Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 198 views

    Nhs Forth Valley: Perineal Repair

    Uploaded by

    Kamilah Shafii
    This document provides guidelines for perineal repair following vaginal childbirth. It outlines that all women must have a systematic examination after delivery to assess perineal trauma. It also classifies degrees of trauma from first to fourth degree. The guidelines recommend repairing any trauma involving muscle tissue. It describes principles of repair including timing, anatomy restoration, haemostasis and use of minimal sutures. It recommends using Vicryl Rapide sutures and a continuous non-locking technique. A step-by-step modified Fleming technique is outlined.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Nhs Forth Valley: Perineal Repair

    Uploaded by

    Kamilah Shafii
    198 views7 pages
    This document provides guidelines for perineal repair following vaginal childbirth. It outlines that all women must have a systematic examination after delivery to assess perineal trauma. It also classifies degrees of trauma from first to fourth degree. The guidelines recommend repairing any trauma involving muscle tissue. It describes principles of repair including timing, anatomy restoration, haemostasis and use of minimal sutures. It recommends using Vicryl Rapide sutures and a continuous non-locking technique. A step-by-step modified Fleming technique is outlined.

    Original Title

    PerinealRepair

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidelines for perineal repair following vaginal childbirth. It outlines that all women must have a systematic examination after delivery to assess perineal trauma. It also classifies degrees of trauma from first to fourth degree. The guidelines recommend repairing any trauma involving muscle tissue. It describes principles of repair including timing, anatomy restoration, haemostasis and use of minimal sutures. It recommends using Vicryl Rapide sutures and a continuous non-locking technique. A step-by-step modified Fleming technique is outlined.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    198 views7 pages

    Nhs Forth Valley: Perineal Repair

    Uploaded by

    Kamilah Shafii
    This document provides guidelines for perineal repair following vaginal childbirth. It outlines that all women must have a systematic examination after delivery to assess perineal trauma. It also classifies degrees of trauma from first to fourth degree. The guidelines recommend repairing any trauma involving muscle tissue. It describes principles of repair including timing, anatomy restoration, haemostasis and use of minimal sutures. It recommends using Vicryl Rapide sutures and a continuous non-locking technique. A step-by-step modified Fleming technique is outlined.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    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

    You might also like