Obstetrics and Gynecology - A.M. Gromova 2000

Birth injuries
Perineal and vulvar tears

Perineal tears occur in 10% of deliveries. The occurrence of perineal tears is facilitated by the following circumstances:

— loss of tissue elasticity in elderly primigravidae, and scars from previous labors;

— a high Perineum;

— expulsion of the fetal HEAD in an unfavorable dimension, which is observed in deflexion presentations or an excessively large head;

— operative deliveries;

— a contracted pelvis;

— improper Management of Labor.

Perineal injury does not happen suddenly; it is preceded by changes indicating an imminent tear. Signs of an impending perineal tear include a dome-shaped protrusion of the perineum, which becomes cyanotic and edematous. Subsequently, the Skin of the perineum pales, becomes shiny, and develops fine fissures.

Three degrees of perineal tears are distinguished.

First-degree tear — the perineal skin is damaged, while the perineal Muscles remain intact.

Second-degree tear — the perineal skin, vaginal wall, and perineal muscles are damaged, excluding the external anal sphincter.

Incomplete third-degree tear — the aforementioned Tissues and the external anal sphincter are ruptured, while in a complete third-degree tear, the wall of the rectum is also involved.

Central perineal tear is characterized by damage to the center of the perineum while the posterior commissure remains intact. The fetus is born not through the vulvar cleft, but through an opening formed in the center of the perineum.

Repair of Perineal Tears

Suturing of the perineum is performed after the delivery of the Placenta. The repair of perineal tears is carried out adhering to all aseptic rules. For first- and second-degree tears, sutures are placed under local novocaine anesthesia; for third-degree tears, sutures are applied under general anesthesia.

During suturing, the parturient woman is positioned so that the pelvic region is at the edge of the table, with her legs flexed at the knee and hip joints, drawn toward the abdomen, and abducted.

In a first-degree tear, catgut sutures are first applied to the vaginal mucosa, followed by silk sutures to the perineal skin. The sutures are placed 1 cm apart from each other. The needle is passed beneath the Base of the wound. When tied, the wound edges must be in close apposition.

In a second-degree tear, a suture is first placed at the upper angle of the wound, after which the torn perineal muscles are joined using several buried catgut sutures (these sutures must not capture either the skin or the mucosa). Thereafter, catgut sutures are applied to the vaginal mucosa up to the posterior commissure. The ends of the ligatures are cut, except for the suture placed on the commissure. This last suture is pulled upward to facilitate the suturing of the perineal skin. Silk sutures are applied to the perineal skin and their ends are cut. The sutured wound is painted with iodine tincture.

In a third-degree tear, the ruptured rectal wall is repaired first, after which the separated ends of the torn sphincter are identified and approximated with sutures. Subsequently, sutures are applied in the same order as for a second-degree perineal tear.

Postoperative care for perineal tears consists of keeping the suture line clean. During perineal care, the suture area is not washed; it is only carefully dried with a sterile swab and smeared with a disinfectant solution. After urination and defecation, additional care of the external genitalia and drying of the suture area are performed. In cases of a third-degree tear, tincture of opium is additionally administered, 8–10 drops twice daily until the sixth day, to delay bowel movements. Diet — diet table no. 1, as after surgery: sweet tea, fruit jellies, broth, and other easily digestible foods. On the sixth day, castor oil is prescribed. Silk sutures are removed from the perineal skin on the 5th–6th day. The parturient woman is allowed to get out of bed the day after suture removal.