1. PERINEAL INJURY AND EPISIOTOMY

2. OUTLINE OF PRESENTATION
• ANATOMY OF PERINEUM
• FIRST AND SECOND DEGREE TEAR – REPAIR
• THIRD AND FOURTH DEGREE TEAR - REPAIR

3. PERINEUM
• Diamond shaped area between the thigh
• Perineal body:
– mass of interlocking muscular, fascial, and fibrous
components lying between the vagina and anorectum
– attachment point for components of the urinary and fecal
continence mechanisms, which are commonly damaged
during vaginal childbirth
• Anterior and posterior triangle

4. Anterior triangle: superficial compartment

5. • bounded deeply by the perineal membrane and
superficially by Colles fascia
• closed compartment  infection or bleeding within it
remains contained
• Contains muscles that are cut during episiotomy:
– Bulbospongiosus
– Transverse perineal

7. Anterior triangle: deep compartment

8. Posterior triangle
• Contents:
– Ischiorectal fossa
– Anal canal
– Sphincter complex

9. ANORECTUM

11. External anal sphincter

12. Internal anal sphincter

13. CLASSIFICATION OF PERINEAL INJURY

14. RCOG GREEN TOP GUIDELINE
• Risk factors (for 3rd degree tear):
1.
2.
3.
4.
5.
6.
7.
8.
9.
BW > 4.0 kg
Persistent OP position
Nulliparity
IOL
Epidural analgesia
Prolonged second stage ( > 1 hour)
Shoulder dystocia
Midline episiotomy
Forceps delivery

15. • Prognosis:
– Good prognosis following EAS repair
– 60 - 80% asymptomatic at 12 months
– Those with symptoms: flatus incontinence or faecal urgency
– Endoanal ultrasound as part of follow-up  persistent defects
in 54–88% of women after primary repair of recognised thirddegree tears

16. • Future deliveries (for those who sustained obstetrics
anal sphincter injury):
– should be counselled about the risk of developing anal
incontinence or worsening symptoms with subsequent vaginal
delivery
– no evidence to support the role of prophylactic episiotomy in
subsequent pregnancies
– Those who are symptomatic or have abnormal endoanal
ultrasonography and/or manometry should have the option of
elective caesarean birth