Perineal Suturing.docx

A. Routine episiotomy offers no maternal benefits 1. Limit use to fetal indications 2. Hartmann (2005) JAMA 293:2141-8 [PubMed] III. Grading of perineal Lacerations A. First degree Laceration 1. Vaginal Laceration 2. Perineal skin torn B. Second degree Laceration 1. First degree Laceration and 2. Perineal muscles torn C. Third degree Laceration 1. Second degree Laceration and 2. External anal sphincter torn D. Fourth degree Laceration 1. Third degree Laceration and 2. Complete anal sphincter tear and 3. Rectal mucosa may also be torn IV. Preparation A. Suture 1. Polyglactin 910 (Vicryl) a. Vicryl 3-0 on CT-1 needle i. Used to close vaginal mucosa and perineal muscles b. Vicryl 4-0 on SH needle i. Used to close perineal skin ii. Used to close rectal mucosa c. Efficacy i. Polyglactin is less associated with discomfort ii. Greenberg (2004) Obstet Gynecol 103:1308-13 [PubMed] 2. Polydioxanone sulfate (PDS) a. PDS 2-0 on CT-1 needle i. Used to close external anal sphincter B. Anesthetic 1. Lidocaine 1% 2. Syringe 10 cc with 27 gauge 1.5 inch needle C. Instruments 1. Needle driver 2. Suture scissors 3. Forceps with teeth 4. Gelpi or Deaver retractor (as needed) 5. Allis Clamps (2) V. Management: Vaginal Laceration Repair

A. Description 1. Closure of vaginal mucosa (behind hymenal ring) 2. Vaginal tears may involve both sides of vaginal floor B. General 1. Indicated in first through fourth degree Lacerations 2. Repaired with Vicryl 3-0 on CT-1 needle C. Anchor Suture 1 cm above apex of vaginal Laceration D. Use Running stitch (continuous) to close vaginal mucosa 1. Locking Suture is optional (used for hemostasis) E. Each pass should include 1. Vaginal mucosa 2. Rectovaginal fascia (important for vaginal support) F. Continue RunningSuture up to hymenal ring 1. May be tied off proximal to hymenal ring or 2. May be passed under hymenal ring to perineum a. May be used for closing perineal skin (see below) VI. Management: Perineal muscle repair A. Description 1. Bulbocavernosus and transverse perineal muscle closed B. General 1. Indicated in second through fourth degree Lacerations 2. Repaired with Vicryl 3-0 on CT-1 needle C. Close each muscle body with interrupted figure 8 Suture 1. Closure of bulbocavernosus muscle a. Located immediately below introitus b. Located above transverse perineal muscle 2. Closure of transverse perineal muscle a. Located above external anal sphincter VII. Management: External anal sphincter repair A. Description 1. Closure of external anal sphincter B. General 1. Indicated in third and fourth degree Lacerations 2. Repaired with Polydioxanone (PDS) 2-0 on CT-1 needle C. Identify external anal sphincter ends 1. Clamp each external anal sphincter muscle 2. Must include rectal sphincter sheath (capsule) a. Must be included in closure for adequate strength D. Close external anal sphincter 1. Option 1: End to end external anal sphincter closure a. Standard method, but may be replaced by Option 2 i. Associated with poorer functional outcomes

ii.

Kammerer-Doak (1999) Am J Obstet Gynecol 181:1317 [PubMed] b. Close sphincter with 4 interrupted figure 8 Sutures i. Posterior (3:00) position ii. Inferior (6:00) position iii. Superior (12:00) position iv. Anterior (9:00) position 2. Option 2: Overlapping external anal sphincter closure a. May be preferred method due to better outcomes b. Overlap each end of external anal sphincter i. Allow sufficient overlap to place 3 Sutures c. Place 3 mattress Sutures through overlapped edges i. Pass Suture through superior end and inferior end ii. Pass Suture through inferior, then superior end iii. Tie at top overlying superior sphincter edge VIII. Management: Rectal mucosa and internal sphincter repair A. Description 1. Closure of rectal mucosa 2. Closure of internal anal sphincter B. General 1. Indicated in fourth degree Lacerations 2. Closed with Vicryl 4-0 on SH needle 3. Gelpi retractor used to maximize visualization C. Close rectal mucosa with RunningSuture 1. Start at apex of rectal mucosal tear 2. Keep Suture passes closely spaced 3. Do not Suture complete thickness of rectal mucosa a. Risk of anal fistula formation 4. Continue Suture to anal verge on perineal skin D. Close internal anal sphincter 1. Allis clamp placed at each end of internal sphincter 2. Close internal anal sphincter with PDS 2-0 IX. Management: Perineal skin repair A. Description 1. Bulbocavernosus and transverse perineal muscle closed B. General 1. Indicated in first through fourth degree Lacerations 2. Closure of perineal skin is controversial a. May be associated with higher rate perineal pain i. Gordon (1998) Br J Obstet Gynaecol 105:435-40 [PubMed] b. Some advocate closure only as needed i. Indicated if skin not well approximated 3. Repair materials

a. Vicryl 4-0 on SH needle or b. Vicryl 3-0 on CT-1 continued from vaginal mucosa C. Running deep Suture 1. Start unlocked continuous Suture from below introitus a. May be continued from vaginal mucosa i. Passed from behind hymenal ring via deep layer 2. Continue RunningSuture down to posterior tear edge D. Running subcuticular Suture 1. Subcuticular Suture starts at posterior perineal tear 2. Run back up to introitus 3. Tie off perineal skin Suture a. Pass through deep tissue and tie behind hymen or b. Tie deep to perineal skin X. Complications A. Chronic perineal pain including Dyspareunia 1. Associated with perineal skin closure B. Urinary and Fecal Incontinence 1. Associated with third and fourth degree tears C. Anal Fissure 1. Associated with fourth degree tears