NHS FORTH VALLEY

Perineal Repair

Approved 22/07/2008
Version 1.0
Date of First Issue 01/07/2006
Review Date 01/08/2010
Date of Issue 01/08/2008
EQIA Yes 28/07/2008
Author / Contact Debbie Houston

Group / Committee Unit Business Meeting

– Final Approval
NHS Forth Valley

Consultation and Change Record

Contributing Authors: Anne Paterson and Paul Holmes

Consultation Process: Obstetric Consultants, Midwifery Managers, Midwifery Team

Leaders and Clinical Shift Co-Ordinators

Distribution: Women and Children’s Unit

Change Record
No changes Required
 NHS Forth Valley
Women & Children’s Unit

1
PERINEAL REPAIR

; All women having a vaginal delivery MUST have a systematic examination of the
perineum, vagina and rectum to assess the severity of damage prior to suturing
(NICE 2007)

; Following all vaginal deliveries a rectal examination should be undertaken to

ensure that 3rd and 4th degree tears are recognised. If you are unsure of what
you are seeing on inspection of the perineum ask for assistance from Middle
Grade Doctor. It is critical that 3rd and 4th degree tears are identified and
effectively managed

; When a 3rd or 4th degree tear is diagnosed follow Management of 3rd & 4th
Degree Perineal Tear protocol

CLASSIFICATION OF PERINEAL TEARS (NICE 2007)

This classification allows differentiation to be made between injuries to the external anal
sphincter (EAS), internal anal sphincter (IAS) and anal epithelium.

Degree Trauma
First Injury to the skin only
Second Injury to the perineum involving perineal muscles but not
involving the anal sphincter
Third Injury to the perineum involving the anal sphincter complex
Fourth Injury to perineum involving the anal sphincter complex (EAS
and IAS) and anal epithelium
; I
t is current Unit policy to repair any perineal trauma involving muscle tissue
; Women should be advised that in the case of first-degree trauma, the wound
should be sutured in order to improve healing, unless the skin edges are well
opposed. NICE Guidelines (September 07). There is no evidence to support
leaving 2nd degree or worse unsutured.
; Practitioners must be cautious about leaving trauma unsutured unless it is the
woman’s explicit wish; this must be documented in the case notes
PREREQUISITE FOR MIDWIVES SUTURING
; Midwives will have read the current protocol on perineal repair
; Midwives will have sound knowledge of the structure and anatomy of the
perineum
; Midwives have attended the perineal repair study day
; Midwives will have received instruction on perineal repair by an experienced
operator
; Midwives will be supervised until they feel confident / competent in their practice
or are deemed competent by an experienced operator
; Student midwives will always be supervised
 NHS Forth Valley
Women & Children’s Unit

PERINEAL REPAIR 2

PURPOSE OF REPAIR
; To control bleeding
; To prevent infection
; To assist the wound to heal by primary intention – healing is usually rapid and
scarring is minimal providing there is no infection or excessive
bleeding/haematoma
; If the wound is left unsutured it will heal by secondary intention with the formation
of granulation tissue, which contracts to form scar tissue.

The following are the basic principles and constitute good practice when repairing any
perineal trauma

PRINCIPLES OF REPAIR
1. Check the extent of perineal trauma by thoroughly examining the vagina and
perineum to establish the extent of the trauma. A rectal examination should be
performed as part of the assessment following vaginal delivery
2. Suture as soon as possible after delivery; ideally this should be carried out within
30 minutes following the third stage of labour. Repair is less painful and this also
reduces the risk of infection
3. Ensure good anatomical restoration and alignment to encourage healing; when
aligned properly the process of wound healing begins.
4. Ensure haemostasis. Suturing must achieve this in each part of the repair
otherwise haemorrhage can continue between the layers resulting in a
haematoma or post partum haemorrhage
5. Handle tissue gently using dissecting forceps
6. Close all dead space; haemorrhage may occur into areas of dead space resulting
in a haematoma
7. Use minimal amount of suture material. An excessive amount of sutures may well
cause severe discomfort in the puerperium and beyond. Only enough sutures to
achieve haemostasis are required
8. Don’t over-tighten sutures or have too loose as this may impede healing
(“approximate, don’t strangulate”)
9. Make sure knots are tied securely but are not too bulky
10. Rectal examination after completing the repair will establish if any suture material
has been accidentally inserted through the rectal mucosa. Inform Middle Grade
Doctor if this found on examination
 NHS Forth Valley
Women & Children’s Unit

PERINEAL REPAIR 3

ANALGESIA DURING SUTURING

If the woman has an epidural, ensure that it provides adequate pain relief. If it does not
then local anaesthesia should be used.

The perineum is infiltrated using Lidocaine 1% see: Patient Group Directive. The total
amount of Lidocaine 1% should not exceed 20mls, (including infiltration for episiotomy)
which should provide effective analgesia for the woman.

PRIOR TO COMMENCING THE REPAIR

Place the woman in a comfortable position or if necessary use lithotomy poles. The
baby can continue with skin-to-skin contact throughout the procedure. Support can be
given from her partner to assist this.

1. Check you have all the equipment required

2. Check swabs/sutures/local anaesthesia with an assistant prior to commencing
procedure
3. Thoroughly examine vagina and perineum to establish the extent of the trauma.
If more extensive than originally thought or if there is any doubt regarding the
extent of trauma or structures involved ask for the assistance of Senior Sister
Midwife/Middle Grade Doctor. Difficult trauma should be repaired by an
experienced operator in theatre under regional or general anaesthesia. DON’T
BE AFRAID TO ASK FOR ASSISTANCE
4. Insert a vaginal tampon only if necessary, to provide a clearer view. If tampon
required press fundus, mop out vaginal vault and insert tampon, securing tail with
an artery forceps
5. Ensure you have adequate light to carry out repair
6. Fully explain the extent of the trauma and suturing procedure to the woman and
gain her verbal consent

SUTURE MATERIAL
The use of a more rapidly absorbed synthetic suture, such as Vicryl Rapide is
associated with a significant reduction in perineal pain, analgesia used, dehiscence,
resuturing and reduction in suture removal when compared with standard absorbable
synthetic material (RCOG 2007).

; A suitable suture material is No 2/0 Vicryl Rapide, W9962

 NHS Forth Valley
Women & Children’s Unit

PERINEAL REPAIR 4

METHOD OF CHOICE FOR THE REPAIR

‘ A loose, continuous non-locking suturing technique used to appose each layer (vaginal
tissue, perineal muscle and skin) is associated with less short term pain compared with
the traditional interrupted method’ (NICE 2007)

METHOD OF REPAIR – MODIFIED FLEMING TECHNIQUE

1. Confirm the local anaesthetic is working before commencing suturing
2. Insert a vaginal pack, only if necessary, to provide a clearer view of the area to
be sutured (this should not be routinely done)
3. Identify anatomical landmarks
4. Identify the apex of the wound. Place the first stitch approximately 0.5 cm beyond
the apex to allow for haemostasis of any small vessels, which may have retracted
beyond this point
5. Repair the vaginal wall using a continuous stitch with approximately 0.5 cm
between each bite
6. Carry out the repair from apex to the introitus; ensuring sutures are not placed in
the hymenal remnants.
7. At this point place the needle behind the exit point of the last stitch. Sweep it
under the fourchette bringing the suture material out into the perineal muscle.
Alternatively, where there is a deep tear that requires the muscle to be repaired in
2 layers, repair from apex to hymenal remnants and then sweep suture behind
last stitch to repair the muscle layer
8. Repair the perineal muscles in one or two layers with the same continuous stitch.
It is important to appose the muscle edges carefully and leave no dead space.
Usually three or four stitches are all that is required in any one layer
9. At the distal end of the tear/episiotomy, reposition the needle in the needle holder
so that it points in the opposite direction
10. Using a side-to-side technique when suturing subcutaneously (1/2 cm bites),
continue until the proximal end of the wound is reached
11. Sweep the needle behind the fourchette back into the vagina. Pick up a small
amount of vaginal tissue to tie off the stitch and cut (the knot is tucked into the
vagina to minimise discomfort). Alternatively, the repair may be completed using
the “Aberdeen” knot
 NHS Forth Valley
Women & Children’s Unit

PERINEAL REPAIR 5

IMMEDIATE POST OP CARE

1. Inspect the repair to check that haemostasis has been achieved. NB – an
excessive amount of sutures may well cause severe discomfort in the
puerperium and beyond. Only carry out the required amount of suturing to
achieve haemostasis
2. Remove the vaginal tampon, if used, and account for all instruments, swabs
and needles – discard of sharps safely
3. Perform rectal examination following completion of the repair to detect any
suture material which may have been accidentally inserted through the rectal
mucosa
4. Diclofenic Acid 100mgs may be given PR, if no contraindications
5. Remove woman's legs from lithotomy position
6. Make the woman comfortable
7. Document repair and sign prescription for local anaesthetic (PGD)
8. Any difficulty experienced in suturing should be documented in the labour
notes, e.g. excessive bleeding, friable tissue, bruising, etc.
9. Explain the extent of trauma and advise woman regarding hygiene and pain
relief associated with perineal trauma
10. Document procedure in the woman’s notes

GUIDANCE FOR DOCUMENTATION 0F PERINEAL REPAIR

11. Date and time of repair of laceration/episiotomy
12. Procedure explained and consent obtained.
13. Anaesthesia achieved with ……..mls of 1% Lidocaine
14. Apex identified and repair carried out using Vicryl Rapide 2/0. Document
repair method used
15. Haemostasis achieved
16. PV and PR satisfactory
17. Swabs, sutures and instruments correct
18. Perineal hygiene advice given
19. Sign and print name and designation

REFERENCE
NICE (2007) Intrapartum care: Management and delivery of care to women in
labour September 07

August 2008: Review August 2010 or Sooner

Debbie Houston