This document discusses perineal issues related to childbirth. It notes that 65% of women experience some degree of perineal trauma during delivery, which can cause pain, infection, wound breakdown, and dyspareunia. Tears are classified from first degree (skin tear) to third degree (involving the anal sphincter). Reasons for more severe third and fourth degree tears include large baby size, forceps delivery, and prolonged second stage of labor. Episiotomies are sometimes performed to expedite delivery or prevent severe trauma, but midline incisions can increase the risk of anal sphincter damage. Perineal massage during pregnancy may slightly increase the chances of an intact perineum

1. Perineal Issues
Compromised Health

2. 65% women sustain a degree of
perineal trauma during childbirth
• Pain: 42 % at 10 days; 10% at
18 months
• Infection
• Wound Breakdown
• Dysparunia: Pain on sexual
intercourse 58% at 3 months
• Changed anatomy
• 3rd degree: bowel incontinence

3. 1st Degree Tear
• Skin tear from fourchette.
• Suturing depends on:
• 1. Degree of bleeding

4. 2nd Degree Tear
• Skin from Fourchette down
• Perineal muscle
• Usually Vaginal Muscle
• Sutured

5. 3rd Degree tear
• Skin from Fourchette down
• Perineal Muscle
• Vaginal Muscle
• Anal Muscle
• Anal Shyncter
• Sutured

6. Reasons for 3rd/4TH Degree Tears
• Large Baby: over 4kgs
• Midline Incision
• Forceps Delivery
• Prolonged duration of 2nd stage
• Direct OP Position at delivery

7. Episiotomy: Surgical incision
• Expediate delivery – fetal
distress
• Reduce maternal pushing
• Prevent severe trauma from
instrumental delivery
• Shoulder dystocia
• After coming head – breech
delivery
• Rigid perineum
• PPH
• Midline: risk of anal sphincter
damage
• Reduction in pelvic floor
muscle function
• Increases vertical risk of HIV
Transmission
• Indications
• Risks

8. Episiotomy

9. Infiltration
• Guard with middle &
index fingers
• Insert needle fully into
Perineal Tissue at
fourchette and direct it
midway between anus
and ischial tuberosity.
• Inject 10mls of 1%
lignocaine on slow
withdrawal

10. Repair
• Vicryl Rapide: breaking
tension lost by 10-14 days &
absorbed by 42 days
(Gemynthe, 1996)
• One suture continous method
– Flemings Method (1990)
• Can leave skin unsutured
(Gordon, 1999)
• Aseptic technique (tap water
Calkin, 1996)
• Lithotomy position optional –
hips/dignity/ previous sexual
abuse
• Pain relief: Epidural top-up;
entonox; local

11. Postnatal Care
• Hygiene
• Pain Relief
• Pelvic Floor Exercises
• Diet & Rest
• Fluids & Avoidance of Constipation
• Healing Process
• Dyspareunia/Incontinence

12. Key Points
• A restricted episiotomy policy reduces rates of
posterior perineal trauma
• Use of vicryl rapide is associated with less
perineal pain
• Loose, continuous , non-locking suturing
associated with significant reduction in perineal
pain
• Must recognise anal sphincter involvement
• Pelvic Floor exercise during & after childbirth
help to reduce morbidity

13. Perineal Massage to reduce perineal
trauma
• NCT (1995): RCT 2334 women – 22% practiced
perinal massage & 10% increase in intact perineum
in primigravida
• Shipman (1997): RCT 861 women – 6.1 % reduction
in perineal tears; women over 30 yrs most benefit
with a 12.1% reduction in tears
• Labreque (1999): RCT 1,500 women – 7% increase
in intact perineum
• Labreque (2002): No difference in perineal function
at 3 months (pain;dyspareunia; continence)

14. Gomme, Sheridan & Bewley:
BJM, “Antenatal Perineal Massage”:
Part 1 (Dec 2003) & Part 2 ( Jan 2004).
• Women given bottle of
Almond oil (alternative for nut
allergies)
• Information leaflet – massage
for 5 minutes per day x four
times a week from 34 weeks
gestation
• Midwives trained
• Excluded: Planned C/S; Poor
English; Female Genital
Mutilation
• Increase in intact perineum
rate by 6%
• Women who decided not to
massage: 50% not interested;
other reasons cited as long
fingernails/extensions; lack of
privacy for in-patients;
haemhorroids; vaginal/urinary
infections; abdoman too large;
massage uncomfortable
• - no evidence to link refined
almond oil with child
sensitivity to nuts – this
deterred some women

15. HOOP Study: “Hands on/Hands poised”
• 5,500 women (1994-1996)
England
• Outcome measured was
perineal pain
• Reduction in mild perineal
pain at 10 days in “hands on”
group
• Episiotomy rate lower in
“hands poised” group
• No differences in pain at 3
months
• Concluded that: no evidence to
support either method
• Discuss:
Hands on
Vs
Hands Poised