Perineal Care Procedure

/ CHHS15/059

Canberra Hospital and Health Services

ClinicalProcedure

Perineal Care- Maternity

Contents

Purpose

Alerts

Scope

Background

Section 1 – Warm Compresses for use on the perineum

Section 2 – Episiotomy

Section 3 – First and second degree genital tract repair

Section 4 – Third and fourth degree genital tract repair

Section 5 – Postpartum management of genital tract trauma

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Purpose

Using best practice to optimise perineal outcomes following vaginal birth,women who are labouring are offered warm compresses to the perineum to increase comfort, reduce pain and genital tract trauma.

To ensure that episiotomies and genital tract repairs are done by appropriately skilled midwives or doctors in appropriate situations as defined by evidence, and that all women with genital tract trauma have appropriate postnatal perineal care, management and follow up.

Scope

Alerts

Midline episiotomies are not recommended unless absolutely necessary and are to be done by experienced midwives or doctors only.A midline episiotomy increases the chances of the cut extending through to the anus and causing a 3rd or 4th degree tear.

Scope

Doctors and Medical Studentsunder the direct supervision of a skilled medical officer
Midwives and student midwives (who have undertaken the accredited competency through the Maternity Unit, Woman and Babies, CHWCor under the direct supervision of an accredited midwife or doctor,).

Background

Perineal injury is the most common maternal morbidity associated with vaginal birth. Anal sphincter injury is a major complication that can significantly affect women’s quality of life.

Although risk factors have been identified it is difficult to predict the occurrence of severe perineal trauma.

Risk factors for anal sphincter injury

Knowledge of anal sphincter injury risk factors is not generally useful in the prevention or prediction of anal sphincter injury. Risk factors for third and fourth degree tears include:

birth weight over 4 kg
persistent occipitoposterior position
nulliparity
induction of labour
epidural analgesia
second stage longer than 1 hour
shoulder dystocia
midline episiotomy
forceps delivery

Intrapartum interventions to reduce perineal trauma

Either the 'hands on' (guarding the perineum and flexing the baby's head) or

the 'hands poised' (with hands off the perineum and baby's head but in

readiness) technique can be used to facilitate spontaneous birth

Warm Compresses to the perineum should be applied
Women should be encouraged to adopt upright positions which she finds comfortable
Women should be encouraged with physiological pushing rather thandirected pushing in the second stage of labour
Do not perform perineal massage in the second stage of labour
Do not carry out a routine episiotomy during spontaneous vaginal birth

Section 1 – Warm Compresses for use on the perineum

Warm compresses to the perineum during the second stage of labour have been identified in studies to increase comfort,reduce pain to the perineum and to reduce third and fourth degree tears.

Physiology literature supports the potential beneficial effects of warm packs in dilating blood vessels, increasing bloods flow, influencing transmission of pain by reducing the level of nociceptive stimulation, and increasing collagen extensibility (Dahlen et al, 2007)

Procedure

Obtain consent from the woman for use of warm compresses to her perineum and document in her clinical record
Ensure the woman is able to discriminate between cold by applying a cool pack or ice first, if ok you can proceed with warm compresses
Fill a sterile bowl with warm water, to ensure that it is a safe temperature add 300mls of boiling water to 300mls of cold tap water. Replacing the whole bowl of water every 15 mins. Do not “top up” or add hot water as this increases the risk of burning
Soak a perineal pad in the warm water; wring out the water before placing the warm compress to the perineum. The pad is resoaked to maintain warmth between contractions
Apply lightly without pressure and check skin after each application
Do not use when skin has reduced thermal sensitivity (e.g. epidural)
Discontinue or modify practice as directed by the woman
Be aware that this may be a suitable pain relief option for some women who prefer to use non-pharmacological pain relief

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Section 2 – Episiotomy

An episiotomy is a surgical enlargement of the vaginal orifice by an incision of the perineum during the last part of the second stage of labour or delivery, routine episiotomy does not protect the perineum from severe injury.

It is used tofacilitate birth

if there is a non-reassuring Cardiotocograph (CTG) or
if there are non-reassuring fetal heart sounds birth if the
if birth of the fetal head is being prevented by a tight perineum
to aid a difficult delivery
with instrumental deliveries where necessary

Equipment

Curved mayo scissors
1% lignocaine
20ml syringe and 23g needle

Process

Discuss with the woman whyyou are recommendingan episiotomy is needed, explain procedure and gain verbal, informed consent. Document in clinical notes
Utilise local anaesthetic if the perineum is not already anaesthetised (e.g.: epidural/spinal anaesthesia)
Elevate the perineum from the presenting part by inserting 2 fingers (usually of the left hand) into the woman's vagina. Using curved mayo scissors, placed at a 450 angle from the midline of fourchette, make a single incision to form a medio-lateral episiotomy.

Note: control the presenting part as the episiotomy is done to prevent a precipitous birth.

Midline episiotomies are not recommended unless absolutely necessary and are performed by experienced midwives or doctors only

Female genital mutilation

If a women is identified as having Female genital mutilation (FGM) refer to an obstetrician in the antenatal period for assessment and discussion on management. Refer to the Female genital mutilation guideline on sharepoint for further information.

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Section 3 – First and second degree genital tract repair

Women who sustain a first and second degree genital tract tear may require genital tract repair. Women who sustain a second degree tear will always require a repair.

First degree : Injury to perineal skin, includes the fourchette, the hymen, labia and

vaginal epithelium

Second degree : Injury to perineum involving perineal muscles but not involving the anal sphincter

Equipment

2/0 Vicryl round bodied needle

2/0 or 3/0 Vicryl Rapide(absorbable suture material) cutting needle

light source
sterile drapes
dressing pack
sterile gloves
Local anaesthetic (if regional block is not in place)
Syringe and needle for local infiltration

Procedure

Staff performing the repair must be accredited through the competency through the Maternity Unit, Woman and Babies, CHWC(Junior medical staff and midwives who are not accredited to perform repairs will be supervised by a senior colleague)
Ascertain the degree of injury and the need for repair – including significant anatomical disruption, poor tissue alignment and/or bleeding. Some first degree tears, labial lacerations or vaginal wall tears maynot require suturing
Obtain consent from the woman Document ij clinical record
Position the woman comfortably with optimal light and exposure for the practitioner completing the repair
Document the time if the woman is placed in lithotomy with leg supports being careful to note that prolonged placement can have an effect on the sacral spine
Perform surgical scrub and glove
Slowly administer local anaesthetic by slow, local infiltration avoiding inadvertent blood vesselinjection. This will not be necessary if a working epidural or pudendal nerve block is in place
Consider IDC if excessive periuretheral trauma or swelling

Repair the tear or episiotomy: A variety of different surgical techniques may be used depending on the skill and experience of the staff member. The evidence suggests that the following method(s) are the most appropriate:

Vaginal epithelium - single layer continuous non-locking 2/0 Vicryl round bodied needle
Muscles - continuous, non-locking or interrupted (for deeper muscle) 2/0 Vicryl round bodied needle
Skin – single layer subcuticular 2/0 or 3/0 Vicryl Rapide cutting needle
Labial lacerations – interrupted 2/0 or 3/0 Vicryl Rapide cutting needle
On completion of the repair perform a vaginal then rectal examination. Or document why this was considered unnecessary
Place clean pad and icepack on perineum
Complete a surgical count
Discuss pain relief, ice, hygiene, diet, pelvic floor exercises, bowel and bladder function.
Prescribe (medical staff) and administer appropriate pain relief and urinary alkalinisers. Consider rectal analgesics initially at the time of repair, then oral NSAIDs, paracetamol +/- codeine
Document details of repair which mayinclude a diagram to illustrate the extent of the trauma
Once repaired, offer to show the woman the repair
Advise woman if she has any concerns about her repair after discharge from hospital to contact her CMP or Midcall midwife or staff in Birthing if discharged from Midcall.

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Section 4 – Third and fourth degree genital tract repair

Repair should be undertaken by an experienced consultant or registrar experienced in the recognition, repair and management of third and fourth degree tears. Junior staff may undertake the repair only if directly supervised by a senior accredited member of staff.

A third degree tear is defined as injury to the perineum involving the anal sphincter complex and is classified as:

3a: less than 50% of the external anal sphincter (EAS) thickness torn,

3b: more than 50% of the EAS torn,

3c: the internal anal sphincter (IAS) torn.

A fourth degree tear involves the anal sphincter complex (EAS and IAS) and the rectal mucosa. On occasion there may be interruption to the rectal mucosa without EAS or IAS involvement and these should be documented as fourth degree tears.

Equipment

2/0 Vicryl round bodied needle
2/0 or 3/0 PDS(Polydioxanone, a monofilament synthetic absorbable suture) maybe requested
light source
sterile drapes
dressing pack
sterile gloves

Procedure

Obtain informed consent to examine all women after vaginal birth to assess the degree of perineal/vaginal/rectal injury and obtain consent to perform the repair.
Women who have had an extensive perineal laceration should be examined by a consultant or experienced registrar.
Classify degree of tear; in conjunction with the Third and Fourth degree clinical Pathway guideline and this Clinical Procedure, follow and complete Third and Fourth degree tear Pathway
Fourth degree tears should always be repaired under general anaesthetic or adequate regional anaesthesia, preferably in the operating rooms (OR) with a consultant or registrar who is experienced in third and fourth degree tears present.
An evidence based method of repair is described as follows: Identify the internal anal sphincter and include in repair if involved
Identify the extent of the external anal sphincter involvement and perform the appropriate repair.
Repair the remaining part of the tear as per the MPG for 2nd degree tears
Consideration should be given to repairing the muscle layers with PDS not Vicryl (50% of tensile strength remains at 5 days and is lost within 10-14 days for Rapide whereas approx. 75% remains at 2 weeks and approx 50% remains at 3 weeks for Vicryl).
Complete a surgical count or, if in the Operation room (OR), according to OR protocol.
Document on the third and fourth degree tear clinical pathway, vacuum/forceps pathway (or OR notes) details of repair, which may include a diagram to illustrate the extent of the tear. To avoid repetition, document repair details clearly in one area only and write ‘refer to ….’ on the various pathways.
Prescribe and administer appropriate analgesia. Avoid rectal administration of medications for women with 4th degree tears.
IV broad-spectrum antibiotics should be administered at the time of repair for third and fourth degree tears. For fourth degree tears intraoperative and postoperative broad-spectrum antibiotics should be considered. A single dose of iv antibiotics should be prescribed for 3rd and 4th degree tears, plus 7 days oral antibiotics following anal sphincter tears
External ointment maybe prescribed for haemorrhoids if present. Preference should be given to topical ointment containing high dosage steroids and analgesia (eg Scheriproct or similar)
Regular aperients should be prescribed. These should be bulking agents such as Normicol and psyllium husks (eg Metamucil) rather than peristaltic agents or stimulants.
The midwife responsible for the Birth Register entry records in the register, classification of tear, repaired by whom and location.
The Accoucheur should complete the Riskman for all third and fourth degree tears, the CMC of Birthing or the CMP ensures that this has been attended to.
Advise the use of a stool softener and bulking agent for about ten days after the repair.
Appointment/s for the Postnatal Follow up clinic are made by Postnatal or CMP midwife.

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Section 5 – Postpartum management of genital tract trauma

Procedure

With the woman’s consent, assess through observation of the vulva and perineum daily or more often if required and document condition. Assess for signs of healing with particular reference to oedema, haematoma formation, signs of infection and pain.
Inspection of vaginal trauma is required if signs or symptoms of haematoma present.
Consultation with RMO is required for haematoma and analgesia more than paracetamol.
Ice packsinside a sanitary pad and then applied to the perineum may be beneficial to reduce swelling and pain during the first 48 hours (change when melted according to woman’s comfort).
Discuss the healing process with the woman and daily hygiene including washing, drying and frequent pad change.
Respond to specific concerns.
Provide dietary and fibre supplement information about the prevention of constipation.
Provide analgesia as required avoiding narcotics.
Liaise with the Women’s Health physiotherapist to access appropriate assessment, treatment and follow up for any woman that may require this service
Ensure woman has been provided with education in regards to pelvic floor exercises.
Record observations and interventions on the clinical pathway and in the clinical record as necessary.
Advise the woman to consult a health professional if concerned about pain or healing after discharge.

Third and Fourth Degree Trauma:

In addition to the above management:

Ensure third and fourth degree pathway is initiated
Ensure correct management of In-dwelling Catheter
Commence regular fibre and/or aperients as ordered
Dietician consultation is offered
Follow up appointments are arranged at the Gynaecology Outpatients Oasis (Postnatal Perineal) Clinic at six weeks and six months
Advise the woman to consult a health professional if concerned about pain or healing after discharge
Advise the woman to consult a health professional if concerned about incontinence after discharge

Implementation

This guideline will be:

discussed at Maternity inservice education
discussed at Maternity multidisciplinary education;
placed on notice boards in tea rooms; and
distributed to maternity staff via email
Available on Sharepoint

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Related Policies, Procedures, Guidelines and Legislation

Guidelines

ACT Health; Intimate Care

ACT Health; Heat and Cold Application

ACT Health; Aseptic Non Touch Technique

ACT Health; Wound management

ACT Health; Clinical record documentation

ACT Health; Maternity-Female Genital Mutilation (FGM)

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References

Albers, L.L., Sedler, K. D., Bedrick, E. J., teaf, D. And Peralta, P. (2005) Midwifery care measures in the second stage of labour and reduction of genital tract trauma at birth: a randomized trial. Journal of Midwifery and Women’s Health 5, 12, 365-372

Aasheim, V., Nilsen, A.B., Lukasse M. and Reiner L. Perinela techniques during the seconf stage of labour for reducinh perinela trauma. Cochrane Datebase of Systemataic Reviews. 2011; Issue 3. Art.No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews. 2009 (1).Available from:

Dahlen, H.F., Homer, C.S.E., Upton, A.M., Nunn, R. and Brodrick, B. (2007) Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labour: a randomized controlled trial. Birth 34, 4, 282-290

Hastings-Tolsma, M., Vicent, D., Emeis, C. and Francisco T. (2007) Getting through birth in one piece: protecting the perineum. The American Journal of maternity Care Nursing 32, 3, 158-164

National Institute for Health and Clinical Excellence (2006) NICE Clinical Guideline 37. Routine Care of Postnatal Women and Their Babies.

Royal College of Obstetricians and Gynaecologists, Guideline No. 23 Methods and Materials Used in Perineal Repair June 2004

Sanders, J., Peters, T.J. and Campbell, R. 2005 Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery 21, 154-160

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Lai, C.Y., Cheung, H.W., Lao, T.T.H., Lau, T.K & Leung, T.Y. 2009 Is the policy of restrictive episiotomy generalisable? A prospective observational study. The Journal of maternal-Fetal and Neonatal Medicine, 22(12), 1116-1121.

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Definition of Terms

Accoucheur: person assisting to birth baby

Anterior perineal injury: Injury to the labia, anterior vagina, urethra or clitoris.

Episiotomy: Episiotomy is the surgical enlargement of the vaginal orifice by an incision of the perineum during the last part of the second stage of labour or birth.

Female genital mutilation: A cultural or non-therapeutic procedure that involves partial or total removalof female external genitalia and/or injury to the female genital organs

First degree Injury to the skin only (i.e. involving the fourchette, perineal skin and

vaginal mucous membrane; but not the underlying fascia and muscle sometimes referred to as a ‘graze’)