Perineal Trauma & Epsiotomy

1. Perineal Trauma & Epsiotomy Prepared By: Mr’sRaheegeh AWNI 07/10/2010

2. 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).

3. CONT. • Immediate repair: * Promotes healing * Limits residual damage * Decreases the possibility of infection

4. CONT. - Primary health care provider continue to inspect the perineum carefully and evaluate lochia to identify any missed damage during the early postpartum period.

5. 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

6. CONT. 3. Third degree: Laceration continues through the anal sphincter muscle. 4. Fourth degree: Laceration involves the anterior rectal wall.

7. 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.

8. CONT. - Antimicrobial therapy may be used - Enemas and suppositories are contraindication

9. 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.

10. CONT. - Vaginal vault laceration may be circular and result from forceps rotation especially in the cephalopelvic disproportion, rapid fetal decent.

11. 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.

12. 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.

13. 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.

14. Episiotomy - Is an incision in the perineum to enlarge the vaginal outlet.

15. 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.

16. When used in conjunction with forceps delivery, most practitioners perform an episiotomy after application of the blades.

17. Episiotomy - Indication: 1. Facilitates vacuum or forceps assisted birth 2. Fetal distress 3. Facilitates the birth of large baby 4. Premature baby

18. 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.

19. 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.

20. 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

21. CONT. 6. Prolong second stage of labor 7. Fetal distress 8. Rapid labor

22. 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

23. 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.

24. 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).

25. 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.

26. 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.

27. Thank you

28. 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.

29. 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

32. 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

33. 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.

34. 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

35. Nursing diagnosis during 3rd stage - Risk for infection - Anxiety - Compromised family coping

37. 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.

39. 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.

40. 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

41. 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.

42. CONT. - Nurse assess the newborn’s physical condition , weight is measured, given eye prophylaxis, vitamin k injection, and identification bracelet.