Care of the Perineum During & After Birth

CARE OF THE PERINEUM DURING & AFTER BIRTH

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Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

For Reviewed &/or Updated Policies Only:

VALIDATION FORM

• Standard 1 -Governance and accountability framework
• Standard 2 -Equality, Diversity and Human rights
• Standard 7 -Safe and Clinically effective care
• Standard 8 -Care planning and provision
• Standards 9 – Patient Information & Consent
• Standard 10 – Dignity & Respect
• Standard 18 – Communicating Effectively
• Standard 22 – Managing Risk and health and safety
• Standard 13 – Infection Prevention & Control & Decontamination

• No specific training required.

• Nil noted.

• Nil Noted

Equality Assessment Statement

Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all

• Nil Noted

• Nil noted

• Nil Noted

CARE OF THE PERINEUM DURING & AFTER BIRTH

1. Relevant to:

This guideline is written for Powys Midwives.

1. Purpose:

It is estimated that over 85% of women will sustain some degree of perineal trauma following a vaginal delivery; 60-70% of these will require some form of perineal suturing (RCOG 2007). Routine episiotomy is not recommended as a method of preventing extended perineal trauma. Perineal suturing is an integral part of the midwives role. Perineal repair should be performed as soon as possible using an aseptic technique, ensuring adequate analgesia and with full explanation to and consent from the woman. The overall aim must be to ensure safe and effective care is provided to women whilst allowing them to make an informed choice regarding perineal care during and after birth.

1. Definitions

First degree involves skin only

Second degree involves perineal muscle and skin, this would includeepisiotomy

Third degree partial or complete disruption of the anal sphincter.

3A: less than 50% of external anal sphincter torn

3B: more than 50% of external anal sphincter torn

3C: both the internal and external anal Sphincter is torn

Fourth degree involves anal sphincter complex disruption of theexternal and internal anal sphincter and anal epithelial.

(RCOG 2007).

1. Process

Action

Key Points

Identify and control bleeding points

Eliminate dead space

Avoid inserting too many sutures too close together.

The use of Vicryl Rapide is the recommended material as this has been

shown to aid perineal wound healing and cause less pain in the postnatal

period. (Mackrodt et al, 1998; Kettle, 1998, NICE 2008). Literature reviews strongly suggest a continuous, subcuticular technique to be superior to the interrupted suture technique for the closure of skin

(Enkin et al, 2000; Kettle and Johanson, 2000b; Jackson, 2000, NICE

2008).

1. Procedure

Women should be informed of the recommendation that in the case of first degree trauma the skin should be sutured unless well opposed. The vaginal muscle and mucosa should be sutured for all second degree tears as well as the skin layer unless well opposed [NICE 2008].

Explain procedure to the woman and her partner to obtain informed verbal consent and ensure their understanding of procedure to be performed.

Check number of swabs and instruments with a 2nd person prior to commencing procedure. Record that this has been done in the perineal care element of the All Wales Pathway for Normal Labour.

Assist the woman into a suitable position to facilitate inspection of

the laceration to aid repair.

Inspection should include a digital rectal examination [NICE 2008]. Prior to carrying out a rectal examination, the procedure and reason for the examination should be explained to the woman and verbal consent obtained.

Cleanse the vulva using a clean technique, water is an acceptable solution for cleansing.

Inspect the vulva and vagina and determine extent of episiotomy/tear. Transfer to DGH if perineal trauma appears extensive or the midwife feels the repair merits the expertise of a more experienced practitioner.

If analgesia is required 20ml Lidocaine 1% can be used to infiltrate the perineum [NICE 2008]. The total amount of Lidocaine (Lignocaine) 1% must not exceed 20mls – this total includes any Lidocaine 1% used for perineal infiltration prior to episiotomy. If the perineum was infiltrated with Lignocaine prior to episiotomy it should be effective for 1 hr and further analgesia may not be required.

Lubricate and insert a sterile tampon into the vagina above the level of the wound to be repaired. Attach an artery forceps to the tail and clamp onto abdominal sterile cover. Under no circumstance must the vagina be packed with anything other than a tailed tampon or tailed swab.

Use a separate receptacle for used swabs to reduce risk of inaccurate swab count following procedure.

The vaginal mucosa is sutured using Vicryl Rapide sutures. Insert an anchor suture above the apex of the wound. Use a continuous stitch to repair the vaginal wall to the level of the hymenal remnants. The sutures are inserted into the epithelium and submucosa only and should not be pulled too tight.

The perineal muscle is sutured using Vicryl Rapide sutures using a continuous suturing technique. [NICE 2008]

The perineal skin should be repaired using Vicryl Rapide; the subcuticular suturing technique is most suitable [NICE 2008]. Commence suturing from the apex of the inferior end of the wound until the superior edge is reached.

Remove the tampon and inspect the vagina to confirm satisfactory repair and that haemostasis has been achieved.

Perform a digital rectal examination to ensure the sutures have not extended into the rectum.

Check swabs, needles and instruments to ensure all items are accounted for and document that this has been completed. This is to reduce the risk of retention of suturing equipment or swabs following the procedure.

Ensure women have adequate pain relief following the procedure.

Advise the woman of the importance of good perineal hygiene and of performing postnatal exercises.

Discrepancy in Swab count

As stated in above procedure all swabs need to be counted with asecond person and documented prior to procedure commencing.

A separate receptacle should be used during the procedure tohold used swabs to ensure all are accounted for.

A swab count should be performed with a second personfollowing the procedure and documented.

In the event of a discrepancy in swab count:

a) Do not remove any items from the room prior to swab count beingreconciled.

b) Re-check the used swabs again with a 2nd person.

c) Re inspect the vagina

d) Check the swab count again

e) If there is any possibility that a swab has been retained per vagina- transfer to a DGH must be arranged for an x-ray.

Retained foreign object identified in the postnatal period

If an unintentionally retained foreign object is found by a womanfollowing discharge from a DGH or birth Centre, the place at which thewoman gave birth should be notified.

The retained foreign object should be examined to confirm it is a swab.

If confirmed as a retained swab; advice should be sort from Primary care regarding the commencement of prophylactic antibiotics.

A Datix must be completed and National Patient Safety Agencyinformed. (NPSA 2010)

Record Keeping.

Ensure perineal care element of the All Wales Clinical pathway for

Normal labour is completed in full.

Contraindications to a Midwife Suturing

The midwife must acknowledge her limitations, as in all areas of practice and refer to an appropriate person any situation outside their scope of practice.(NMC, 2008). Third/fourth or other complicated perineal trauma would necessitate transfer to DGH as per All Wales Birth Centre Guidelines (2009)

1. Responsibilities

The overall aim must be to ensure safe and effective care is provided to women whilst allowing them to make an informed choice regarding perineal care during and after birth.

1. Training

All Midwives working within Powys hold a recognised midwifery qualification, no additional qualifications are required to carry out this policy if the midwife received appropriate training during her preparation as a midwife. Midwives will be required to attend regular updates on care of the perineum after their initial training.

1. Monitoring Compliance/ Audit

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system. Notes audits will be regularly undertaken.

1. References

Enkin M. Keirse. M. Renfrew. M. Neilson. J. (2000) A Guide to Effective Care in Pregnancy and Childbirth. Oxford Medical Publications. Oxford.

Jackson K. (2000) The bottom line: care of the perineum must be improved. British Journal of Midwifery. 8 (10) pp609 – 614.

Kettle, C. (1998) Suture Materials used for perineal repair following childbirth. British Journal of Midwifery. 6 (12) pp760.

Kettle C. Johanson R. (2000b) Continuous versus interrupted sutures

for Perineal repair. (Cochrane review). The Cochrane Library.Oxford.

Mackrodt C. Gordon B. Fern E. Ayers S. Truesdale A. Grant. A. (1998) the Ipswich Childbirth study 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. British Journal of Obstetrics and Gynaecology. 105 pp441 – 445

National Patient Safety Agency (2010) Rapid Response Report – Risk

of Retained Swabs following Vaginal Birth and Perineal Suturing.

Royal College of Obstetricians and Gynaecologists (2007) Methods and Materials used in Perineal repair. RCOG. London.

NICE [2008] Intrapartum Care Guideline. National Institute of Clinical excellence. London

Nursing and Midwifery Council [2008] The code. NMC. London

Walker R. & Jay A. (2001) Perineal care and repair workshop ENB

Approved Study day. Hatfield.

Relevant Policies

All Wales Birth Centre Guidelines

Post Natal Care – Powys LtHB policy

1. Appendices