PERINEAL

TRAUMA &
EPSIOTOMY
Pembimbing : dr. Arief Budiono, Sp.OG
 PERINEAL TRAUMA R/T
CHILD BIRTH
- Lacerations:
-Most acute injuries or laceration of the
perineum, vagina, uterus and their
supportive tissues occur during child birth.
- Laceration if not repair lead to
genitourinary and sexual problem (pelvic
relaxation, uterine prolapse, cystocele,
rectocele, dyspareunia, urinary and anaL
bowel dysfunction).
 CONT.
- Immediate repair:

* Promotes healing
* Limits residual damage
* Decreases the possibility of infection
 CONT.

- Primary health care provider

continue to inspect the perineum
carefully and evaluate lochia to
identify any missed damage during
the early postpartum period.
 PERINEAL LACERATIONS
Degree of laceration:
1. First degree: laceration extends through the
skin and structures superficial to muscle.

2. Second degree: Laceration extends through

muscles of the perineal body
 CONT.
3. Third degree: Laceration continues through the
anal sphincter muscle.

4. Fourth degree: Laceration involves the anterior

rectal wall.
 CONT.
- Special attention must be paid to third and fourth
stage laceration so that woman retains fecal
continence.

- Measures are taken to promote soft stools (e.g.

roughage, fluid, activity, and stool softeners) to
increase comfort and healing.
 CONT.

- Antimicrobial therapy may be used

- Enemas and suppositories are

contraindication
 VAGINAL & URETHRAL
LACERATION
- Vaginal laceration occur in
conjunction with perineal laceration

- Vaginal laceration tend to extend

up the lateral walls and if deep enough
involve the levator ani muscle.
 CONT.
- Vaginal vault laceration may be
circular and result from forceps
rotation especially in the
cephalopelvic disproportion, rapid
fetal decent.
 CERVICAL INJURIES
- Occur when the cervix retracts over the advancing
fetal head.

- This laceration occur at the angles of the external os,

most are shallow, bleeding is minimal.
 CONT.
- Cervical injuries when extend to vaginal vault or
beyond it into the lower uterine segment serious
bleeding may occur.

- Cervix laceration can have adverse effect on future

pregnancies and child birth.
 EVIDENCE
-The highest rate of trauma have consistently
been observed in first births or operative
vaginal deliveries (forceps or vacuum
extraction).
-Rate of trauma appear to increase with
infant birth weight, maternal weight gain
in pregnancy, and fetal malposition.
- Use of episiotomy increases serious trauma
to genital tract, especially third and
fourth degree laceration.
Leah L .Reduction Genital Tract Trauma at Birth. 2003.
 EPISIOTOMY

- Is an incision in the perineum to

enlarge the vaginal outlet.
 TIMING OF EPISIOTOMY

• If performed unnecessarily early, bleeding from the

episiotomy may be considerable during the interim
between incision and delivery.
• If it is performed too late, lacerations will not be
prevented. It is common practice to perform
episiotomy when the head is visible during a
contraction to a diameter of 3 to 4 cm.
• When used in conjunction with forceps delivery, most
practitioners perform an episiotomy after application
of the blades.
 EPISIOTOMY
- Indication:
1. Facilitates vacuum or forceps assisted birth
2. Fetal distress
3. Facilitates the birth of large baby
4. Premature baby
 TYPE OF EPISIOTOMY
1. Median: -Is most commonly used
- It is effective
-Easily repaired
-Least painful

- Midline episiotomy are associated with a

higher incidence of third and fourth degree
of laceration.
 TYPE OF EPISIOTOMY
2. Mediolateral: Is used in operative births when need
for posterior extension.
- Fourth degree laceration may be prevented, third
degree may occur.
- Blood loss is greater, painful, difficult repair than
midline.
 RISK FACTOR
ASSOCIATED WITH
PERINEAL TRAUMA
1.Nulliparity
2. Maternal position
3. Pelvic inadequacy
3. Fetal malpresentation and position 4. Large baby
5. Use of instruments to facilitate birth
 CONT.

6. Prolong second stage of labor

7. Fetal distress
8. Rapid labor
 EVIDENCE
- Episiotomy should not be used unless indicated .
Measures should be taken to avoid perineal trauma
during labor to establish bonding early between
mother and infant & to minimize perineal discomfort
after birth.
Karacam Z. Effects of episiotomy on bonding and mothers health.
2003
 TIMING OF THE
EPISIOTOMY REPAIR
• The most common practice is to defer episiotomy
repair until the placenta has been delivered.
• This policy permits undivided attention to the signs of
placental separation and delivery.
• A further advantage is that episiotomy repair is not
interrupted or disrupted by the obvious necessity of
delivering the placenta, especially if manual removal
must be performed.
 TECHNIQUE

• There are many ways to close an episiotomy incision,

but hemostasis and anatomical restoration without
excessive suturing are essential for success with any
method.
• A technique that commonly is employed . The suture
material ordinarily used is 3-0 chromic catgut, but
Grant (1989) recommends suture composed of
derivatives of polyglycolic acid. rates of suture
removal within 3 months of delivery (3 percent
removal versus 13 percent removal for rapidly
absorbed versus standard polyglactin).
• Sanders and co-workers (2002) emphasized that
women without regional analgesia can experience
high levels of pain during perineal suturing.
• A decrease in postsurgical pain is cited as the major
advantage of the newer materials, despite the
occasional later need to remove some of the suture
from the site of repair because of pain or dyspareunia.
 PERINEAL
MANAGEMENT
- Warm compress
- Massage
- Kegel’s exercises in the prenatal and postpartum
periods
- Good nutrition, hygienic measures
- As advocates, encourage women to use alternative
birthing positions and use spontaneous bearing
down effort.
Thank you
 CONT.
- After the birth of the fetus, strong uterine
contraction cause the placental site to shrink.
This causes the anchor villi to break and the
placenta to separate from its attachment,
normally strong contraction that occur 5 to 7
minutes after the baby’s birth cause the
placenta to be separated away from the basal
plate.
- - Placenta can’t detach it self from a flaccid
uterus because the placental site is not
reduced.
-
 PLACENTA SEPARATION
Is indicated by the following signs:
1.A firmly contracted fundus
2.A change in the uterus from a discoid to a
globular ovoid shape
3.Sudden gush of dark blood
4.apparent lengthening of the umbilical cord
5.Vaginal fullness
 ACTIVE APPROACH MAY
BE USED TO MANAGE
OF 3RD
1- Expectant management involves natural,
spontaneous separation and expulsion of the
placenta by effort of the mother with clamping
and cutting of the cord after pulsation ceases
 CONT.
2. Use of the gravity or nipple stimulation to
facilitate separation and expulsion.
3. A quiet, relaxed environment
4. Close skin to skin contact between mother and
baby
5.Adminstration oxytocic medication after birth of
the anterior shoulder.
 COLLABORATIVE CARE
1. Placenta Examination and Disposal
2. Maternal physical status
3. Sign of potential problems
4. Care after placenta delivery
5. Care of the family during 3rd stage
6. Family –Newborn relationship
 NURSING DIAGNOSIS
DURING 3RD STAGE
- Risk for infection
- Anxiety
- Compromised family coping
 CARE AFTER THE
PLACENTA DELIVERY
- Vulvar area cleansed with warm water or normal
saline.
- Perineal pad or ice pack is applied to perineum.
- Birthing bed is repositioned.
- Draped are removed
- Dry linen is placed under the woman’s
buttocks.
 CONT.
- Woman is provided with a clean gown and
blanket which is warmed.
- Transferred from birthing area to recovery area.
- Side rails are raised during transfer.
- Woman may be given the baby to hold during
transfer or father may carry the baby or transport
him in a crib.
 CONT.
- Maternal and neonatal assessments for the fourth
stage of labor are instituted.
- When fourth stage recovery is complete the
woman may be transferred by wheelchair to a
room on the postpartum unit
 CARE OF THE FAMILY
DURING 3RD STAGE
- Most parents hold and examine the baby immediately
after birth.
- Skin to skin contact helps the mother maintain the
baby’s body heat.
- Care must be taken to keep the head warm.
- Begin breastfeeding.
 CONT.
- Nurse assess the newborn’s physical
condition , weight is measured, given eye prophylaxis,
vitamin k injection, and identification bracelet.