement can have an effect on the sacral spine
 Perform surgical scrub and glove
 Slowly administer local anaesthetic by slow, local infiltration avoiding inadvertent blood
vessel injection. This will not be necessary if a working epidural or pudendal nerve block
is in place
 Consider IDC if excessive periuretheral trauma or swelling

Repair the tear or episiotomy: A variety of different surgical techniques may be used
depending on the skill and experience of the staff member. The evidence suggests that the
following method(s) are the most appropriate:
 Vaginal epithelium - single layer continuous non-locking 2/0 Vicryl round bodied needle
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 Muscles - continuous, non-locking or interrupted (for deeper muscle) 2/0 Vicryl round
bodied needle
 Skin – single layer subcuticular 2/0 or 3/0 Vicryl Rapide cutting needle
 Labial lacerations – interrupted 2/0 or 3/0 Vicryl Rapide cutting needle
 On completion of the repair perform a vaginal then rectal examination. Or document
why this was considered unnecessary
 Place clean pad and icepack on perineum
 Complete a surgical count
 Discuss pain relief, ice, hygiene, diet, pelvic floor exercises, bowel and bladder function.
 Prescribe (medical staff) and administer appropriate pain relief and urinary alkalinisers.
Consider rectal analgesics initially at the time of repair, then oral NSAIDs, paracetamol
+/- codeine
 Document details of repair which may include a diagram to illustrate the extent of the
trauma
 Once repaired, offer to show the woman the repair
 Advise woman if she has any concerns about her repair after discharge from hospital to
contact her CMP or Midcall midwife or staff in Birthing if discharged from Midcall.

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Section 4 – Third and fourth degree genital tract repair

Repair should be undertaken by an experienced consultant or registrar experienced in the

recognition, repair and management of third and fourth degree tears. Junior staff may
undertake the repair only if directly supervised by a senior accredited member of staff.

A third degree tear is defined as injury to the perineum involving the anal sphincter complex
and is classified as:
3a: less than 50% of the external anal sphincter (EAS) thickness torn,
3b: more than 50% of the EAS torn,
3c: the internal anal sphincter (IAS) torn.

A fourth degree tear involves the anal sphincter complex (EAS and IAS) and the rectal
mucosa. On occasion there may be interruption to the rectal mucosa without EAS or IAS
involvement and these should be documented as fourth degree tears.

Equipment
 2/0 Vicryl round bodied needle
 2/0 or 3/0 PDS (Polydioxanone, a monofilament synthetic absorbable suture) may be
requested
 light source
 sterile drapes
 dressing pack
 sterile gloves

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Procedure
 Obtain informed consent to examine all women after vaginal birth to assess the degree
of perineal/vaginal/rectal injury and obtain consent to perform the repair.
 Women who have had an extensive perineal laceration should be examined by a
consultant or experienced registrar.
 Classify degree of tear; in conjunction with the Third and Fourth degree clinical Pathway
guideline and this Clinical Procedure, follow and complete Third and Fourth degree tear
Pathway http://inhealth/acthmr/Clinical%20Record%20Forms%20NEW/Third%20and
%20Fourth%20Degree%20Tear%20Clinical%20Pathway.pdf
 Fourth degree tears should always be repaired under general anaesthetic or adequate
regional anaesthesia, preferably in the operating rooms (OR) with a consultant or
registrar who is experienced in third and fourth degree tears present.
 An evidence based method of repair is described as follows: Identify the internal anal
sphincter and include in repair if involved
 Identify the extent of the external anal sphincter involvement and perform the
appropriate repair.
 Repair the remaining part of the tear as per the MPG for 2nd degree tears
 Consideration should be given to repairing the muscle layers with PDS not Vicryl (50% of
tensile strength remains at 5 days and is lost within 10-14 days for Rapide whereas
approx. 75% remains at 2 weeks and approx 50% remains at 3 weeks for Vicryl).
 Complete a surgical count or, if in the Operation room (OR), according to OR protocol.
 Document on the third and fourth degree tear clinical pathway, vacuum/forceps
pathway (or OR notes) details of repair, which may include a diagram to illustrate the
extent of the tear. To avoid repetition, document repair details clearly in one area only
and write ‘refer to ….’ on the various pathways.
 Prescribe and administer appropriate analgesia. Avoid rectal administration of
medications for women with 4th degree tears.
 IV broad-spectrum antibiotics should be administered at the time of repair for third and
fourth degree tears. For fourth degree tears intraoperative and postoperative broad-
spectrum antibiotics should be considered. A single dose of iv antibiotics should be
prescribed for 3rd and 4th degree tears, plus 7 days oral antibiotics following anal
sphincter tears
 External ointment maybe prescribed for haemorrhoids if present. Preference should be
given to topical ointment containing high dosage steroids and analgesia (eg Scheriproct
or similar)
 Regular aperients should be prescribed. These should be bulking agents such as
Normicol and psyllium husks (eg Metamucil) rather than peristaltic agents or stimulants.
 The midwife responsible for the Birth Register entry records in the register, classification
of tear, repaired by whom and location.
 The Accoucheur should complete the Riskman for all third and fourth degree tears, the
CMC of Birthing or the CMP ensures that this has been attended to.
 Advise the use of a stool softener and bulking agent for about ten days after the repair.
 Appointment/s for the Postnatal Follow up clinic are made by Postnatal or CMP
midwife.

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Section 5 – Postpartum management of genital tract trauma

Procedure
 With the woman’s consent, assess through observation of the vulva and perineum daily
or more often if required and document condition. Assess for signs of healing with
particular reference to oedema, haematoma formation, signs of infection and pain.
 Inspection of vaginal trauma is required if signs or symptoms of haematoma present.
 Consultation with RMO is required for haematoma and analgesia more than
paracetamol.
 Ice packs inside a sanitary pad and then applied to the perineum may be beneficial to
reduce swelling and pain during the first 48 hours (change when melted according to
woman’s comfort).
 Discuss the healing process with the woman and daily hygiene including washing, drying
and frequent pad change.
 Respond to specific concerns.
 Provide dietary and fibre supplement information about the prevention of constipation.
 Provide analgesia as required avoiding narcotics.
 Liaise with the Women’s Health physiotherapist to access appropriate assessment,
treatment and follow up for any woman that may require this service
 Ensure woman has been provided with education in regards to pelvic floor exercises.
 Record observations and interventions on the clinical pathway and in the clinical record
as necessary.
 Advise the woman to consult a health professional if concerned about pain or healing
after discharge.

Third and Fourth Degree Trauma:

In addition to the above management:
 Ensure third and fourth degree pathway is initiated
 Ensure correct management of In-dwelling Catheter
 Commence regular fibre and/or aperients as ordered
 Dietician consultation is offered
 Follow up appointments are arranged at the Gynaecology Outpatients Oasis (Postnatal
Perineal) Clinic at six weeks and six months
 Advise the woman to consult a health professional if concerned about pain or healing
after discharge
 Advise the woman to consult a health professional if concerned about incontinence
after discharge

Implementation

This guideline will be:

 discussed at Maternity inservice education

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 discussed at Maternity multidisciplinary education;

 placed on notice boards in tea rooms; and
 distributed to maternity staff via email
 Available on Sharepoint
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Related Policies, Procedures, Guidelines and Legislation

Guidelines
ACT Health; Intimate Care
ACT Health; Heat and Cold Application
ACT Health; Aseptic Non Touch Technique
ACT Health; Wound management
ACT Health; Clinical record documentation
ACT Health; Maternity-Female Genital Mutilation (FGM)
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References

Albers, L.L., Sedler, K. D., Bedrick, E. J., teaf, D. And Peralta, P. (2005) Midwifery care
measures in the second stage of labour and reduction of genital tract trauma at birth: a
randomized trial. Journal of Midwifery and Women’s Health 5, 12, 365-372

Aasheim, V., Nilsen, A.B., Lukasse M. and Reiner L. Perinela techniques during the seconf
stage of labour for reducinh perinela trauma. Cochrane Datebase of Systemataic Reviews.
2011; Issue 3. Art.No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews.
2009 (1).Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000081.pub2/pdf

Dahlen, H.F., Homer, C.S.E., Upton, A.M., Nunn, R. and Brodrick, B. (2007) Perineal outcomes
and maternal comfort related to the application of perineal warm packs in the second stage
of labour: a randomized controlled trial. Birth 34, 4, 282-290

Hastings-Tolsma, M., Vicent, D., Emeis, C. and Francisco T. (2007) Getting through birth in
one piece: protecting the perineum. The American Journal of maternity Care Nursing 32, 3,
158-164

National Institute for Health and Clinical Excellence (2006) NICE Clinical Guideline 37. Routine
Care of Postnatal Women and Their Babies.
http://www.nice.org.uk/guidance/cg37/resources/guidance-postnatal-care-pdf

Royal College of Obstetricians and Gynaecologists, Guideline No. 23 Methods and Materials
Used in Perineal Repair June 2004

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Sanders, J., Peters, T.J. and Campbell, R. 2005 Techniques to reduce perineal pain during
spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice.
Midwifery 21, 154-160

The Cochrane Collaboration , Copyright © 2009, Episiotomy for vaginal birth

(Review) 47. Published by John Wiley & Sons, Ltd.
http://www.mrw.interscience.wilev.com/cochrane/cIsysreviarticles/CD000081/pdf
abstract fshtml

Lai, C.Y., Cheung, H.W., Lao, T.T.H., Lau, T.K & Leung, T.Y. 2009 Is the policy of
restrictive episiotomy generalisable? A prospective observational study. The
Journal of maternal-Fetal and Neonatal Medicine, 22(12), 1116-1121.

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Definition of Terms

Accoucheur: person assisting to birth baby

Anterior perineal injury: Injury to the labia, anterior vagina, urethra or clitoris.

Episiotomy: Episiotomy is the surgical enlargement of the vaginal orifice by an incision of the
perineum during the last part of the second stage of labour or birth.

Female genital mutilation: A cultural or non-therapeutic procedure that involves partial or

total removal of female external genitalia and/or injury to the female genital organs

First degree Injury to the skin only (i.e. involving the fourchette, perineal skin and
vaginal mucous membrane; but not the underlying fascia and muscle sometimes referred to
as a ‘graze’)

Fourchette: The labia minora extend to approach the midline as low ridges of tissue that
fuse to form the fourchette.

Fourth degree Injury to perineum involving the anal sphincter complex (external and
internal anal sphincter) and anal epithelium (i.e. involving anal epithelium
and/or rectal mucosa)

Intact No tissue separation at any site

Nulliparity: a woman who has never given birth

Posterior perineal injury: Injury to the posterior vaginal wall, perineal muscles or anal
sphincter that may include disruption to the anal epithelium

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Second degree Injury to the perineum involving perineal muscles but not involving the anal
Sphincter

Third degree Injury to perineum involving the anal sphincter complex

• 3a: Less than 50% of external anal sphincter thickness torn
• 3b: More than 50% of external anal sphincter thickness torn
• 3c: Both internal and external anal sphincter torn

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Search Terms

Perineum
Perineal tear
Genital tract trauma
1st degree
2nd degree
3rd degree
4th degree
Warm compress
Repair
Postnatal
Labour
Episiotomy

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for
its own use. Use of this document and any reliance on the information contained therein by any third party is at
his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By

Eg: 17 August 2014 Section 1 ED/CHHSPC Chair

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