Third & Fourth Degree Tears guideline (GL926) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Chair, Maternity Clinical Governance Committee 6 th October 2017 Change History for previous versions see V6.0 March 2012 Version Date Author, job title Reason 6.0 Jan 2012 Pat Street, Consultant Review due Obstetrician 7.0 Jan 2014 Femi Ajibade, Staff Grade Review due also changes following audit 7.1 Sept 2014 T Haxton (Snr midwife DAU) Amended to reflect changes in DAU practice 7.2 May 2015 A de la Horra (Audit Midwife) Update to auditable standards and minor text corrections (pg2 4) 7.3 Feb 2016 Christine Harding (Clinical Lead MW) Clarification of time to suture pg 2 8.0 July 2017 T Haxton, P Bose, C Harding Reviewed, minor changes throughout Consultant MW This document is valid only on date ast printed Page 1 of 5
Overview: The overall incidence of obstetric anal sphincter injury is 2.9%%in the UK with an incidence of 6.1% in primiparae compared with 1.7% in multiparae. An appropriately trained Obstetrician must identify and repair this serious complication of vaginal delivery to reduce maternal morbidity, especially subsequent anal incontinence. The repair should ideally be completed within an hour of the delivery of the placenta, or as soon as possible. 1.0 Definitions: Third degree tear: partial or complete disruption of the anal sphincter muscles, which may involve either or both external (EAS) and internal (IAS) anal sphincter muscles. Classification: 3a: < 50% of EAS torn 3b: > 50% of EAS torn 3c: both EAS and IAS torn If there is any doubt about the grade of third degree tear, it is advisable to classify it to the higher degree rather than lower degree. Fourth degree tear: disruption of the anal sphincter muscles with a breach or damage of the rectal mucosa. Button hole tear: This tear involves the anal mucosa with intact anal sphincter muscles. It should be documented separately. Non recognition may cause rectovaginal fistulae. 2.0 Assessment Before assessing for genital trauma, the healthcare professionals should: Explain to the woman what they plan to do and why Offer appropriate analgesia Ensure good lighting Position the woman so that she is comfortable and so that the genital structures can be seen clearly. The initial examination should be performed gently and with sensitivity 3.0 Management The consultant on-call MUST be informed about every 3 rd or 4 th degree tear. This should be documented in the woman s health care record. Repair must be carried out in theatre with adequate assistance and illumination under regional or general anaesthesia. This document is valid only on date last printed Page 2 of 5
Only an appropriately trained obstetrician should undertake this level of repair. If necessary a referral should be made to a colorectal surgeon. (Please refer to Maternity Training Needs Analysis - CG360). The woman should be informed of the extent of the trauma. Appropriate consent for repair must be obtained- (Hyperlink to RCOG consent advice no. 9) 4.0 Technique The woman should be placed in lithotomy and cleansed with an Octenalin solution and draped The rectal mucosa if damaged is sutured with fine, interrupted Vicryl sutures taking care to approximate the mucosal edge and tying the knot in the rectal lumen. The anal sphincter is repaired with at least two interrupted Vicryl sutures (the retracted end may need a temporary traction suture), using an overlapping technique or end-to-end. At the Royal Berkshire Hospital we DO NOT use PDS only Vicryl. The remainder of the perineum is repaired according to the guideline Episiotomy repair (see Episiotomy and perineal trauma guideline GL836). A urinary catheter should be inserted until full bladder sensation has returned if regional anaesthesia is used Detail of the procedure must be documented both in writing and pictorially on the perineal repair sheet in the woman s health care record or K2. Post-operative instructions must cover dietary bulking agents and laxatives. Broad spectrum antibiotics ARE recommended. Antibiotics must be prescribed on Trust prescription chart Post-operative pain relief Paracetamol 1g orally up to 4x daily Non-steroidal anti-inflammatory (NSAIDs) options: o Diclofenac 100mg rectally. If this method of administration chosen the prescriber is responsible for ensuring that any ibuprofen prescribed/administered subsequently is not done so for 12-16 hours following Diclofenac administration. This must be clearly documented on the drug chart. o Alternatively prescribe and administer oral ibuprofen 400mg up to 4x daily This document is valid only on date last printed Page 3 of 5
Oral codeine phosphate 30-60mg up to 3 times daily may be given to those unable to take NSAIDS or those requiring additional analgesia. Please provide patient information leaflet titled: 'Codeine and breastfeeding' Offer the woman the maternity information leaflet Management of 3rd & 4th degree tears, discuss care for sutures document in maternal health record Arrange physiotherapy review on the ward and pelvic floor exercises taught and started* before discharge. Complete clinical incident form Postnatal review should be arranged in the relevant consultant s clinic in 6-12 weeks. Routine episiotomy is NOT recommended in subsequent deliveries. The wound should be visualised at each postnatal examination and documented in the woman s postnatal health record In the event of serious breakdown or infection the woman should be referred to the Day Assessment Unit and reviewed by a senior obstetrician. A perineal assessment tool should be commenced (see Multi-disciplinary wound assessment and care plan tool). All cases of perineal breakdown or infection referred to the Day Assessment Unit will be monitored and reported monthly to the Maternity Clinical Governance Committee. Where trends are identified action will be taken In the case of urinary or faecal incontinence or recto vaginal fistulae the woman should be referred to a specialist gynaecologist or colorectal surgeon. 5.0 Auditable standards: 1. Perineal suturing will commence within one hour of delivery of the placenta. 2. All 3rd and 4th degree tears will be repaired by an obstetrician that has undergone 3rd and 4th degree tear training. 3. Consent will be sought and documented for all types of perineal trauma repair. This will be documented in the Perineal repair documentation page 4. In all cases where perineal trauma is sustained the form Examination of the vagina, labia & perineum to ensure systematic assessment of the trauma sustained and suturing, or perineal repair details will be fully completed (as applicable). 5. Suturing will be offered for all 3rd and 4 th degree tears. The routine suturing material and the method of repair will be as stated in the guideline. This document is valid only on date last printed Page 4 of 5
6. All women that sustain a 3 rd and 4 th degree tears will have antibiotics prescribed, repaired carried out in theatre, and will be offered a 6 weeks postnatal appointment. An incident form will be completed in all cases where a 3 rd or 4 th degree tear has been sustained. 7. All women will be offered the PIL Perineal trauma Management of third and fourth degree tears for third/fourth degree tears. Caring for sutures will be discussed for all women that have undergone perineal repair. This will be documented in the maternal health care record. 6.0 References 1. Royal College of Obstetricians & Gynaecologists. (2015). The management of Third and Fourth Degree Perineal Tears. Green-top guideline No.29 London: RCOG. 2. National Institute for Health and Care Excellence. (2014). Intrapartum care for healthy women and babies London: NICE 3. Consent Advise No.9 RCOG June 2010. Repair of Third & Fourth Degree perineal Tears following Childbirth - hyperlink to RCOG This document is valid only on date last printed Page 5 of 5