Editing Perineal tears

== Incidence ==

* 70% of vaginal childbirth leads to some form of vaginal or perineal injury

== Classification ==

* First-degree: injury to skin and subcutaneous tissue of the perineum and vaginal epithelium only
* Second-degree: laceration extends into fascia and musculature of perineal body, including the deep and superficial transverse perineal muscles and fibres of pubococcygeus and bulbocavernosus. Anal sphincter remains intact.
* Third-degree: laceration involves some or all of the fibres of the anal sphincter complex
** 3a: <50% external sphincter
** 3b: >50% external
** 3c: both external and internal
* Fourth-degree: injury to the perineum involving both anal sphincter complexes and anal mucosa

== Repair: ==

* Choice of suture
** Synthetic absorbable such as Vicryl or Vicryl Rapide (previously catgut)
* Indications:
** We would be involved with third and fourth degree tears
* Goals:
** Restore continuity of both external and internal anal sphincters
*** Create a muscular cylinder >2cm thick and >3cm long
*** Meticulous haemostasis and anatomical re-approximation of all structures
** Create a thick perineal body and rectovaginal septum
** Lengthen the anal canal and restore a functional high-pressure zone within it
* Repair
** Anal mucosa
*** Repair torn anal mucosa with continuous 3/0 Vicryl
** Sphincter repair
*** Internal sphincter - usually retracts laterally and superiorly - seen as a thickened, pale pink, shiny tissue just above the anal mucosa. Repair continuously.
*** EAS - often retracts laterally. Plicate the severed ends with two or three interrupted figure-of-eight sutures.
** Rebuild the distal rectovaginal septum and perineal body
*** Interrupted 2/0 Vicryl
** Repair vagina
*** Reapproximate vaginal epithelium, including the apex of any episiotomy
**** Match landmarks - hymenal ring, vermillion border
**** Loose, continuous, non-locking suture
*** Reapproximate perineal body and bulbocavernosus muscle (use same suture as above, continuing on - 'transitional suture'
**** Need to realign the muscles to allow skin closure with minimal tension


(A) Fourth-degree laceration.

(B) The torn anal mucosa is repaired using a running stitch, but interrupted stitches are also acceptable.

(C) The internal anal sphincter should be properly identified and repaired as a separate layer.

(D) The external sphincter is then identified and repaired. The repair consists of either end-to-end or overlapping plication of the disrupted external anal sphincter and capsule using interrupted or figure-of-eight sutures.

[[Category:O+G]]