Number of pages: This policy and procedure guideline applies to all obstetrics and gynecology medical and midwifery staff.

Transcription

1 Saudi Society of Obstetrics and Gynaecology Policy and Procedure Title/Description: REPAIR OF PERINEAL TRAUMA Effective Date: 1st July PURPOSE Department: Obstetrics and Gynecology (Labour & Birth) Policy Number and Version: SSOG-L&D-002(V1) Number of pages: This procedure details the repair of perineal trauma 1.2 The document details the expectations required of doctors and midwives in order to maintain safe practice standards and infection control principles. 1.3 Define the immediate postpartum care for perineal trauma. 2. SCOPE 2.1 This policy and procedure guideline applies to all obstetrics and gynecology medical and midwifery staff. 3. ACCOUNTABILITY 3.1 Obstetric consultants who are on-call. 3.2 The midwife or nurse who is in charge of the shift. 4. POLICY STATEMENTS 4.1 Repair of perineal trauma Competency: Doctors and midwives were unable to correctly estimate angles and lengths required to perform safe mediolateral episiotomies. None of the midwives, and only 22% of doctors were able to perform a truly mediolateral episiotomy. Only 13% of episiotomies were at a post-delivery angle of 40 degrees or more Formal training in anal sphincter repair techniques should be an essential component of obstetric training. Obstetricians who are appropriately trained are more likely to provide a consistent, high standard of anal sphincter repair and contribute to reducing the extent of morbidity and litigation associated with anal sphincter injury Midwives shall only perform the perineal repairs stated in the definition on completion of the Perineal Repair Competency. Page 1 of 13

2 4.2.1 Who should repair perineal trauma? The accoucheur (medical and midwifery) is responsible for the initial assessment of genital tract trauma after the birth and for initiating prompt repair of identified trauma by the most appropriate clinician. Episiotomies: first-degree tears and second-degree non-extended perineal tears may be sutured by residents or midwives. Interns may repair episiotomies and second degree tears with supervision from the assigned senior resident Medical and midwifery staff who are credentialed to conduct perineal repair are responsible for ensuring correct apposition and hemostasis of the wound; for documentation and ensuring the swab, instrument and needle count is correct. Medical and midwifery staff assisting the credentialed clinician are responsible for assisting the operator and ensuring that the swab, needle and instrument count is correct and documented All OASIS repairs should be carried out either by: A consultant obstetrician who received formal training A competency-certified registrar A registrar/resident directly supervised by a consultant Perineal trauma repair can be done in the birth room. OASIS Repair should take place in an operating theatre, under regional or general anaesthesia, with good lighting and with appropriate instruments. It may be performed in certain circumstances after discussion with a senior obstetrician in the labour and birth room Documentation The repair should be documented in detail in the file Document patient debriefing. The woman should be informed about: The nature of the injury The need for prophylactic antibiotics and laxatives The importance of follow up at the Perineal Clinic. The importance of early reporting of any symptoms of incontinence N.B: all supported by relevant written information 5. PROCEDURES 5.1 Repair of Perineal Trauma Ensure that the uterus is well-contracted and that the mother s condition is satisfactory. If there is excessive bleeding, a vaginal pack should be inserted and the woman should be taken to the theatre as soon as possible. Page 2 of 13

3 Close the door to the delivery room. Draw the curtain around the bed. (Ensures patient privacy and dignity) If the repair is beyond the operator s skill level, a more experienced operator must be notified. Repair should be conducted by an appropriately trained clinician or by a trainee under supervision Repair can be delayed for 8 to 12 hours with no detrimental effect. Delay may be required so a more experienced care provider is available for the repair Using aseptic technique, carefully inspect the vagina and perineum Refer to P.P perineal trauma, section 6.5 regarding diagnosis) Consent: Verbal consent for a repair in the labour and birth room. Explain the need for and the procedure of perineal repair to the patient. (To gain the patient s permission and compliance and to allay anxiety). Document that Sign an informed consent if you are taking the patient to the operating room Ensure that the midwife/nurse in charge of the shift is aware of the procedure to be performed. (Needs to be constantly aware of events in the labour and birth unit) Prepare area, wash hands and prepare equipment. Check equipment and count cotton swabs and sponges prior to commencing the perineal repair and repeat the same procedure following completion of the repair Refer below to section 6 regarding sutures and equipment Position the patient appropriately, allowing for adequate visualization and access to the perineal area The extent of the repair required and the patient s compliance are the deciding factors for the position. If the patient is placed in the lithotomy position, care must be taken to raise her legs simultaneously and to avoid excessive abduction of the hips Wear protective eyewear. Wash hands and put on a sterile gown and gloves Any repair, other than a superficial readily accessible tear, requires an assistant with sterile gloves who will help in: Good exposure and minimize poor repair of the trauma Handling extra equipment required, e.g. suture material, antiseptic solution etc., (keep suture packets) ensuring aseptic technique. Adjusting light source to illuminate the perineum. Page 3 of 13

4 Using the sponge-holding forceps, swab the vulva, perineal area and inner thigh with antiseptic fluid and cotton wool balls. (To ensure the area is clean, swab the vulvar and perineal area, antero-posteriorly and the inner thigh medial-tolateral.) Position sterile drapes Part labia with non-dominant hand, gently insert vaginal tampon and anchor to drape The proximal end of the tampon must be above the apex of the wound. Insertion of the tampon ensures that lochia seeping through the cervix does not obscure the area to be sutured Anaesthesia and analgesia: For local infiltration Using aseptic technique, note the expiry date of the 1% plain Lignocaine Hydrochloride vial. Check the medication and dosage with an assistant. Using the syringe and 19-gauge needle draw up 10mL of 1% plain Lignocaine Hydrochloride. Ideally the infiltration should be done a few minutes prior to the repair to ensure adequate analgesia. The maximum dose of lignocaine Hydrochloride1% plain should not exceed 3 mg/kg/body weight. Change the needle to 21 or 22-gauge needle (infiltration needle) and Insert superficially, under the sensitive vaginal skin on one side of the wound margin. Direct needle from fourchette to apex of the wound: I. Withdraw plunger of syringe prior to injection of Lignocaine to check whether needle has entered a blood vessel. If blood is aspirated, the needle should be re-positioned and procedure repeated. II. Infiltrate area by injecting Lignocaine, continuously, as the needle is slowly withdrawn back along the line of needle insertion. III. Re-direct needle just before the tip is withdrawn from the fourchette and re-insert in a downward motion, under the perineal skin, following the steps above. (This provides a wider area of perineal anesthesia) Repeat all steps in on the other side Proceed to infiltrate deeper into the musculature and sub-cutaneous tissue with the same precautions mentioned in Time for the local anesthetic agent to be effective. Ask patient if she can feel any painful stimuli upon touch of the perineal area. (Lignocaine Hydrochloride takes 3-4 minutes to take effect) Repair of the vaginal wall: The use of a loose, continuous non-locking method for the vaginal wall and perineal muscles and a continuous subcuticular technique for perineal skin is recommended. Page 4 of 13

5 N.B: Either standard suture or adhesive glue may be used to repair a hemostatic first-degree laceration or the perineal skin of a second-degree laceration Identify the apex of trauma on the vaginal wall/floor With the needle secured in the needle holder, insert the anchor stitch approximately 0.5 cm above the apex of the wound. Trim the short end only of the anchor stitch. (Ensures hemostasis of any small vessels which may have retracted beyond this point) Suture full thickness posterior vaginal wall/floor with loose, continuous interlocking stitch (blanket stitch) Continue from the apex of the wound to the introitus (hymenal remnants) Just behind introitus, bring suture down into hymenal remnants and insert the needle through the skin at the fourchette to emerge in the center of the perineal muscle trauma and leave it at the side to tie off with sub-cuticular stitch, or if it a is 2nd degree tear continue as steps mentioned in i. Each bite being approximately 0.5 cm below the preceding bite, taking the full vaginal wall thickness including the epithelium and its underlying fibromuscular and adventitia. ii. Bites taken too deep, especially near the introitus, may penetrate rectal mucosa, leading to the formation of a recto-vaginal fistula, if the sutures are left in-situ. iii. Because the incision is in a lateral direction, the medial tissue will be lower than the distal edge, and careful approximation is necessary to avoid subsequent distortion of the vaginal opening. Placing sutures diagonally rather than horizontally will help maintain appropriate anatomical approximation and not stitched too tight. iv. If there are lacerations in the lateral or anterior vaginal walls, repair first, before proceeding to the posterior vaginal wall. v. Close dead space and ensure haemostasis is achieved to prevent haematoma formation. vi. Avoid suturing hymenal remnants. Check for hemostasis Repair of the perineal muscle: Examine the extent of muscle repair needed. If the suture used in the vaginal epithelium reaches the fourchette, then the suture should be everted and used for the muscular layer until you reach the apex in the skin. The same suture can be used to come back up sub-cuticle until the fourchette again Perineal muscles are repaired with continuous non-locking stitches. It includes putting the bulbospongiosus and transverse perineal muscle together, as a continuation of the step (see above) If deep muscles are involved, insert three to four continuous non-locking stitches, firstly in the deep muscle layer, then proceed to insert continuous non-locking stitch sutures into the superficial muscle and fascia to reconstruct the perineal body. Page 5 of 13

6 If superficial muscles only are involved, insert three to four continuous non-locking stitches into the muscle and fascia The following explanations apply to both deep and superficial muscles: I. Oppose muscle edges carefully. Non-tooth forceps should be used to pick up the muscle layers. II. The bulbospongiosus muscle will usually need to be repaired because it extends into the incision site. The upper end of the muscle, if transected, will have retracted and will need to be identified and re-approximated. Sutures should be placed in the fascial sheath and not the muscle. III. Diagonal, not horizontal, sutures should be used. IV. It is not necessary to ligate individual bleeding points as an accurate and prompt repair should provide good hemostasis Upon completion, ensure there are no dead spaces and the wound is shallow enough to allow the skin edges to be gently drawn together Check for hemostasis. Ensuring all bleeding points have been scaled Skin repair: The following steps describe subcuticular suturing but interrupted sutures can be used for perineal skin repair in certain situations (e.g. particularly ragged tears or small skin tears, requiring only one or two stitches). N.B: Either standard suture or adhesive glue may be used to repair the perineal skin of a second-degree laceration At the inferior end of the wound, bring the needle out just under the skin surface, reversing the stitching direction. The skin sutures are placed below the skin surface in the subcutaneous tissue. Continue to take bites of tissue from each side of the wound edges until the hymenal remnants are reached. Secure the finished repair with a loop or Aberdeen knot placed in the vagina behind the hymenal remnants Using the sub-cuticle stitch, thus avoiding the profusion of nerve endings, insert sutures in parallel lines, at opposing points along the wound margin, just below the skin (do not penetrate the skin) Take approximately 0.5 cm bites of tissue on either side. It is important that stitches are neither too deep nor too large Draw edges gently together. Then continue towards the introitus. (Ensure good approximation and avoid puckering of the skin) Check that hemostasis has been obtained. N.B: If there is excessive bleeding with a well-contracted uterus, re-check the vagina and cervix for other lacerations Third and fourth degree tear: Anal sphincter components should be sutured before the vagina. Page 6 of 13

7 Give prophylactic intravenous antibiotics should be administered for the reduction of perineal wound complications before the repair of obstetrical anal sphincter injury. Refer below to section Insert a Foley's catheter, and leave it in for at least 24 hours since OASIS are associated with an increased risk of postpartum urinary retention The anal rectal mucosa can be carried out with an interrupted suture with the knots tied in the anal lumen or external to the anal canal. Alternatively, the anal rectal mucosa can be approximated with a submucosal continuous suture The external anal sphincter: Women should be informed that it may take a long time for these sutures to dissolve (more than 6 weeks) and that they may be aware of the knots around the anus. For repair of a full thickness external anal sphincter (EAS) tear, either an overlapping or an end-to-end (approximation) method can be used with equivalent outcomes. Repair of the external anal sphincter should include the fascial sheath. An overlapping technique often requires more dissection and mobilization of the sphincter ends and is only possible with full thickness 3b sphincter tears or greater. For partial thickness (all 3a and some 3b) tears, an end-to-end technique should be used Internal anal sphincter: Where the torn internal anal sphincter (IAS) can be identified, it is advisable to repair this separately with interrupted or mattress sutures without any attempt to overlap the IAS. If it is recognized that the internal anal sphincter is disrupted, the edges should be grasped and an end-to-end anastomosis performed. Figure of eight sutures should be avoided during the repair of OASIS because they are haemostatic in nature and may cause tissue ischemia The remainder of the repair is carried out for a second degree tear or episiotomy Anterior Perineal Trauma Small and superficial labial grazes involving the labia, periclitoral and periurethral tissues that are not bleeding or distort do not usually require suturing. When the labia are torn irregularly, even in the absence of bleeding, re-approximation may be required for cosmetic reasons to prevent the formation of irregular tags of tissues. Periurethral tears that are deep and bleeding will need suturing. It is ideal to insert a urinary catheter prior to commencing the procedure Page 7 of 13

8 and to repair the tear with an interrupted fine absorbable suture material Vaginal and Rectal Examination Check that all pads and the vaginal tampon have been removed from the vagina Ensure the vagina and introitus admits two fingers. If not, seek more experienced help, as the repair may need to be redone Perform a rectal examination to ensure that no sutures have penetrated the rectal mucosa. If sutures are felt, they must be removed. Notify medical staff of such Insert lubricated little finger into the rectum. Run your finger along the anterior rectal wall. Insert Rectal Diclofenac 100 mg at completion of repair Assess blood loss, and check fundus. N.B: With vaginal tampon removed, there may be heavy lochia, or clots to be expelled Ensure needle count is correct Check needles against empty packets. Ensure swab count is correct and document on the Perineal Repair Section in the patient s file Clean vulva area. Remove wet linen and incontinence liner. Place clean sanitary pad on vulva of patient Ensures patient s comfort after procedure. If patient was placed in the lithotomy position for procedure, remove patient s legs from stirrups, simultaneously and with assistance Dispose of equipment appropriately and wash hands Observe the perineum for swelling or hematoma Document Appropriately Who performed perineal repair Vaginal and rectal examination findings detailing perineal trauma degree Medications and amount of lignocaine used Type of suture material used and method of repair Rectal examination performed Blood loss 6. EQUIPMENT AND SUTURES Page 8 of 13

9 6.1 Equipment Sterile/Perineal Suture Pack with Sterile drapes Sterile Gloves and Gown Antiseptic Solution 1 x 19-gauge needle 1% Plain Lignocaine Hydrochloride (20 ml) Syringe 20 ml 21 or 22 g Needle X2 (infiltration needle) Needle holder/needle driver Stitch cutting scissor Small artery/mosquito clamp Allis clamps (4) Pickup with teeth and without teeth Deaver or gelpi retractor Protective Eye Wear (Optional) K-Y Gel Lamp Irrigation 6.2 Suture Material Repair of the vaginal epithelium and perineal muscles: use coated Vicryl Rapide (polyglactin 910), 2/0, on a swaged (eyeless) round bodied 36 mm ½ circle needle with tapered point or taper cut Repair of the perineal skin: use coated Vicryl Rapide (polyglactin 910), 2/0 on a swaged (eyeless) round bodied 26 mm ½ circle needle with tapered point Repair of labial tears and anterior FGM incisions: use coated Vicryl Rapide (polyglactin 910), 2/0 on a swaged (eyeless) round bodied 26 mm ½ circle needle with tapered point Repair of deep perineal muscle layer: use Vicryl (polyglactin 910 plus), 2/0 on a swaged (eyeless) 36 mm ½ circle needle with tapercut point Repair of obstetric anal sphincter injuries: i. Vicryl (Polyglactin 910 plus) 3-0 should be used to repair the anorectal mucosa as it may cause less irritation and discomfort than polydioxanone (PDS) sutures. ii. When repair of the EAS and/or IAS muscle is being performed, either monofilament sutures such as 3-0 PDS or modern braided sutures such as 2-0 Vicryl (polyglactin 910 plus) can be used with equivalent outcomes. You may use a swaged (eyeless) round bodied 26 or 31 mm ½ circle needle with tapered point. 7. PERINEAL TEAR MANAGEMENT & FOLLOW-UP Page 9 of 13

10 This section is primarily for OASIS post partum care and follow up. However, refer to sections 7.2, 7.4, 7.9 and 7.11, for the other perineal tears care The use of broad-spectrum antibiotics is recommended following repair of OASIS to reduce the risk of postoperative infections and wound dehiscence. Antibiotic prophylaxis should be given. Intravenous antibiotics Cefotetan 2 gm or Cefoxitin or (Cefuroxime 1.5g and Metronidazole 500mg) should be commenced intra-operatively and continued to its equivalent orally for 3 days. OR IV amoxicillin/clavulanate 1.2 g STAT at repair, followed by: Oral amoxicillin/clavulanate 625 mg TDS for 3-5 days (optional, no data on that) For patients with mild Penicillin allergy: IV Cefazolin 1g (or IV Cefuroxime 750 mg) and IV metronidazole 500 mg STAT at repair, followed by: Oral Cefaclor 500 mg TDS and metronidazole 200 mg QID for 3-5 days. For patients with severe Penicillin allergy: IV Clindamycin 600 mg and IV gentamicin 5-7 mg/kg STAT at repair, followed by: Oral Clindamycin 300 mg QID and Ciprofloxacin 500 mg BD for 3-5 days Analgesia should be prescribed: Paracetamol 1.5g STAT at completion of repair I.M Diclofenac 75 mg SR 12 hourly is given, and prescribed regularly for 48 hours for third and fourth degree lacerations. Oral non-steroidal anti-inflammatory and Paracetamol as required. Avoid opiate analgesia as this may cause constipation A stool softener should be prescribed Lactulose mls BD for 10 days. Kiwi crush or Sodium docusate tablets are an acceptable alternative Ice therapy to decrease swelling for first hours. Apply an ice pack in a sanitary pad to the perineum for 20 minutes every 3-4 hours Severe perineal discomfort particularly following instrumental delivery is a known cause of urinary retention. It can take up to 12 hours following regional anaesthesia before bladder sensation returns. Therefore, a Foley's catheter should be left in for at least 24 hours Referral to the Obstetric Dietician should be made on arrival to the postpartum floor. Written information while the woman is an inpatient will be provided giving advice on avoiding constipation or diarrhea and adequate fluid intake (1.5 2L / day) Referral to the obstetric physiotherapy should be made on arrival to the postpartum where the woman should remain an inpatient for at least 48 hours. Provide information on pelvic floor muscle exercises. Page 10 of 13

11 7.8. Post-delivery the obstetrician performing the repair should ensure that the woman has a full understanding of the implications of the tear and the plans for subsequent follow-up at the postpartum visit Before discharge, i. ask and offer to assess the woman if she has any concerns about the healing process of the perineal wound; including perineal pain, discomfort, stinging, or offensive odor. Instruct her to come back to emergency room if she will have any of the mentioned symptoms. ii. advise to change sanitary pads every 2-3 hours and wash and dry her perineum after each void and bowel action. iii. counsel her about ways to avoid constipation The woman should be provided with a leaflet Perineal Trauma Facts Sheet The woman should be assessed by her doctor at the usual 6-week check-up to ensure perineum healing, pain resolved and no faecal incontinence. Accordingly, advise her about when to start her sexual relationship OASIS outpatient follow-up: At 3 months: at specialized gynaecology clinic in this field for further assessment. Mode of delivery for subsequent pregnancy should be discussed at this point. If a woman is experiencing incontinence or pain at follow up, referral to a specialist gynecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry should be considered. 8. THIRD AND FOURTH DEGREE TEAR AUDIT STANDARDS 8.1 SSOG & MOH are encouraging the collection of data for audits that may include: Numbers of third and fourth degree tears as a percentage of vaginal deliveries. Review of documented systemic examination of the vagina, perineum and rectum prior to suturing of the obstetric anal sphincter injury. Proportion repaired in theater, type of analgesia, suture material and method of repair. Long term continuation rate following repair. Short and long term complications. 9. REVIEW 9.1 A formal review will be after 3 years. This policy will be revised if there are any update in evidence based practices. 10. SECONDARY DOCUMENTS Perineal Trauma Facts Sheet 11. EFFECTS ON PREVIOUS STATEMENTS Page 11 of 13

12 11.1 This policy supersedes any previous statement, policy rules or regulations regarding Repair of Perineal Trauma. 12. CROSS-REFERENCES 12.1 PP Perineal Trauma (V1) 13. RELATED REFERENCES 13.1 ACOG practice bulletin no. 165, Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstetrics & Gynecology: July Volume Issue 1 - p e1 e ACOG.Episiotomy-Procedure and repair techniques Abdul H. Sultan, Ranee Thakar, Dee E. Fenner, Perineal and Anal Sphincter Trauma, Diagnosis and Clinical Management book, Baston H. The second stage of labour. The Practising Midwife. 2004;7(3):30-6. RCOG (2015) Thirdand Fourth-degree Perineal Tears, Management (Green-top Guideline No. 29). RCOG, London Fitzpatric M et al (2000). A randomized clinical trial comparing primary overlap with approximately repair of third degree obstetric tears. American Journal of Obstetrics & Gynecology, Nov;183(5): Kettle C, Therese Dowswell, Khaled MK Ismail. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database of Systematic Reviews, Kettle C, Therese Dowswell, Khaled MK Ismail.. Absorbable suture materials for primary repair of episiotomy and second degree tears, Cochrane Database of Systematic Reviews, Mahony R et al (2004) Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of third degree obstetrics and sphincter tear. Dis Colon Rectum. Jan;47(1):12-7. Epub 2004 Jan Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair Published December 2015, SOGC clinical practice guidelines Queensland Maternity and Neonatal Clinical Guidelines, Perineal care program, 2015, UK Sultan AH et al (1999) Primary repair of obstetric sphincter rupture using overlap technique. British Journal of Obstetrics & Gynecology, 106 (4): The Rosie Hospital, Cambridge University Hospital NHS Foundation Trust, Guideline: Repair of Third Degree Tears; July The Royal Women's Hospital Clinical Guidelines Guideline and Procedure Manual. Perineal Trauma Assessment, Repair and Safe. Practice, Viswanathan M, Hartmann K, Palmieri R. et al. The Use of Episiotomy in Obstetric Care: A Systematic Review. Rockville, Md: Agency for Healthcare Research and Quality; May Page 12 of 13

13 14. ABBREVIATIONS AI EAS FGM IAS MOH NSAID OASIS SSOG SUG SVD WHO Anal incontinence External anal sphincter Female genital mutilation Internal anal sphincter Ministry of health Non-steroidal anti-inflammatory Obstetric anal sphincter injuries Saudi society of obstetrics and gynaecology Saudi Urogynecology group Spontaneous vaginal delivery World Health Organization 15. APPROVAL Prepared by: Dr. Fatma Alshangiti & Date prepared: 23 rd June 2016 Dr. Fatma Noorwali Reviewed by: Dr. Faisal Kashgari Date reviewed: 27 th June 2016 Approved by: SSOG Date approved: 30 th June POLICY AND PROCEDURE HISTORY Initial PP: SSOG-L&D-002 (V1) Page 13 of 13