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MRCOG PART 2 SBAs and EMQs

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Essay 358

Posted by Mamta B.

Preoperative management:

  • I would take the history regarding any antepartum or intrapartum complications-medical disorders like diabetes, hypertension, obstetric problems like big baby, precipitate delivery.
  • Assess the general condition of the patient- pulse, BP, amount of bleeding, whether uterus is well contracted.
  • Before examination, inform about the procedure and take an informed consent.
  • Put in an IV cannula. At the same time take some bloods- FBC, clotting screen
  • Ensure adequate analgesia/ inhalational analgesia and adequate lighting.
  • Do a vaginal examination to see the extent of tear. Also a PR examination to assess the intactness of the anal sphincter and rectal mucosa. 
  • Explain the nature of the tear to the patient and relatives and the procedure required to repair it and the complications anticipated, like incontinence of flatus, and stools, hematoma, rectovaginal fistula. - take a consent .

Intraoperative management given that a 3c tear is confirmed:

 

  • Repair of perineal tear should be undertaken in the operation theatre under anaesthesia/ analgesia, with adequate lighting after taking informed consent.
  • I would do a detailed examination including vaginal and rectal examination to assess the extent of injury.

I would repair the tear in layers-

Internal anal sphincter repair with interrupted or mattress using 3-0 polydioxanone(PDS).

External anal sphincter is repaired with 2-0 PDS, either end to end or overlapping technique.

Vaginal mucosa with continuous suture with 2-0 absorbable polygalactin rapid.

Skin with 2-0 polygalatin rapid-subcuticular stitches.

  • I would document the procedure in detail and the sutures used and extent of injury in the operative notes. And fill in the incident form.
  • I would ensure that the patient has voided urine in the postoperative period.
  • I would ensure patient receives adequate postoperative analgesia in the form of NSAIDS(after ensuring that the patient does not have any allergies). Avoid opiates(as they can cause constipation) and rectal suppositories.
  • Iv Broad spectrum antibiotics intra-op and then oral antibiotics for 7 days.
  • Laxatives to prevent constipation.
  • Discharge the patient home only after she opens her bowels.
  • Advise regarding perineal exercise and physiotherapy.
  • On discharge, I would like to advise the patient regarding diet, hygiene and symptoms of complication- incontinence of flatus and stools, excessive pain in perineum(due to hematoma) or any form of discharge PV.
  •  I would like to follow her up in 12 weeks time in order to assess her recovery and to check whether she has any complications in the form of incontinence of flatus or stools.
Posted by I N.

A) The clinical assessment should be started with a brief history about the patient including the parity of the woman, the mode of delivery of her previous pregnancies and he possibility of any anal sphincter injury during her previous deliveries. The timing of this antecedent delivery is also important to be elicited. Then a thorough clinical examination should be performed ideally in the lithotomy position with good light. The examination can be quite uncomfortable therefore appropriate explanation should be provided to the patient and the importance of the thorough examination should be stressed. Analgesia in the form of local anaesthetic combined with entonox is also essential to allow a good examination of the perineal tear. Initially the perineum should be inspected and an assessment of the amount of bleeding to be made. A per rectum (PR) examination is essential to identify the anal sphincter assess the degree of the third degree tear and rule out a 4th degree tear. Explain the findings to the patient and partner and inform the anaesthetis and theatre staff about the need to go to theatre to repair the tear. An intravenous access should be sited and a FBC and G+S sample obtained pre-operatively. The patient should be consented for the repair of the tear in theatre and the risks of infection, bleeding and possible risk of future incontinence of flatus and faeces explained.

 

B) The perineal tear should be repaired under spinal analgesia unless the patient already had an epidural sited during labour. This will provide adequate analgesia and also allows the sphincter to relax and enable the surgeon to pull the edges back together as the edges normally retract after the tear. The anaesthetist should be asked to give a dose of intravenous antibiotics to reduce the risk of infection intraoperatively. The area should be cleaned with an antiseptic and draped with sterile drapes. A further PR examination in lithotomy position should be performed in theatre with better light to confirm the findings and grade the tear (3a if <50% of sphincter torn, 3b if>50% of sphincter torn, 3c if the internal sphincter is torn as well). The gloves should be changed everytime after a PR examination to minimise the risk of infection. If a 3C tear is identified, the internal anal sphincter should be repaired separately to the external sphincter and the suture of choice would be either PDS or vicryl. Then the external anal sphincter can be repaired with interrupted sutures with either end to end or overlap technique again with either vicryl or PDS. Both thechniques have been shown to be equally effective. If the PDS is used, because its tensile strength lasts for longer, there is a risk that the stitch endings may migrate to the skin and be uncomfortable for the patient, therefore it is important to try and burry the PDS knots under the perineal muscles. After the completion of the repair, a repeat PR examination is important to ensure that the anal sphincter bulk has been restored and that there are no sutures that have passed throught the anal mucosa. This last PR examination could be combined with the administration of PR analgesia that would be beneficial for post-operative pain. It is important to ensure that the patient is prescribed antibiotics for at least 5 days as well as laxatives for about 10 days after the repair in order to prevent any infection and avoid any strain that would disrupt the stitches. Finally a postnatal follow up should be organised for 6/52 post-natally to review the patient and her symptoms.

Posted by A 4.

a. I will review the patient's notes to identify if she had a previous third degree tear as this may increase her chances of being symptomatic after the repair and I will need to counsel her appropriatly. I will record the estimated blood loss at delivery so I can make an accurate blood loss calculation after the repair. I will need to examine the patient with a good light in lithotomy and perform a rectal examination to identify the external and internal anal sphincter. This will be uncomfortable for the patient if she does not have an effective epidural so I will offer her gas and air. If I identify a vessel that is actively bleeding and there will be a delay in transfer to theatre if a third degree tear has been identified, then I will secure any bleeding vessels so I can acheive haemostasis. I will explain my findings to the woman and obtain written consent. In the consent form I will explain the purpose of repair is to prevent symptoms of faecal and flatus incontinence and rebuild the perineum and this needs to be performed in theatre where she will have effective anaesthesia, good lighting and aseptic technique to prevent infection. I will explain the risk of infection may be prevented with intraoperative and postoperative antibiotics and vulval hysgeien. The risk of bleeding is common. Faecal and flatus incontinece are common but may improve with pelvic floor exercises. She will be referred to a physiotherapiat. There is a risk of wound breakdown and this may prevented by avoiding straining and taking lactulose an Fybogel for 10 days to prevent constipation. Rarely there is a risk of fistula formation and need for a secondary repair. I will explain to her that we will review her in a consultant clinic in 6-8 weeks to look for any complications and review her perineum. I will explain that additional procedures include blood transfusion if she bleeds very heavily. I will give her an information leaflet and a copy of the consent form.

I will cannulate her and send a group and save and full blood count if this has not already been done. I will prescribe 150mg of oral ranitidine or 50mg of IV ranitidine in the event she has to have a general anaesthetic. I will inform the anaesthetist, ODP, theatre team and the coordinating midwife. A senior obstetric trainee ST6/7 or consultant should be supervising the repair so they should be informed if necessary. I will ask the midwife to performa a theatre checklist.

b. I will perform the repair in theatre, position the patient in lithotomy with sterile drapes to reduce the risk of infection. Intraoperatively I will ask the anaesthetist to administer intravenous prophylactic antibiotics such as Cefuroxime 1.5g and Metronidazole 500mg to reduce the risk of infection. I will insert an indwelling catheter and leave this in situ for 12 hours to prevent urinary retention as the patient will have a dense regional block. I will ask for an assistant to ensure I have adequate exposure to the perineum. I will clean the perineal area with chloroxehidine and insert a vaginal tampon to ensure good exposure. I will identify the internal sphincter and grasp it with Alice forceps. I will close the internal sphincter with an absorbable suture 3-0 vicryl using interrupted sutures. I will then identify the external anal sphincter and grasp it with Alice forceps. The external sphincter may need dissecting to free the ends and I will do this at this point if I will be performing the overlapping technique. This may not be required if performing the end-to-end technique. I will use an absorbable suture either 3-0 PDS or 3-0 vicryl. If 3-0 PDS is used the knots may cause anal fissures and irritation so it is important to cut the suture short and bury the knot by closing the superficial perineal muscles above the anal sphincter. I will suture vaginal mucosa and muscular layer using continuous vicryl rapide 2-0 suture and continue closing the skin subcuticular with the same suture. I will inspect the perineum for any other tears and repair these if necessary. If the tear is oozing and the tissue is friable I may leave a vaginal pack insitu to ensure haemostasis and prevent vaginal haematoma. I will perform a rectal examination to identify any sutures that may have penetrated the rectal mucosa. If there are not contraindications then I will insert a Diclofenac suppository. I will make an estimated total blood loss in conjunction with the anaesthetists and perform a needle and swab count to confirm there is not swabs or tampons left in the patient. 

 

Essay 358 Posted by Christa R.

a)

I would first of all introduce myself to the patient and explain that I have attended because there is a concern that following the birth of her baby, she has sustained a tear that has extended to the muscle around her back passage (anus).  I would inform her of the importance of identifying and repairing such tears, as if they are missed it could lead to significant problems with control of her bowel (faecal +/- flatus incontinence).  As I am intoducing myself I would assess whether the patient appears stable and observe for significant PV loss.  I would ask the midwife for a set of observations on the patient (HR, BP, SaO2, RR, temp) and  enquire about the labour and the use of any analgesia, for example epidural anaethesia (which I may indeed notice from the end of the bed).  After gaining consent, I would proceed to examine the woman.  I would initially check the tone of her uterus abdominally and if it is well contracted I would proceed to a systematic vaginal and perineal examination, including a PR.  I would adjust the lighting and  if the woman has not had any analgesia, I would encourage the use of entonox during my initial assessment.  

Following suspicion of a 3rd degree  tear, I would inform the on call consultant (obstetrician),along with the anaesthetist, the theatre team and the midwife in charge.  If I had any concerns about the possibility of a 4th degree tear, I would request the consultant obstetrician to attend, along with the colorectal surgeon.  I would ensure the patient has IV access and take bloods for FBC and G&S.  If I am concerned about significant bleeding I would XM blood.  I would then gain written consent  from the patient allowing me to take her to theatre to properly assess and then repair her 3 degree tear.  I would explain that it is better to repair the tear in theatre as it provides better lighting, asepsis and analgesia which all contribute to a better outcome.   The tear can either be repaired under regional anaesthesia (EDB or spinal) or under GA.   During the consenting process I would highlight the complications which include: infection, bleeding, haematoma formation, pain, breakdown, ongoinging problems with contol of her bowel (faecal +/- flatus incontinence) and thromboembolism.  I would explain that I will be prescribing a course of antibiotics to be taken afterwards to minimise the risk of infection, along with a stool softner so as not to strain when opening her bowels.  I will inform her that I will be inserting a urinary catheter, which, if all is well will be removed the following morning.

 

b)

In theatre, prior to commencing the repair I would check my instruments.  As a minimum I would ensure  the tray has 4 Allis forceps, 4 artery forceps, McIndoe scissors, stictch scissors and a needle holder.  Once the patient is on the table I would ensure all members of my theatre team present and perform the  WHO check.  The patient would then be placed into lithotomy, prepped with antiseptic skin wash and draped.  I would ensure the anaesthetist gives a dose of IV broad spectrum antibiotics (co-amoxiclav or cef & met) and  I would ensure good lighting.  I would then perform a thorough, systematic examination of the vagina and perineum with rectal examination.  During the rectal examination I would have my index finger in the anal canal and my thumb in the vagina.  With a pill rolling motion, I would assess the ano-rectal mucosa and sphincter.  I would carefully assess both the internal and external sphincter.  On identifying the 3c tear I would identify and grasp both ends of the internal anal sphincter with Allis forceps.  I would then perform an end -to- end repair of the internal sphincter  using matress sutures with 3-0 PDS.  Once the internal sphincter has been repaired I would then grasp the ends of the  external anal sphincter( with Allis forceps) and perform either an end-to -end or overlapping repair of the sphincter using 3-0 PDS.  If using the overlap technique, I would dissect around the retracted ends of the sphincter with the McIndoes, separating it from the ischio-anal fat laterally and ensuring the full length of the sphincter is identified before attempting the repair.  Once the sphincter is repaired I would repair the vaginal mucosa and the perineal muscles, reconstrucing the perineal body providing support the repaired anal sphincter.  For this part of the repair I would use 2-0 vicryl.  I would then perform a recto-vaginal examination (PR &PV) once more, to not only confirm complete repair and check haemostasis, but also to ensure that all swabs and the tampon have been removed.  At the end of the procedure I would place an indwelling urinary catheter and ensure my swabs, sharps and instrument count is correct.  My operation notes would include documention of my findings and the technique of my repair.  I would also document that the patient should be seen by the physio whilst an inpatient and is only to be discharged once she has opened her bowels and has been seen by myself.  I will arrange and OPD appt for 6-8 weeks post partum.  I would finally write up LMWH (1st dose 6 hours post op), antibiotics and lactulose/fybogel on the drug chart.

  

Essay 358 Posted by Candice W.

(a)

I would ask in the history for her parity as nulliparous patients are at higher risk of perineal tears. I would check if she had any prior 3rd or 4th degree tear and associated incontinence problems previously. By looking through her antenatal notes, I would check for any GDM or evidence of fetal macrosomia this pregnancy which are risk factors for perineal tears. I would check with the midwife if there were problems in the 2nd stage of labour such as shoulder dystocia or use of vacuum or forceps, as well as if any midline episiotomy was performed. Lastly I would check if the patient has any form of analgesia such as epidural.

Examination should not interfere with the skin-to-skin contact between the patient and her baby unless she is actively bleeding. It has to be undertaken by someone with experience or at least under supervision of an experienced operator. It is essential to have adequate lighting and the patient in lithotomy position for proper examination. I would ensure that the patient has adequate analgesia before examining her. The extent of bleeding is assessed and a per vaginal and per rectal examination would be undertaken simultaneously to assess for the extent of tear.

A group and save, and FBC would be taken in cases of excessive bleeding which may require transfusion.

I would inform the consultant obstetrician of my examination findings and need for repair of a third degree tear in operating theatre. The anaesthetist would be informed as well to help with giving the patient anaesthesia or analgesia to facilitate repair. I would inform the patient the extent of tear and need for repair in operating theatre under anaesthesia to restore perineal anatomy and prevent future faecal incontinence. Serious risks would  include fistula formation, haematoma and urinary/faecal incontinence. Frequent risks would include difficulty in passing stools initially, wound infection,urinary infection,  migration of knots causing discomfort, dyspareunia, keloid/immature tissue scar formation. I would get her to sign the consent if she is agreeable. An incident report would be submitted as well.

(b)

The repair has to undertaken by someone with experience or done under supervision of an experienced operator in the operating theatre with adequate lighting and assistants. The patient should have adequate analgesia with regional or general anaesthesia and in lithotomy position. I would examine her again as she is now relaxed, and confirm the extent of tear. Intra operative antibiotics would be given and an indwelling urinary catheter inserted.

I would identify the internal anal sphincter and repair with interrupted 3-0 polydiaxanone or polygalactin sutures with knots buried under perineal muscles to prevent knot migration. I would identify the external anal sphincter and repair with 3-0 polydiaxanone or polygalactin sutures with either the overlap or end-to-end  method. Knots will be buried under perineal muscles to prevent knot migration. The vaginal apex would be identified and vaginal wall repaired in a continuous manner with non-locking vicryl rapid sutures. The perineal muscles are identified and repaired in continuous non-locking vicryl rapid sutures. Lastly, the skin is opposed with subcuticular vicryl rapid sutures.

I would do a final examination to ensure that I have secured all bleeding points and not missed other tears. No suture material should be felt on per rectal examination. Swabs and instruments are checked to make sure all are accounted for. I would give her per rectal analgesia at the end of the surgery.

ans to essay 358 Posted by m T.

Qn: You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks].

a) Firstly I will do a quick review of her labour - was there any shoulder dystocia, instrumental delivery, fetal macrosomia? What was the birth weight of the baby? She should not be separated from her baby unless she is actively bleeding. She should be examined under adequate lighting and analgesia,in lithotomy position, to confirm that she has a 3rd degree perineal tear. This should be assessed or at least supervised by an obstetrician with suitable experience and training in identifying and repairing 3rd degree perineal tears. I will then explain to her the need for examination under anaesthesia and repair of perineal tears in the operating theatre. I will explain that she has a perineal tear that has extended to her anal sphincter. I will tell her the possible consequences of a 3rd degree tear including serious but less common risks such as rectovaginal fistula especially if left unrepaired; faecal incontinence can occur and is due to the tear, not from the repair; wound infection and haematoma. Other common risks include faecal urgency, flatus incontinence. She will need to come for follow up appointments and be referred to a physiotherapist for pelvic floor exercises post operatively. I will reassure her that most women recover well after adequate surgical repair. I will then explain the procedure, obtain consent from her and inform the anaesthetist. Analgesia/anaesthetic options should be discussed with the patient.

b) Ensure that there is good lighting and adequate analgesia/anaesthesia for the patient. The anal sphincter is relaxed when the patient is under anaesthesia and that will aid surgical repair. An assistant should be present and the procedure performed by a suitably trained and experienced obstetrician. Repeat assessment of the tear by doing a per vaginal and per rectal examination. Under aseptic techniques, first identify and repair the internal anal sphincter with Vicryl 2-0 or PDS 3-0 using end to end or overlapping sutures. Then identify and repair the external anal sphincter similarly. Ensure the knots are buried under the superficial perineal muscles to prevent knot migration. After that proceed to identify the apex of vaginal tear and repair with continuous nonlocking absorbable sutures such as Vicryl rapide, followed by repair of perineal muscles using continuous nonlocking absorbable sutures. Then repair the skin with subcuticular rapidly absorbable continuous sutures as this is associated with less pain postoperatively.

Swab counts should be checked before and after repair. Repeat per rectal examination after repair to ensure that no sutures have been placed in the rectal mucosa. Insert an indwelling catheter and order prophylactic antibiotics.

Posted by Lola B.

(a) I would ensure she is haemodynamically stable by checking her pulse for tachycardia and blood pressure for hypotension. If she is actively bleeding and requires resuscitation, I would call for help early and ensure that the repair is done as soon as possible. I would give her intravenous crystalloids like Hartmann’s solution and ensure blood is ready for standby and blood is transfused early if required and the patient is agreeable. I would check that her placenta has been delivered and her uterus is well contracted. I would confirm the diagnosis by doing a vaginal examination looking at the integrity of the external and internal anal sphincters, if any of the anal sphincters are torn then the diagnosis of 3rd degree laceration is made. I would also check for other vaginal and cervical lacerations if present. I would do a per rectum examination to ensure that the rectal mucosa is intact otherwise it would be a 4th degree laceration. After confirming the diagnosis, I would explain to the patient the diagnosis and explain to her the subsequent management needed. I would need to do blood investigations like a full blood count to check her baseline haemoglobin if it has not been done and ensure blood is crossed matched. I would ensure that she has an intravenous cannula inserted. I would explain to her that she needs to go to the operating theatre for repair of her vaginal tear to ensure that there is adequate lighting and support and explain the procedure to her. I would take an informed consent by explaining that the common risks of a 3rd degree tear are flatus incontinence and faecal urgency however, most will do well if the injury is repaired. The other risks are infection which we would give prophylactic antibiotics pre and post operatively to prevent infection. The risk of bleeding which might require blood transfusion. The risk of haematoma forming which might require a second operation. I would inform the anaesthetist to review her to ensure that she has adequate analgesia during the repair like a spinal or epidural anaesthesia. I would inform the operating theatre staff to prepare the theatre for the operationI would inform the consultant and ensure adequate help is available if I am not qualified to repair it independently.

 

(b) Intraoperatively, I would ensure it is done in an operating theatre with adequate lighting and exposure. The anaesthetist needs to ensure that she has adequate anaesthesia like spinal or epidural. I need to ensure a senior obstetrician is available in the theatre for the surgery. She needs to be in a lithotomy position with a screen to block her view of the operating field if she is under regional anaesthesia. We need to clean her vagina, perineum and up to her mid thighs with iodine and draped her with sterile drapes. She needs to be catheterized with a Foley’s indwelling catheter as she might have difficultly passing urine post operatively because of the regional anaesthesia and the post-operation pain. The vagina and cervix needs to be re-examined under anaesthesia to ensure all lacerations are identified and repaired. We need to identify the internal and external anal sphincter as both are torn in a 3C perineal tear. Firstly the internal anal sphincter should be repaired with interrupted stitches with 3-0 PDS suture. Next we need to repair the external anal sphincter via an end-to-end technique with 2-0 PDS suture. We need to close the vaginal epithelium with a continuous non-locking suture with Vicryl rapid 2-0 and recreate the perineum body. We need to ensure that all the spaces are closed to prevent haematoma formation and ensure haemostasis is secured. Lastly we need to close the vulva skin with subcuticular sutures with vicryl rapid 2-0. After repairing, we need to ensure the rest of the lacerations are repaired and a check per rectum examination is done to ensure that no sutures can be felt through the rectal mucosa. Lastly we need to ensure the swab counts are correct and all swabs are removed from the vagina.

You have been asked to review a healthy 33 year old woman because she is thought to have a third deg Posted by S F.

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks]. 

 

a.  As part of my assessment I will assess her antenatal past medical history to idently possible underlying risk factors such as previous perineal/anal spincter tears, Diabetes, Hypertension and macrosomia.  In the past medical history I will look for possible causes for increased bleeding such has haemophillia and anticoagulation for underlying conditions. 

During my assessment of the patient I will assess her cardiovascular status and exclude possible hypovolaemic shock secondary to blood loss during delivery and the tear.  Whilst sitting a large bore venflon bloods will be sent for G&S and FBC to identify preoperative hb inorder to assess the need for blood transfusion.

On examination under adequate lighing and analgesia following verbal consent I will assess the tear with digital recatal examination to assess the extend of the tear involvment of the internal and external anal spincter inorder to clarify the staging of the tear.  I will pay assess the blood loss and apply pressure if there is any evidence of active bleeding from the tears and inform the teams to speed up the transfer to theatre. 

Written conset will be obtained from the patient explaining the intention to take to theatre inorder for adequate exposure and analgesia and assessment of the tear thoroughly.  I will explain to her the likely risk factors such as faceal/flatus incontinence, infection, bleeding, would haematoma and wound break down. 

I will contact the consultant oncall and make them aware of teh patient and my management plan to repair the tear.  I will request the anaesthetic team to assess the patient to review patient inorder for general or regional anaesthesia.  I will inform the theatre staff about the patient inorder for them to prepare theatre for patient.

 

Discuss your intra-operative management given that a 3c tear is confirmed [10 marks].

the patient will be lithotomy position under adequate lighting and analgesia.  I will clean and drap the patient under sterile condition and an indwelling catheter inserted.  Having assessed the extend of the tear I will initially identify the external and internal anal spinter and repair the anal spincter end to end with PDS interrupted sutures individually. I will assess the rectal mucosa to exclude any sutures entered the rectum if so to remove the sutures and re do them to avoid rectovaginal fisutal.  the vaginal wall mucosa will be sutured continous non locking with vicryl.  The perinal muscle will be closed with vicryl continous sutures.  Finally continous subcutaneous sutures will close the perianal skin.  To complete my examination I will perform a digital rectal examination to assess the spincter which as been repaired and vaginal and parautrethral area to exclude any other tears.  To complete my surgery I will count the swabs and instruments with the scrub nurse and dispose the sharps appropriately.  Weight the swabs and agree on an estimated blood loss.

As per protocol I will commence patient on Cefuroxime and Metronidazole antibiotics, regular analgesia, Laxatives such as Lactulose and Fybogel.  I will debrief the patient of my findings and answer any questions.  A follow up appointment postnataly be arranged 6-8 weeks with the obstetric team and she will be refered to the physiotherapy to help with perineal muscle exercise.

I will document my findings and operation techniques including blood loss.  Fill in an incident form as part of risk management.

ESSAY 358 Posted by QAMAR H.

 

ESSAY 358

(A)

After introduction ,I will explain the patient there is possibility ofanal sphincter injury  which needs appropriate assessment and  repair  under good relaxation  with general or regional anesthesia  in good light  in theater .

I will assess her  general condition by measuring  blood pressure(hypotension) ,pulse (tachycardia),and estimate  blood loss  as she may need resuscitation.

Intravenous line will be established  and blood would be taken for preoperative tests including Full blood count,group and save and cross match if bleeding profusely. Intravenous fluid will be commenced.

I will inform my consultant ,anesthetist,theater staff  and blood bank  before  shifting the patient into theater.

If there is significant bleeding,other genital tract injuries(vaginal or cervical) should be expected .Urgent volume replacement  and resuscitative  measures instituted.

Consent would be taken with explaination of the position(lithotomy),procedure,benefits and risks, type of anesthesia  and rectal examination.Then  patient will be shifted  into theater  for repair.

(B)

Repair will be performed under aseptic condition in theater,by experienced  clinician with appropriate assistance,with correct  instrument .

  Procedure  will be undertaken  in lithotomy position, in good light to provide optimal visualization  , under general or regional anesthesia to achieve good relaxation for good repair.Intravenous antibiotics

such as Cephalosporin and Metronidazole  are  administered  to prevent from infection.

Patient will be examined for the extent of injuries .Anal sphincter injury grade  3 C will be confirmed if both external and internal sphincters are found torn.Any other injuries of vagina or cervix will be noted at the same time.Immediate attention will be paid to any rapidly bleeding vessels.

Internal anal sphincter will be identified and repair  with interrupted sutures  by monofilament suture Such as 3/0 polydioxanone(PDS) .External ananl sphincter will be identified and mobilized  as the torn ends may be retracted .It should be repaired with end to end or overlapping  technique with equivalent outcome by  3/0 PDS  .Alternatively both sphincters may be repaired with modern braided suture such as  Polyglactin(vicryl 2/0 )as  these fine sutures  are associate with less irritation and discomfort.Knots should be buried beneath the  superficial perineal muscle to prevent from migration.

Perineal   muscles and vaginal epithelium will be closed with continuous ,non locking  sutures ,

 

with good approximation by  Vicryl 2/0.Perineal  skin will be closed by subcuticular  suture with vicryl 2/0, as it gives good result  and less pain .

Vaginal and rectal examination will be performed to ensure  adequate  repair.Swabs and instruments are  counted  at the end of repair.

Meticulous documentation will be done as good practice ,for audit  and  risk management.

 

answer for essay 358 Posted by sushma S.

1. I  will assess her general condition , pulse ,blood-pressure ,temperature ,pain relief and bleeding  status. She should be  assessed for  her risk factor for such tear like nulliparity , macrosomic baby ,instrumental delivery and prolong  labour. I will examined her per abdominal to see the condition of the uterus whether it is well contracted or not as all the above risk factors usually associated with atonic uterus. If it is not well contracted uterine message along with oxytocics should be given along with completeness of the placenta removal should be ensured .  

Two IV line should be taken and blood should be sent for FBC coagulation profile and group and cross match.she should be explained the need of local examination of the vagina and adequate  pain relief should be ensured by giving top up of epidural or any other suitable method. Then she should examined systematically to determine the extent of the perineal injury in presence of good light ,position and assistant .if difficult to determine then help of senior  expert person should be sought.

Extent of injury should be classified according to standered classification eg in third degree tear there will be injury to the external anal sphinter as well as internal sphinter along  with skin and pereneal muscles. It can be further subclassified into 3a – where less than 50 %if external sphincter is torn ,3b- where more than 50% of the external sphincter torn and 3c- where external along with internal sphincter is torned . however if there is doubt about the grade then it should be graded in  higher degree. Per rectal examination should be done to exclude any buttonhole injury .

Patient should be explained about the nature of the injury and need to repair in order to avoid longterm anal dysfunction , to restore normal anatomy  and to promote healing ,if it will not  be repaired then it will leads to distorted anatomy ,fecal  and flatus incontinence and fistula formation .

She needs to be repaired under good relaxing anaesthesia in order to get good apposition of the torn muscle and tissue. After repair htere is very common  possiblity of flatus incontinence  ,fecal incontinence and fecal urgency .There is also common possibility of knot migration (needs removal of the stitches),wound disruption (may need secondary repair) and dysparunia . there is also very rare possibility of rectovaginal fistula formation. Although in majority of the cases outcome ins good.

After giving appropriate information ,written consent should be taken , and all the discussion should be documented in the notes. operation  theater should be intimated and anaesthesist should be informed and mode fo anaesthesia should be discussed as in this case general anaesthesia is preferable to regional anaesthesia to have good relaxation of the muscle s well as apposition. Premedication should be given in the event of general anaesthesia.

 

2.Involvement of the senior obstetrician having experience in repair of such injury should be done as it will influence the outcome. Patient should be exposed appropriately ,good ligh and assistant should be ensured. Reassessment of the extent of injury should be done ,any other associated injury of the genital tract should be noted and repaired. adequate antiseptic precaution and pre operative antibiotic should be given to avoid infection. Suture material should be choosen in form of delayed absorbable suture either polydiaxonone 3 -0 or 2-0 or polygalactin 2-0. Both of them have same out come .rapidly absorbable suture should be avoided.

After delineating the anatomical structure internal sphinter muscle should be repaired in iterrupted stitches. External sphinter can be repaired either by end to end of overlapping technique depend on the surgeon choice and preference as both method have same outcome,however overlap technique is associated with less fecal urgency and flatus incontinence.it should be sutured in intrupted stitches. Then vaginal mucosa should be sutured by continous nonlocking manner followed by perineal muscle in same manner.

Perineal skin should be closed by subcuticular stitches as it is associated with less post op pain and dysparunia  in later life.  Per rectal examination should be done to feel any rectal stich ,if found it should be dealt immediately .Indwelling catheter should be kept till patient is fully mobile . vaginal packing  can be  done in the event of oozing and later on removal. Mops and instrument should be counted and ensured. blood loss should be estimated.post operative notes should be written in detail about the extent of injury ,method of repair, type of suture material used ,any other event arises and dealt .

Post operative antibiotic ,analgesic and laxative should be advised .post operative physiotherapy should be advised.

 

Posted by sadaf A.

a)first i will introduce myslf to patient and will as permission for examination to assess nature and extent of trauma.then quick history regaring parity,previous delveries,their outcome and baby weight now will be taken.

then i will examine the woman under adequate analgesia, good light and expouser to see extent of perneal trauma and any active bleeding.will insert wide bore cannula and send blood for full blood count,coaguation profile and cross match.

after acertening the extent of perinal tear i will discuss with woman and explian her nature of trauma and need of repair in operation theatre under regional or general anesthesia.informed consent will be taken after explaing all risk factors.

reapir should be done by trained and experienced professional and as soon as possible to prevent blood lsoe.operation theatre staff and anaesthatist will be informed for the case. 

b)re-examine the patient under anesthesia,adequate assistace and good light to make sure of degree of perinear tear before embarking repair.swab and instument should be counted before starting repair.method of surgical repair will be for Inernal anal sphincter with pds/polyglatin 3/0,2/0 with interrupted sutures.knots should be buried under superficial perineal muscle to prevent discomfort later on.

while internal anal sphincter will be repaied with end-to-end or overlaping tecnique by using either 3/0 PDS or polyglytin 2/0.rest vaginal mucosa,perineal muscles with be repaied with continuous lose sutures to avoid dysparunea in future.skin will be done with sub cutaneous sutures.

cathetrise for 24hours to prevent urinary retention,adequate analesia,antibiotics,stool softener and proper hygene should be advised to woman

at end PR examination will be done in case suture passed through mistakenly.swab and instument count will be done at end.proper doumentation for extent of trauma and technique of repair shold be documented in order to avoid letigation.written information should be given to woman

Posted by Pradnya K.

A )  Discuss your pre-operative management.

The call should be attended  immediately because early repair of the perineal tears help to prevent the infections and bleeding.

A quick history should be taken about the delivery events asking about instrumental delivery, difficult delivery.

Delivery of the placenta (if not yet delivered) should be done to avoid PPH.

Patient’s general condition should be checked including pulse, blood pressure, pallor.

Appropriate fluid management should be started simultaneously.

Careful examination of the perineal injury should be done to assess the extent of tear & amount of bleeding.

If 3 rd degree tear is confirmed, further assessment of the extent of the tear ( 3a,3b,3c) can be done with rectal examination, preferably under adequate analgesia in operation theatre.

Patient & her partner should be debriefed about the trauma & informed consent should be taken for the further management.

Seniors should be informed about the injury, & the suturing should be done by a trained operator or trainee under supervision.

 Theatre staff & the anaesthetist should be informed about the procedure.

B ) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks]. 

3c tear means internal sphincter is torn.

Repair of this tear is to be done in operation theatre under adequate analgesia / anesthesia, by trained person.

Good exposure can be achieved with lithotomy position.

Good light source is needed.

Rectal examination is done to rule out the tear in rectal wall.

Vaginal examination should be done to assess the extent of the tear in vaginal wall & to rule out possible cervical tears.

Perineal area should be cleaned, prepared with antiseptic solutions  as per the protocol & draped appropriately.

Internal anal sphincter should be identified, approximated & sutured with interrupted or mattress stitches with absorbable sutures like 3-0 PDS.

External anal sphincter should be sutured with 2-0 PDS with end-to-end or overlapping  stitches.

Vaginal mucosa should be sutured with rapid absorbable 2-0 Polyagalactin , in continuous non-locking  fashion.

Perineal body should be repaired with 2-0 polygalactin sutures with interrupted stitches.

Perineal skin should be repaired with rapid absorbable 2-0 polygalactin with subcuticular stitches.

Vaginal & rectal examination should be done to assess that the suturing is complete & to rule out any inadvertent  suture running through the rectal wall.

Adequate hemostasis should be confirmed & mop count checked.

Urethral catheter should be inserted.

 If catheter is not inserted, voiding should be ensured every 6 hours.

Broad spectrum antibiotic should be administered (single dose intravenously & oral dosage thereafter)

Proper analgesia should be given but avoiding opiates ( which can cause constipation putting strain on the sutured wound )

All the important steps in the procedure should be properly documented & appropriate incident forms to be filled up.

 

 

 

 

 

Chandu S Posted by Sailaja C.

 

She should be explained  about the purpose of examination which includes assessment of extent and nature of the injury and to enable appropriate repair to prevent longterm consequences. Woman is enquired about the degree of analgesia. She should be informed that she would be placed in lithotomy position and needs rectal examination to be done. Consent is taken for the examination.  Care is taken that examination will not interfere with her interaction with the baby unless she is bleeding.

 pulse, BP and temperature are recorded. Examination should be systematic under good lighting to identify third degree perineal tear which requires appropriate training and under supervision.  It is ensured that the woman is under adequate analgesia. Uterine tone is assessed. Overt bleeding is assessed. Simultaneous vaginal and rectal examination is carried out. Vaginal examination is done to assess the extent of tear to rule out presence of other tears or lacerations . Rectal examination done to assess integrity of rectal mucosa & presence of tone & degree of involvement of external anal sphincter & check for internal anal sphincter involvement.

After examination, clear explanation is given regarding the nature of injury including the anal sphincter injury.  For the purpose of obtaining informed consent she should be informed that repair is essential to restore the anatomy of vagina and perineum and if not repaired the long term consequence would be as incontinece of faeces. The common risks are explained such as short term pain, bleeding and knot migration. Serious risks are explained which include infection, fecal incontinence and urgency. The available options for  anesthesia ( regional or general) and analgesia are informed.Possibility of indwelling urinary catheter in the post operative period is informed.Written information is provided for better understanding and discussion with the family members.

 

After obtaining written consent, anesthetist and OT are informed about the case. IV cannula is inserted. Ensured that a surgeon with appropriate training is available for the third degree tear repair .

 

B) 

Third degree perineal tear 3c involves Both EAS and IAS 

Repair is undertaken in operating theatre in an aseptic environment with under good light. Good assistance is required for carrying out the repair of third degree tear. Performed under regional or general anaesthesia for adequate relaxation of anal sphincters which is essential to retrieve torn ends of anal sphincters and to repair without tension. Through examination including rectal examination under anaesthesia would be done again before repair to identify nature and extent of injury. Internal anal sphincters(IAS) and external anal sphincters are identified separately. Internal anal sphincter IAS is repaired by using 3,0 polydiaxanone or polygalactin with interrupted stiches. EAS is repaired by by end-to-end or by overlapping sutures with 3,0 polydiaxanone or polygalactin  . Knots in anal sphincters are buried under superficial perineal muscles  to prevent knot migration / perineal irritation.The apex of vaginal wall injury is identified and repaired by continuous non-locking technique with rapidly absorbable suture ( polyglactin vicryl rapide).The perineal muscles are repaired by same methods(continuous non-locking with rapidly absorbable sutures). After that the perineal skin is repaired by sub-cuticular with rapidly absorbable sutures which will lower perineal pain . Rectal examination is performed to see whether rectal mucosa were involved in sutures or not and to see sphincteric integrity . Instruments , sharps, swabs will be accounted for. Indweling bladder catheter is inserted to avoid urinary retention.

 
answer to essay 358 Posted by Moon M.

)Review the case records in regards details of delivery and the timing of each stages, type of analgesia she had,if it was precipitate labour duration of labour,any episiotomy taken by the midwife,the parity of the woman and the size( weight)of the baby big baby>5 kgs and estimated blood loss.Confirming the diagnosis of 3rd degree tear by examining the patient ,making sure that she has enough regional epidural for analgesia before examining her with good lightening system ,Anal muscles torn, internal anal sphincter and intact anal mucosa leads to diag,per rectum examination is necessary for confirmation..Assess the amount of bleeding the patients is getting .  I.V acess blood for FBC, group&save should be taken as baseline.Document all these findings and inform the obstetrician consultant , Prepare the patient for repair of 3rd degree tear under anaesthesia in the operative theatre.Informed consent should be signed by the patient before proceeding with the procedure.Anaethetist ,theatre nurse staff  should be contacted .it worth mentioning that 3rd degree tears carry higher risk of litigation in obstetriic so documentation is crucial for safety of the patient.

b) Repair of 3rd degree tear should be done in operating theatre under good lightening system for good visualization,patient lying in lithotomy position under effective regional anaethetics  or general anaethesia if regional not effective for pain relief that will assist relaxation of muscle and Anal muscles should be repaired 1st by interrupted suturing using PDS followed by repair of the vaginal mucosa ,perineal muscles and skin using vicryl rapid(adsorpable suture)matrial.per rectum examination is important to make sure that anal mucosa is free at the end of procedure,haemostasis should be assured and swabs count and instrument should be correct. Documentation of all the steps taken ,material used and timing. prop-ylactic antbiotic  maybe p-rescribed Co amoxy calvanic acid I.V ,1.2 mg ,TDS +metronidazole 500mg IV,tds ,laxative Lactulose syrup- should be prescribed to prevent constipation. physiotherapy of pelvic floor should be requested.Incident report should be filled as this carry high maternal morbidity. thrombopoprophylaxis maybe considdered in the light of other risk factor like obesity as well as  TED thromboembloic deterrant stocking .Debriefing of the patient about the finding and the procedure taken to repair the damage,mentioning the rate of the risk that she might have foecal incontinence 1 :100 and that will be dealt with inconjuntion with specilized surgeon.Reassure the p-atient that this will not affect her mode of delivery in the future pregnancy in term of recurrence.

 

Posted by kunal R.

 

1)   Assessment of risk factors antenatally like, nulligravida, prolong second stage more than 1 hr, induction of labour, epidural analgesia, miline episiotomy, shoulder dystocia, big baby more than 4 kg, forcep delivery.

Assessment of general condition after delivery,  temperature, Pulse, blood pressure, extent of blood loss, placenta removed completely, proper codition of baby, since  perineal tear may be associated with post partum haemorrhage and condition of mother may deteriorate with time, complicated or difficult delivery may compromise immediated baby apgar scores.

 Infrormed  consent obtained for examination of perineal and tear including rectal exmaination, under adequate analgesia, in  lithotomy position under proper lights in theatre. Trained doctor or trainee should conduct examination, or under supervision of experienced or trained doctor, consultant. Patient relative informed of the condition.

Systematic examination of the perineal tear according to perineal tear classification done whether external  inner 50%( 3a) outer 50% (b)  or internal anal sphincter damage ( 3c) or anal epithelium damage (4) and any doubt about the stage should be given as one stage higher.

2) 3c perineal tear  is internal and external anal sphimcters tear but anal epithelium is not damaged, requires repair by trained person having experience and skills in repair of 3c tears with competency assessed. Repair done in theatre in lithotomy position and under good lights and adequate regional anesthesia under aseptic precautions and anitbiotic administered, bladder emptied with catheter prior to suturing.

Internal anal sphincter suturing should be done first with interrrupted sutures with 3,0 Polydioxanone monfilament suture with knot buried inside the perineal muscles to avoid knot migration, Suturing done with either overlay or end to end technique for external anal sphincter, with evidence of no difference in outcomes between two techniques, with either 3,0 PDS or 2,0 polyglactin braided suture with knot buried inside perineal muscles to prevent knot migration. Patient informed of the chance of knot migration.

perineal muscles should be sutured with interrupted sutures and vagina and skin closed in continous suturing. subcuticular stitches, with polyglactin. Rectal exmination done in the the end to exclude suturing through the anal wall. 

cathether kept in situ and removed after 6 hrs with volume of void noted after removal of catheter, to exclude retension and post void urine volume.Documented in patient notes and  cinical incident report form filled, with post natal debriefing done by same doctor or consultant.Post operative anitibiotics given for 7 days including metronidazole and laxatives given for 10 days to avoif straining on suture lines. Physiotherapy adviced for 6- 10 weeks and follow up at 6 weeks to enquire about rectal dysfunction, uregency and incontinence that requires follow up with gynecologist or colorectal surgeon, might require anal manometry and endo anal ultrasound. Persistent symptoms and defects may require secondary suturing.

Posted by Emma S.

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks].

 

The patient needs to be properly assessed by someone with the appropriate skills and training to recognize a 3rd tear. A full examination with regards to the tear needs to be performed. The best possible lighting available should be used and the woman given the option of entonox. She should be positioned in lithotomy to gain adequate access. A systematic approach should be used. Consent should be gained for a rectal examination to assess the integrity of both the internal and external sphincters and to check for button hole tears. Where there is doubt a second opinion if available should be sought and the tear should be classified a grade higher if there remians uncertainty.

 

The extent of the trauma should be discussed with the woman. She should be informed of the need to repair the tear in theatre. This will involve regional anaesthesia to relax the sphincter. It will provide the best lighting and equipment and a sterile environment. A consent form should be completed informing the woman of the risks of infection, bleeding and incontinence of faeces and flatus, which is secondary to the tear and not a consequence of the suturing (1/10). Intravenous access should be secured. If she is bleeding form the tear a FBC and group and save should be taken. Fluids should be commenced.

The anaethetist and theatre team should be informed.

 

In theatre the woman should be cleaned and draped. A catheter should be inserted. She should be in the litotomy position. Theatre lights should be adjusted to ensure adequate lighting. The tear should be fully assess again with a rectal examination. The internal sphincter should be repaired with a fine absorbale suture such as 3.0 vicryl, The stitches should be interrupted. The ends of the external sphincter should be identified and grasped with allis forceps. There is no evidence that repair with either the end to end or the overlap technique is superior and it should be the decision of the surgeon as to which method they are familiar with. The suture material should be either 2.0 PDS or Vicryl. The stitches should be interrupted. The rest of the perineum should then be repaired. The muscle layer should be closed with 2.0 vicryl rapide an the skin should also be closed with 2.0 vicrly rapid with a subcuticular stitch. Intra-operative antibiotics should be given as per the local hospital protocol. At the end of the repair a further rectal examination should be informed to make sure no stitches are communicating with the rectum. The tear and the details of repair should be clearly documented.

 

The woman should be informed of the extent of the tear, the type of repair and the risk of knot migration, hygiene and pelvic floor exercises. She should complete a course of antibiotics and have 10-14 days laxatives such as fybogel (bulking agent) and lactulose (softner). She should also have physiotherapy and a postnatal review.

P Posted by S M.
  1. Important thing is to ensure that patient is haemodynamically stable would enquire about the estimated blood loss at delivery. Will check BP and pulse and resuscitate the patient if she is bleeding excessively.   I would enquire about the time of delivery and analgesia used. If the delivery is recent and epidural is in situ, will just need topping up if 3rddegree tear is confirmed. I would explain to patient that it is very important to assess the extent of tear in lithotomy position and under analgesia as missed 3rddegree tear can lead to troublesome symptoms later on. I will put her in lithotomy position and advice to use entonox or use local anaesthesia to examine her. Per rectal examination combined with vaginal examination is necessary to assess the extent of damage. Once diagnosis is confirmed I would explain to patient the importance of repairing it in theatre under adequate light and sterile condition. She also needs to be completely relaxed during the procedure to ensure adequate and proper repair; hence will need either spinal or epidural topping up.  I will consent her and explain to her the frequent risks such as bleeding, infection requiring antibiotics and serious risks such as incontinence of flatus or faeces and rarely wound break down and fistula formation. I would explain that stitches used will be dissolvable and she will need antibiotics for 5 days and laxatives for 6 weeks. Show will be advised to do pelvic floor exercise and will be seen by physiotherapist. I will also arrange for her to be seen in clinic in 6 weeks time. After this I will inform theatre staff and anaesthetist on call.
  2. In theatre after scrubbing I will prepare my trolley ensuring that I have required instruments and stitches ready.  Once the regional analgesia is working effectively I will position her in lithotomy position. Will ensure that lighting is adequate. I will  clean, drape and catheterise her. I will ensure uterus is well contracted and will insert tampon to prevent lochia obscuring the view. I will reqest the anaesthetist to give her 1.2 grams of cefuroxime and 500 mg of metronidazole intravenously.  Then I will assess the extent of damage by combining PR and vaginal examination. I will also ensure that area is kept sterile and gloves are changed after every PR examination. I will use Allis forceps to identify the torn edges of internal sphincter. I will use interrupted vicryl 2-0 or PDS 3-0 with either overlapping or end to end technique. After repairing internal sphincter the external sphincter will be repaired in similar manner. I will repair perineal muscle and mucosa with continuous vicryl rapide and skin by sub-cuticular. After this I will do PR examination to ensure that there is no defect and no stitches are felt through the rectal mucosa. I would change my gloves, remove tampons and ensure that no more vaginal tears require repair. After this I will insert voltarol PR, count all the swabs and needles and dispose needles off appropriately. I will inform patient of the outcome.

  

3rd degree tear Posted by Samira  K.

a-First of all i will make sure that women is comfortable and not in pain.If she is already on epidural analgesia it will make examination easy.I will ask midwife about events of delivery .I will check her general condition and vital signs and pain score.I will check her BMI as obese women are more likely to tear and have introperative and postoperative complications.I will take permission from patient and examine her Abdomen for the uterus if it is contracted well or not.I will examine her perineum ,vagina and rectum to see the extent of damage under entonox if she is not under epidural. .I will classify the tear if it is 3a meaning <50% of external anal sphinctor is involved.3b if >50% of EAS is involved and 3c if both EAS and IAS is invoved.I will make sure that anal mucosa is intact.After confirmation of the tear and extent of tear i will call my consultant to inform him and anaesthesia on call to assess the patient preoperatively.I will send FBC,Group and save in case if it is not done before.IV line will be secured and WHO checklist should be completed.Informed consent should be taken from the patient explaining the procedure and that for good repair good anaesthesia and good lighting and an assistant is required which is available in theatre.she will be explined that postoperative infection,dehiscence is a risk and migration of sutures to the skin can happen.These risks can be minimised by giving prophylactic antibiotics and using good technique.She should be explined that if left untreated it will lead to fecal incontinence and fecal urgency.

b-Intraoperative i will check my instruments,facilities and after anaesthesia clean and drap the patient well,evacuate her bladder and examine again as anaesthesia relaxes the muscle and ease examination.I will confirm my previous findings and give her prophylactic antibiotic including broad spectrum abx plus metronidazole for anaerobes.I will  start to repair anal sphinctor either by overlapping or end to end anastomosis as both of them have equal outcome.I will use vicryl 20 for EAS repair and PDS 3o for IAS if it is torn I will bury surgical knot beneath perineal muscles to prevent migration of knot .I will complete my repair upto the skin together with any vaginal tear .I will examine to check my repair and strength of anal sphinctor is restored or not.I will also examine rectal mucosa to check its integrity.I will prescribe effective regular analgesia for her and check my swabs and instrument at the end of procedure.I will document typeof injury,type of repair,procedure done, suture used and blood loss .

paul pls mark this essay of mine as typo error in prev one Posted by sadaf A.

 

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks]. 

A) first i will introduce myself to patient and will ask permission for examination to assess nature and extent of trauma. Then quick history regarding parity, previous deliveries, their outcome and baby weight now will be taken.

Then i will examine the woman under adequate analgesia, good light and exposure to see extent of perneal trauma and any active bleeding. Will insert wide bore cannula and send blood for full blood count, coagulation profile and cross match.

After ascertaining the extent of perinal tear i will discuss with woman and explain her nature of trauma and need of repair in operation theatre under regional or general anaesthesia. informed consent will be taken after explain all risk factors.

repair should be done by trained and experienced professional and as soon as possible to prevent blood lose.operation theatre staff and anaesthetist will be informed for the case. 

b) re-examine the patient under anaesthesia, with adequate assistance and good light to make sure of degree of perineal tear before embarking repair. Swab and instrument should be counted before starting repair. Method of surgical repair will be for Internal anal sphincter with pds/polyglatin 3/0, 2/0 with interrupted sutures. Knots should be buried under superficial perineal muscle to prevent discomfort later on.

While internal anal sphincter will be repaired with end-to-end or overlapping technique by using either 3/0 PDS or polyglytin 2/0.rest vaginal mucosa, perineal muscles with be repaired with continuous lose sutures to avoid dysparunea in future. Skin will be done with sub cutaneous sutures.

catheterise for 24hours to prevent urinary retention, adequate analgesia, antibiotics, stool softener and proper hygiene should be advised to woman

At end PR examination will be done in case suture passed through mistakenly. Swab and instrument count will be done at end. Proper documentation for extent of trauma and technique of repair should be documented in order to avoid litigation. Written information should be given to woman

 

 

Posted by arif  K.

I will immediately evaluate the patient to reduce the bleeding and risk of infection which can occur if repair is delayed.  Initial assessment of the woman  by checking her pulse,blood pressure,state of hydration and bleeding status.

Quick history from the patient to know about the delivery whether operative. See whether the placenta has been expelled out or not. Start Iv fluid and send blood for group and save and for crossmatching.

After expulsion of the placenta assess the extent of injury,i willl classify whether the tear is 3a-involving 50 percent of the external anal sphinceter, 3bmore than 50 percent of the external anal sphincetr involved and 3c when internal anal sphincter is also involved. also look for the buttonhole tear involving only the anal mucosa without involving the sphincter.If in doubt i will grade the perineal tear in a higher degre,also i will inform a practitioner experienced in detection and management of perineal tear. 

Inform the patient about the injury, procedure and take her consent. Alert the theatre staff and inforrm the anaesthetic.

Intraoperative management

Repair of the tear can be done under General anaesthesia or regional anaesthesia. Under aseptic precaution repair should be done in OR with  adequate lighting, and the sphincter relaxed. Swabs,instruments and stitch should be counted before the procedure. assistant should be there and bladder catheterised.

Internal anal sphincter should be repaired by interupted sutures.External anal sphincter can be repaired  by overlapping method or end to end method. there is no difference in quality of life between the two method except for the fact that overlapping method has less faecal urgency and anal incontinence as compared to end to end repair. perineal muscles sutured by continuous suture and vaginal mucosa by continuous suture. skin should be closed by subcuticular stitch to avoid the pain. 

There is no difference  in the long term between the use PDS(3-0) or polyglactin suture(2-0) material. The knots should be embedded beneath the  superficial muscles to avoid the knot migration. At the end of the suture, swabs and intruments should be counted and Pv and Pr should  be done. If knot felt during PR then we have to open it again and resuture it to avoid the fistula formation.

Broad spectrum antibiotics and Laxatives should be advised and also catheter inserted which should be removed after 12 hours.

The extent of injury to the perineum, the method of repair and the suture material involved should be clearly documented.

 

suma Posted by Dr  M.

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks]. 

a.

As there is posiiblity of third degree tear I would first talk to lady in detail regarding that their is possibility of tear involving muscles of back passage with or without involvement of rectum. It can occur in 1% of normal deliveries. She will need proper examination of tear along with examination of rectum.

I will explain her need for examination and proper repair as it can give her long term problems of fecal or flatus incontinence, pain and if properly done risk is minimal.

 She will need IV access , full blood count and group and save. She will need proper analgesia before examination

After proper analgeasia she will need examination in good light to confirm tear and extent of tear

Once tear is conformed then I will explain her extent of tear and consent her for repair of third degree tear ,during consenting I will explain her that this is for proper approximation by expirenced operator to minimise problems in future. There is risk of pain(she will need analgesia) bleeding (might need transfusion but uncommon), infection(will receive antibiotics during procedure and after), damange to bowel (thats why doing in theatre by appropriatly trained surgeon), incontinence to fecaes and flatus(rare) ,fistula formation(very rare) She will also need catheter in her bladder until she mobilises.

She will need either regional or general anaesthesia Ask to inform theatre team

Obstetric consultant should be aware of it.

Suturing needs to be done as soon as possible to reduce risk of bleeding

b.

After anesthesia, proper positioning , good exposure, suturing will be done in theatre by appropriatly trained surgeon

As it is 3c tear it is involving external and internal anal spinters.Suturing can be done by overlap or end to end technique There is no evidance to suggest which is better ,so will be dependant on surgeons choice 

For spinter musles 3-0 PDS (polydioxonone) or vicryl(polygactin) is used. it is important to burry knots as they can irritate and delay wound healing.After third degree tears other tears or episiotomy is sutured in usual way.At the end of suturing rectal examination is done to exclude any sutures in rectal mucosa.

I will tell her that she will need  antibiotics(agumentin/Ceftrioxone and metronidazole should be given for 10 days),proper analgesia, laxatives for 10 days(lactulose and fibrogel)

She will need to see physiotherpist and come for follow up in 6 weeks time

I will document suturing properly in notes with diagrams about extent of tear, method used for suturing, suture material used, estimated blood loss along with name and designation

I will also fill incident form

 

 

 

Nee Posted by nee P.

a)I will see her general status,& any signs of bleeding if found to be stable,I will take her hxabout gravidity ,parity,as primiparus lady are more prone for advanced perineal tear.If multiparous lady,her obst hx should be asked regarding previous 3rdor 4thdegree  perineal tear, or pre existing  symptoms like fecal incontinence, as it increases the risk of recurrent tear.I will ask her about the duration passed since delivery as it will be helpful for further management. I will ask & review of the records of mode of delivery as instrumental delivery leads to increased risk of advanced perineal tears. Similarly large baby, occipitoposterior or face presentation-(mentoanterior) may lead to 3rdor 4thdegree tear. I will examine her to know the extent of tear with proper aseptic measures. I will do inspection & see extent of the tear can be reconfirmed by per rectal examination as in third degree tear sphincter complex will be involved & in 4thdegree tear anal mucosa will be involved . Similarly by PR examination button hole tear can also be identified which is common in obstructed labour. After identification of tear (3rdor 4thdegree) preparation for suturing should be done. It should be informed to consultant or senior obstetrician. It should be recorded properly mentioning extent of the tear, asan incident reporting for risk management. Operation theatre , anesthesiologist should be informed & the obstetrician who is skilled in repairing perineal tear should be informed as prognosis is better in skilled hand. Antibiotic prophylaxis should be started covering anaerobic organisms (cephalosporins & Metronidazole) as it reduces postoperative infection & prevents wound breakdown. Blood should be sent forFBC, group & save if not done before. Patient & her partner should be informed about the incidence. Informed consent should be obtained.

b)  3C perineal tear where sphincter complex is involved should be sutured in a operation theatre where sterile environment, good exposure & adequate light is available. It should be done under regional anesthesia as it prevents retraction of sphincter margin & helps in proper approximation. It should be done by a person who has adequate skill in repairing advanced perineal tear. The suture material like vicryl 2-0 or PDS 3-0 should be used for suturing the tissue which helps in proper healing & less postoperative pain. It shouldbe started with the suturing of internal anal  sphincter which can be done by end to end anastomosis or overlapping technique. Both techniques are equally effective. External sphincter sutured after the internal sphincter suturing by end to end or overlapping technique. Then muscle & skin should be sutured. Knot should be buried while suturing the muscle layer as it prevents knot migration. Once surgery is over proper haemostasis is achieved per rectal examination should be done to  review completeness of repair& to see any inadvertent suture material in anal canal. Once surgery is over proper nalgesia should be given but perectal application should be avoided. Gauze , instruments & packs should be counted & recorded. Incident reporting is mandatory so I will fill up the incident reporting form.  

You have been asked to review a healthy 33 year old woman because she is thought to have a third deg Posted by tmalar@yahoo.com C.
  1.  I will assess her vitals to look if she is hemodynamically stable such as blood pressure for hypotension,pulse rate for tachycardia, temperature for pyrexia. Her cardiovascular and respiratory system is also checked and abdominal palpated to look for any uterine atony. If there is uterine atony, i will get an assistant to rub on a contraction while utelising more assistants to insert 2 large branulae and getting blood on the same time for full blood count,electrolytes,coagulation profile,clotting factors, group cross match and save and organising for blood transfusion if blood loss is significant. Intravenous Oxytocin 40 unit is started to prevent uterine atony and further bleeding. Infusion of crystalloid such as Hartmann commenced while waiting for blood transfusion. 

Her antenatal notes is reviewed to look for any risk factors that preludes to the perineal tear such as her parity (primigravida) , prolong second stage of labour,instrumental delivery, persistent occipital posterior, midline episiotomy,macrosomia. Her pass history is looked for if she had similar history of third degree perineal tear. Knowlege of these information will help in the counselling the patient post operatively and subsequent follow up.

I will explained to the patient and her partner  that a vaginal examination will be done for initial assessment and extend of the tear and further management and repair will be done under anaesthesia with adequate  lighting in the operation theatre. With adequate analgesia/inhalation analgesia or if she is on epidural, a top up on anaesthesia is sorted with the help of anaesthetics. Senior consultant experience in repairing perineum tear is called in for further assistance.

Vaginal examination done in lithotomy position  under adequate lighting to confirm the degree of the tear and its extend of damage. Per rectum examination done to look for the rectal mucosa involvement. The findings are explained to the patient and her partner and she is prepared to be taken into the operation theatre for repair under conducive adequate lightings and anaesthesia after informing the anaesthetist.  A written consent is taken and all finding on inspection is documented in the post partum notes. IV antibiotic metronidazole commenced to prevent risk of anaerobic infection.

 

  1. In the operating theatre with good and adequate lighting and appropriate analgesia/anaesthesia for  relaxation of the perineum  and with the supervision of a trained experience practitioner , the repair is done.Intravenous  broad spectrum antibiotics commenced during procedure. Patient on lithotomy position, the perineum is cleaned  and drapped. A good assistance for retraction and adequate visualisation the anal epithelium repaired with 3-0 polygalatin (vicryl) sutures. The internal anal sphinter is identified and repaired using interrupted or mattress 3-0 polydioxanone (PDS). The external sphinter repaired using 2-0 PDS either an end to end or overlapping technique used. The vaginal epithelium approximated using continuous stitch with rapid absorbable vicryl. The perineum body reconstructed to support the repaired  sphincter using inrerrupted 2-0 vicryl.The perineal skin than closed using subcuticular 2-0 rapid absorbable vicyl. A vaginal and rectal examination done to ascertain the  repair is complete. Tampons and swabs are removed and the counts checked. The bladder emptied and urinary catheter inserted and kept for 24/hours. The Intravenous broad spectrum antibiotics continued , following which it is changed to oral antibiotics after repair for one week. Adequate analgesia in form of oral NSAIDS or intramuscular NSAIDS recommended however suppository analgesia is avoided. Opiates avoided as it can lead to constipation.

 

Complete detail of the incident leading to the tear needs to be documented in the notes and post operative notes updated with the procedure of repair done.

 Laxatives prescribed and patient is discharged once the bowel opening is achieved.

A physiotherapist reference for pelvic exercise is organised. Perineal toilet and hygiene is advised. On discharge the patient is ensured she understood the events of her delivery and a contact number given if any problem occurs. She should be counselled that the sutures can occasionally migrate and fragments may pass per vagina pr per rectum. Followup within 6 weeks is given again counselling.

 

 

 

Posted by sindhu H.

A)Third degree perineal tear is a tear involving the anal sphincter complex with 3c meaning involvement of the internal anal sphincter.

Aquick assessment of the woman will be done to check overt bleeding,pulse and B.P. If the woman is haemodynamically unstable, I will send for help from senior obstetrician, anaesthetist and an experienced midwife. Resuscitation will be started following the Airway,Breathing and Circulation steps.

If she is stable, I will explain her the need for a thorough examination . The aim of examination is to confirm the extent of tear and make necessary arrangements for the repair.Adequate analgesia,good light and assistance should be ensured for proper examination. The woman’s consent should be obtained prior to examination after informing her on the nature of examination and the need of vaginal and rectal examination. Baby should not be separated from the mother if no overt bleeding.

The woman is placed in lithotomy position for proper exposure. Per speculum examination is done to check any cervical and vaginal lacerations and the extent of bleeding.Rectal examination is done to ensure an intact rectal mucosa.The internal anal sphincter injury is assessed . The tone of external anal sphincter  and perineum is checked. Any perineal muscle and skin injuries are noted.

Once the assessment is completed a nd a diagnosis of third degree perneal tear is confirmed, the senior consultant on call will be informed.The woman and her family will be informed of the exact nature of the injury. Repair in operation theatre and the possible serious risks like faecal incontinence and sepsis will be explained .The frequent risks are pain,dyspareunia and migration of knot.The nature of anaesthesia will be explained by the anaesthetist . Any objections will be documented and an informed consent for the repair procedure will be taken.

Gynaecologist with experience in third and fourth degree perineal repair will be called for help as outcome is dependant on the dexterity of primary repair. OT and anaesthetist will be informed.FBC and save serum is ensured and the woman is transferred to theatre.

 

B)Repair should be performed in O.T by a gynaecologist with experience in the management of such injuries.General anaesthesia is preferable as it will help with retrieval of torn sphincter edges. Good light, appropriate instruments and good assistance are prerequisites prior to repair.

Complete evaluation of the tear should be performed once again in the theatre under anaesthesia to ascertain the extent of injury by vaginal and rectal examination in lithotomy position.

Internal anal sphincter is repaired with 3/0 PDS with interrupted sutures. External anal sphinter is repaired with 2/0 PDS either by end to end anastomosis or by overlapping technique. The vaginal mucosa is sutured with 2/0 vicryl(polyglactin) with loose continuous non locking sutures. The perineal body is reconstructed  with 2/0 vicryl continuous sutures. Skin is apposed with 2/0 sub-cuticular sutures.

Following repair, vaginal and rectal examination is performed to check the completeness of repair, any inadvertent sutures in rectum and removing any swabs.Instrument , needle and swab count is done.First dose of broad spectrum intravenous antibiotic is given to be continued orally later. Analgesic may be given but avoid opiate analgesia(constipation).Indwelling urethral catheterization is done to ensure bladder drainage.

Documentation of the details of tear, any complications and repair is done.Woman and her family is informed regarding the details of the procedure including any complications if any and the need of intervention.Incident report is filled. Follow up appointment is given . 

Posted by Ana B.

 

 

A thorough examination of the perineum should be undertaken to confirm 3d degree tear ensure that this is the 3d degree injury to avoid unnecessary anaesthesia to patient by misdiagnosing 2nd degree.

I would explain the purpose of the examination and obtain informed consent and perform examination of perineum with PR with adequate analgesia, for example inhalation analgesia good lighting. Examination of the perineum could be done when woman holds her baby unless there is bleeding that requires attention.  If diagnosed: preoperative counseling is very important with explaining the procedure as repair of the sphincter, which requires a good light and adequate analgesia to achieve a good repair to reduce the risk faecal incontinence.

The main risks associated with the procedure being frequent are perineal pain, faecal urgency, dyspareunia, wound infection, migration of the sutures, common incontinence of stool and flatus; and rare haematoma (RCOG)

Anaesthetic option should be mentioned and explanation would be provided by the anaesthtist and discuss this in details. Postoperative management to mention briefly and signs of to look for.

I would explain who is going to do the procedure.

If time allows and  woman is not bleeding, she should be given leaflet and consent form to read

and questions answered. Ideally repair should be performed as soon as possible as tissue get swallen and fragile.

IV access and G&S, FBC should be done before theatre, Consent signed by patient. Incident form needs to be filled in.

 

2) Intraoperatively: repair performed in theatre the most of the under spinal  providing a good pain relief. The light sourse and the assistant required. Supervision if the surgeon is not very experienced is nessessary; Examination again performed and PDS 3.0 polydioxanon is used for internal sphincter (interrupted or matrass sutures) External sphincter is repaired by PDS 2.0 overlapping or end to end sutures. Further repair of vaginal walls performed by Vicryl 2.0 rapid (continuous non-locking suture). It is important to reconstruct perineal body with Vircyl 2.0  to support the repair. Skin is closed by subcuticular Vicryl rapid 2.0.

Vaginal and rectal examination is performed to check the correct repair: and indwelling catheter is inserted to prevent bladder overfilling and consequent damage due to spinal anaesthesia and inability to mobilize and pass urine.

Antibiotics (single dose IV) is given in theatre and prescribed as a week course. Laxative prescribed and patient should be counsel on extend of injury, and repair performed, hygiene , analgesia, bowel habbit, follow up in perineal clinic and what to expect postoperatively. Swabs and needles are counted with second person in theatre to ensure adequate care and no swabs or needles are left with/in the patient. Physiotherapy referral should be made , so as an appointment in perineal clinic . Thorough documenation is performed with drawings of the injury.

Posted by Nick M.

A             This lady should be reviewed promptly to rule out any on-going post-partum haemorrhage.

Its important to know the mode of delivery, time lapsed since delivery and if an episiotomy was performed. This information is important because if its been over an hour since delivery and an episiotomy has been performed and the tissue is oedematous, a difficult repair can be anticipated.

Other factors in the history which can influence pre-operative desision making are previous third and fourth degree tears. If a difficult repair is anticipated or the woman is already symptomatic of sphincter dysfunction it may be sensible to call in the consultant and discuss with surgical colleagues.

I would also ask about drug allergies as this may influence antibiotic cover given.

I would review the maternal condition noting HR, BP and temperature and the examine the perineum to confirm damage to the sphincter. This will include a PR examination. Full explanation should be given to the woman and its important to remember that this may be very uncomfortable especially if she doesn’t have an epidural analgesia. A more thorough examination can be carried out in theatre. If she doesn’t have any IV acces, I would make sure that put one in because of the increased risk of traumatic PPH and send a group and hold if one had not already been sent.

Once I was satisfied that repair needs to be carried out in theatre, i would explain why its important to carry out in theatre, take written consent and inform anaesthetic and consultant colleagues.

B             Repair should be carried out in theatre with assistance. Regional or general anaesthesia should be used because it can relax the anal sphincter facilitating a better repair.

The woman should be placed in lithotomy, cleaned and draped. Suitable broad spectrum antibiotics should be given before staring the procedure (co-amoxiclav 1.2g / cefuroxime and metronidazole or clarithromycin +/- gentamicin are suitable)

As there will be disruption to the internal anal sphincter (IAS), its important to identify this structure, find the ends which may be retracted laterally and repair it with interrupted sutures using a fine (3/0), slowly absorbed monofilament suture such as polyglyconate (maxon) or polydioxone (PDS).

Once I was satisfied that the IAS was repaired, I would then go on to identify the external anal sphincter (EAS). This can often be difficult to find especially if an episiotomy has been performed. More often than not one end is easily identifiable and the other end is retracted. The EAS should be identified and secured with Allis Forceps. If needed the surrounding tissue can be dissected away to to leave the EAS exposed so that the 2 ends can be overlapped.

There are 2 recognised ways of repairing the EAS, either end to end or overlap. There is no conclusive evidence that one is superior to the other.

If the sphincter is completely disrupted – as in this case, I would try to overlap the ends of the sphincter by holding the two ends in Allis Forceps, placing the sutures and holding the individually until all are in place and the tying them individually. Again, a 3/0 PDS (or similar is suitable). The free overlapped end can be secured with 1or2 interrupted sutures using the same material.

Oncet the sphincter has been repaired,I would then close the overlying deep perineal muscles over the sphincter to ‘buttress’ the repair. These deep muscles can be repaired using interrupted vicryl as this absorbs quicker and does not cause superficial irritation. Superficial muscles and skin can be closed with vicryl rapide.

Once the repair is complete, a PV examination should be performed to check there anre no defect and a PR should confir that there is no suture material in the anal canal.

Gloves should be changed and a catheter inserted.

 

Dear Paul ,pls mark this answer as previous had error in numbering. Posted by tmalar@yahoo.com C.

 

Essay 358

Posted byPAUL A.
Mon Jan 16, 2012 01:30 pm

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks].

 

a)            I will assess her vitals to look if she is hemodynamically stable such as blood pressure for hypotension,pulse   rate for tachycardia, temperature for pyrexia. Her cardiovascular and respiratory system is also checked and abdominal palpated to look for any uterine atony. If there is uterine atony, i will get an assistant to rub on a contraction while utelising more assistants to insert 2 large branulae and getting blood on the same time for full blood count,electrolytes,coagulation profile,clotting factors, group cross match and save and organising for blood transfusion if blood loss is significant. Intravenous Oxytocin 40 unit is started to prevent uterine atony and further bleeding. Infusion of crystalloid such as Hartmann commenced while waiting for blood transfusion.  Her antenatal notes is reviewed to look for any risk factors that preludes to the perineal tear such as her parity  (primigravida) , prolong second stage of labour,instrumental delivery, persistent occipital posterior, midline episiotomy,macrosomia. Her pass history is looked for if she had similar history of third degree perineal tear. Knowlege of these information will help in the counselling the patient post operatively and subsequent follow up.I will explained to the patient and her partner  that a vaginal examination will be done for initial assessment and extend of the tear and further management and repair will be done under anaesthesia with adequate  lighting in the operation theatre. With adequate analgesia/inhalation analgesia or if she is on epidural, a top up on anaesthesia is sorted with the help of anaesthetics. Senior consultant experience in repairing perineum tear is called in for further assistance.Vaginal examination done in lithotomy position  under adequate lighting to confirm the degree of the tear and its extend of damage. Per rectum examination done to look for the rectal mucosa involvement. The findings are explained to the patient and her partner and she is prepared to be taken into the operation theatre for repair under conducive adequate lightings and anaesthesia after informing the anaesthetist.  A written consent is taken and all finding on inspection is documented in the post partum notes. IV antibiotic metronidazole commenced to prevent risk of anaerobic infection.

 

b)             In the operating theatre with good and adequate lighting and appropriate analgesia/anaesthesia for  relaxation of the perineum  and with the supervision of a trained experience practitioner , the repair is done.Intravenous  broad spectrum antibiotics commenced during procedure. Patient on lithotomy position, the perineum is cleaned  and drapped. A good assistance for retraction and adequate visualisation the anal epithelium repaired with 3-0 polygalatin (vicryl) sutures. The internal anal sphinter is identified and repaired using interrupted or mattress 3-0 polydioxanone (PDS). The external sphinter repaired using 2-0 PDS either an end to end or overlapping technique used. The vaginal epithelium approximated using continuous stitch with rapid absorbable vicryl. The perineum body reconstructed to support the repaired  sphincter using inrerrupted 2-0 vicryl.The perineal skin than closed using subcuticular 2-0 rapid absorbable vicyl. A vaginal and rectal examination done to ascertain the  repair is complete. Tampons and swabs are removed and the counts checked. The bladder emptied and urinary catheter inserted and kept for 24/hours. The Intravenous broad spectrum antibiotics continued , following which it is changed to oral antibiotics after repair for one week. Adequate analgesia in form of oral NSAIDS or intramuscular NSAIDS recommended however suppository analgesia is avoided. Opiates avoided as it can lead to constipation.Complete detail of the incident leading to the tear needs to be documented in the notes and post operative notes updated with the procedure of repair done. Laxatives prescribed and patient is discharged once the bowel opening is achieved.A physiotherapist reference for pelvic exercise is organised. Perineal toilet and hygiene is advised. On discharge the patient is ensured she understood the events of her delivery and a contact number given if any problem occurs. She should be counselled that the sutures can occasionally migrate and fragments may pass per vagina pr per rectum. Followup within 6 weeks is given again counselling.

 

 

 

 

 

 

 

 

 

 

ans to essay 358 Posted by sindhu K.

 

a. .  I will assess the general condition of the patient by checking  appearance of the patient –anxious or apprehensive,  pulse[rate and volume], blood pressure, pallor, respiratory rate  ,  and the amount of bleeding because in case patient bleeding profusely and unstable I have to immediately resuscitate the patient  and shift to theatre for  controle the bleeding. If the patient is stable ,   after introducing myself, I will explain to the patient  the possibility of sustaining an injury to the anal sphincter  and the need for a thorough examination in order to find out and exactly delineate  the extent injury .then I will review the patient  for any risk factors for anal shinctor injury like  primi parity, induced labour, precipitate labour, prolonged second stage, epidural anaesthesia, instrumental delivery  especially forceps delivery, baby weight more than 4 kg, shoulder dystocia  malposition especially occipito posterior position.. then I will proceed to a thorough local examination  after ensuring adequate lighting and analgesia and look for any  obvious evidence of shinter injury and extent of injury. This will be followed by a speculum examination to assess the extent of tear inside vagina, any additional tears, integrity of the cervix. Then I will do a vaginal and rectal examination. By these I will be able to identify and classify any anal sphincter injury if present, as per the classification system,

        grade 1. perineal skin or vaginal mucosa or both

        grade 2. involvement of perineal muscles

        grade 3. involvement of anal sphincter-  grade 3 A- <50% of external anal sphincter

                                                                         grade 3 B->50% of external anal sphincter

                                                                         grade 3C- Involvement of internal anal

                                                                                                 sphincter

         grade 4.  involvement of anal mucosa and sphincter

 

isolated involvement of anal mucosa without sphincter involvement[button hole injury]  would be separately documented.

I will explain the patient about the nature and extent of injury, need to repair in the theatre under anaesthesia, possible immediate and late complications like perineal pain, wound dehiscence, dysparunia, bowel and bladder incontinence, fistula formation, success rate of surgery, importance of  post natal follow up and its schedule , if available offer a printed leaflet for the patient to be read later on.

 The findings would be clearely documented in the patients file.

With patients informed consent I will prepare the patient for repairing the sphincter injury in the theatre because suturing in the theatre provides the following advantages.

  1. good lighting
  2. good instruments
  3. skilled assistants
  4. anaesthesia can be given, either spinal or general anaesthesia. Anaesthesisia is important  because it will relax the anal sphinter it will be easy to  retract the torn sphincter edges and to repair it without tension.

I will give prophylactic parenteral  broad spectrum antibiotic including metronidazole  because infection can produce wound dehiscence and reduce success rate of surgery. I will also ask for a continuos blader drainage because urinary retention is common during first 24 hours of surgery.

In case blood loss is more than mild I will ask to cross match  packed cells .

 

 

 

 

b. after adequate anesthesia  patient will be placed on lithotomy positon because it will provide better visualisation intra operatively and easy to repair.

If bladder catheter is not inserted already, I will cathetorise the patient with foley’s catheter. Then I will review  the nature and extent of the injury thoroughly because I can assess better under anesthesia. The repair should start with anal mucosa. Synthetic absorbable suture like polygalactin -30  or polydioxonone-30  is appropriate and sutured by loose  continous nonlocking suture. Then internal anal sphincter if able to identify separately[ difficult to identify in acute obstetrical injury] sutured separately with 20 polygalactin or 20 polydioxonone by interrupted sutures. External anal sphincter can be repaired by end to end technique or overlap technique with 20 vycril or polydioxpnone.. Both has shown equivalent results. Perineal body should be sutured over sphincter for support with 20 vycril by interrupted suture. Vaginal mucosa is repaired with continous nonlocking 20 polyglactin sutures. Perineal skin is sutured with 20 polyglactin 20  subcuticalar suture.

 Repair should be documented clearly. An incident form filled.i will advice to continoue broad spectrum antibiotic for  7 days. Laxactive like lactulose is prescribed for 10 days

Also I will ensure adequate analgesia but avoid narcotics [as it will produce constipation]

And rectal suppository as it will traumatize.

Posted by lalitha N.

a)  Would review patient’s records and take history regarding risk factors for perineal trauma  like primiparity, birth weight greater than 4000g, prolonged second stage, vaginal operative delivery, mal-position especially OP and precipitate labour .

 amount of bleeding would be assessed and  see whether uterus is well contracted.

 general condition of the patient to be assessed - pulse, BP to see if patient is stable.

 thorough examination is essential to assess the nature and extent of the injury, enable appropriate repair and minimise long-term consequences.

 Examination should be undertaken by someone trained in the recognition of third degree tears or under supervision .

 such assessment should not interfere with the woman’s interaction with her baby unless she is bleeding .
 adequate analgesia is provided ..

 I will explain the nature of the tear to the patient and the procedure required to repair it and the complications anticipated, like incontinence of flatus and stools, haematoma, rectovaginal fistula.

I would ensure the patient has IV access and take bloods for FBC and  group and save.

Will  take informed consent from the patient.

 I would inform  the anaesthetist, the theatre team and the midwife in charge. 

b)  Repair should be undertaken in the operating theatre with good lighting and appropriate analgesia / anaesthesia and only by a trained operator or trainee under supervision to optimise the outcome.

The internal anal sphincter is identified and repaired using interrupted or mattress sutures using 3-0 polydioxanone (PDS).

The external anal sphincter is repaired using 2-0 PDS , an end-to-end or overlapping technique may be used.  

 knots are buried in anal sphincter under superficial perineal muscles to reduce risk of knot migration and perineal irritation.

Identify apex of vaginal tear.

vaginal epithelium is then closed with loose continuous non-locking sutures with  rapidly absorbable 2-0 polygalactin.

 The perineal body  is re-constructed to support the sphincter repair using interrupted 2-0 polygalactin.

 The perineal skin is closed using sub-cuticular 2-0 rapid absorbable polygalactin.

 A careful vaginal and rectal examination is undertaken to ascertain completeness of repair and remove any swabs / tampons.

 Broad-spectrum iv antibiotics  are administered at the time of repair and oral antibiotics continued after the repair for one week.

 The bladder is emptied and an in-dwelling catheter inserted.

 The repair is documented accurately and an incident form completed.

 Adequate analgesia is prescribed .   Rectal analgesia   avoided.

 Laxatives such as lactulose should be prescribed to prevent constipation.

 Physiotherapy referral should be made.

 The woman is given adequate information on the extent of the injury, perineal care and contacts if symptoms of infection or incontinence develop.

 A follow-up appointment is made ~12 weeks post-partum.

 

         

 

           

 

 

 

 

 

           

 

 

 

 

Essay 358 Answer Posted by Drxyz A.

 

 

Essay 358

You have been asked to review a healthy 33 year old woman because she is thought to have a third degree perineal tear following spontaneous vaginal delivery. (a) Discuss your pre-operative management [10 marks]. (b) Discuss your intra-operative management given that a 3c tear is confirmed [10 marks].

 

ANSWER

[A]

She will be examined systematically by trained clinician to classify the perineal tear. In cases of doubt classify higher class than lower. Patient will be explained about the nature of tear and need of repair in Operation Theater. Short term and long term morbidity will be explained if the tear left without repair. After appropriate repair by experienced gynaecologist there will still be chance of fecal incontinence which will be relieved in  60 – 80% of patients without further intervention. She will be explained about knot migration. Need of anesthesia will be explained, type of anesthesia will be explained by anesthetist. Patient information sheet will be given and informed consent will be taken. Her general condition will be assessed. Vaginal bleeding will be assessed. If there is bleeding then according to the condition, IV line will be saved and blood will be sent for Group and Save and full blood count.

[B]

She will be taken to Operation Theater for reassessment and repaired by an experienced and skilled gynaecologist. Good light and assistant is needed. After anesthesia under aseptic technique lithotomy position will be made. Systematic examination will be done. Cervix and vagina will be examined to rule any tear. Vaginal and rectal examination will tell us about the involvement of anal sphincter. Tear of 3C will involve external and internal anal sphincter. Under anesthesia retracted torn end of the sphincter will be retrieved by Ellice forceps. External sphincter can be repaired by overlap or end to end technique. No method is superior to other. Dexon 3/0 or vicryl 2/0 will be used as this will decrease the pain and wound infection. Internal sphincter will be repaired by 3/0 Dexon or 2/0 vicryl with interrupted sutures. Vaginal skin will be sutured by non-locking continuous suture. Perineal muscle will be repaired by interrupted sutures and burring the knots in perineal muscle to avoid knot migration. Perineal skin by sub-cuticle sutures. There is a short term advantage of three layers to two layer in terms of dyspareunia at three months. The documentation, debriefing and short and long term post natal care will be explained.

 

Posted by Mahnaz A.

 

Third degree perineal tear involves the external and internal anal shpicters. Initial assessment of the patient should be done to detect her haemodynamic status, amount of bleeding, extent of perinel injury etc. She should be examined under good lighting and proper analgesia to facilitate the actual extent of damage. A senior and trained obstetrician should be involved to confirm the diagnosis. The duration of the injury should also be assessed. If it is less than 24 hours old then repair should be done immediately. But if she presents after 24 hrs following delivery then repair should be arranged after 3 months.

Preoperatively an intravenous channel should be opened and broad spectrum IV antibiotics should be started. After proper examination under good lighting and analgesia, a proper explanation of the condition should be expalined to the patient. Consent should be obtained for the procedure. All baseline investigations including complete blood count, blood grouping and saving, clotting factors should be assessed. Everything should be documented and patient should be tranfferred to theatre.

THe repair should be done by a senior and trained obstetrician or under his/her supervision. Adequate lighting source shouls be ensured and repair preferably done under general anaesthesia to facilitate proper relaxation and exposure. Appropriate asepsis should be maintianed and bladder evacuated properly.

Repair is done in 3 layers. First of all the internal anal sphicters are repaired using 2-0 PDS by continuous or interrupted sutures. Then external anal sphicter is apposed by 2-0 PDS with end to end or overlapping sutuers. The results for both end to end and overlapping sutuers are same.

THe apex of the vaginal musoca is then identified. It is closed by 2-0 polygalactin sutures with interrupted stitches or continues no locking sutuers.

Perineal body is then reconstructed. Skin apposed with subcuticular loose stiches.

After completion of procedure an indwelling catheter is placed in situ.

The detail of the procedure should be documented properly. Laxatives advised for the patient to avoid constipation.The woman should be counselled prperly about the extent of injury, procedure done and postoperative advice and perineal hygiene. Information leaflets can be provided . She is advised to have her follow up after 12 weeks.

obstetric anal injury Posted by shazard S.
Iwill first examine her general condition, pulse rate, blood pressure , mucous membranes and obtain an estimate of blood loss. Then establish intra venous access, take blood for FBC and commence a crystalloid infusion as a means of fluid resuscitation. I will encourage skin to skin contact with her baby and breast feeding during this consult. Elicit any history of obstetric anal injury as this may increase the likelyhood of symptoms of incontinence of flatus/stool. A history of allergy to antibiotics will detirmine the intra and post op antibiotic regime. Abdominal palpation is done to ensure a contracted uterus. Prior to the perineal examination ensure adequte analgesia by topping up her epidural if sited or admnistering local anaesthetic to the injury. The patient is placed in the lithotomy position. A vaginal examination(VE) is done utilising a simms speculum (applied against the anterior vaginal wall) and a per rectal (PR)examination will confirm a 3rd degree perineal tear. This examination will also reveal active bleeding and help gauge blood loss. Haemostatic sutures and tampon insertion will aid haemostasis en route to theatre. I will then inform the patient and her partner of my examination findings. Inform them that surgical approximation of the torn sphincter muscles under either general or regional anaesthetic in the operating theatre is optimal management. Inform them that possible outcomes if not repaired include incotinence of faeces or flatus and rarely recto-vaginal fistulation. Counsel them that surgical repair minimises the incidence of incontinence with 60 to 80% being asymptomatic 1 year post op. Morbidity also includes dyspareunia, sexual dysfunction and painful defaecation. Written consent should then be obtained from the patient. Inform the consultant obstetrician, senior anaesthesist, theatre staff and midwife in charge. B) With anaesthesia achieved and the patient placed in the lithotomy position i will procede with the repair utilising an aseptic technique. Identify the torn edges of the internal (IAS)and external anal sphincters (EAS). Appromite the edges of the IAS using interrupted sutures (2-0 vicryl or 3-0 PDS). Then approximate the edges of the EAS utilising either an overlapping or end to end approximation using interrupted sutures (2-0 vicryl or 3-0 PDS). Both overlapping and end to end techniques are equally effective. The knots are buried under the superfiscial perineal muscles to prevent migration to the perineal skin. The vaginal epithelium then the perineal skin are approximated utilising non locking sutures (2-0 vicryl rapide). The vaginal walls and cervix are inspected looking for lacerations. A PR examination is done to ensure to sutures have not gone through the anal mucosa (pre disposes to recto- vaginal fistulation). Counts of swabs, instruments and needles are ensured to be correct and blood loss is estimated. A urinary catheter is inserted to guard against post-operative urinary retention. Intravenous antibiotics are administered ( augmetin 1.2g and metronidazole 500mg). TED stockings are put on. Operative technique should be documented utilising diagrams giving details of suture materials used, method of sphincter approximation, operative findings and mode of anaesthesia used. Post op orders for low molecular weight heparin( prophylactic dose), oral analgesia ( diclofenac 100mg 12 hourly), oral antibiotics ( augmentin 625 mg 12 hourly and metronidazole 500mg 8 hourly for 7 days),lactulose and fybogel should be documented. Debriefing and reassurance should be offered to the patient and her partner while in the recovery room if possible. Delivery of subsequent pregnancies by planned caesarean section may be offered and advise that subsequent vaginal deliveries may worsen sphincter integrity.
Sorry Posted by shazard S.
Sorry my answer got jumbled together while pasting. . . B is indicated.
Posted by Muthu M.

This is a important diagnosis which has high morbidity involved.  Therefore it needs to be checked by a senior obstetrician who is at registrar level and above.  The patient may have had epidural, persistent occipito posterior position during labour, prolonged 2nd stage of pushing or had shoulder dystocia may be the reason for her high suspicion of third degree tear.  The above information should be kept in mind while reviewing the notes.  After introducing to the patient, with verbal consent in presence of chaperone, patient had to examined in the lithotomy position.  It has to be a meticulous examination of genital tear checking the involvement of perineal skin, muscles, external anal sphincter, internal anal spincture, and anal mucosa.  It has to be done in presence of light source, by local inspection, vaginal and rectal examination to be complete.  If in any about the degree of perineal tear, it is better to classify at a higher level than lower level such as 3c instead of 3b.  The findings had to be discussed with patient and treatement options to be informed.  It is better done at operation theatre to have a better outcome should be discussed.  Written consent had to be obtained, benefits and risks informed.  In spite of good repair, still there is long term risk of faecal and flatus incontinence which is very common to be informed. 

 

The repair of 3C tear will be done at operation theatre under regional or general anaesthesia, with good light source and in an aseptic environment.  Surgical assistance needed to help in repair.  At the start of procedure, give intravenous antibiotic to be given to the patient.  The internal sphincture should be closed using 2-0 vicryl or 3-0PDS as interrupted or separate sutures.  It is better to be buried as there is risk of migration which will cause long term discomfort and pain.  For external anal sphincture, 3-0pds used close either overlapping or end to end method.  Rest of the perineal muscle and skin to be closed using 2-0vicryl rapide, for muscle either interrupted or continuous method used and for skin either mattress / interrupted suture or subcuticular suture is done.  At the end of suturing, repeat meticulous examination of vaginal and rectal examination to be performed.  If she had regional anaesthesia, she she needs to foley’s catheter to be left in place for 12hours to avoid bladder distenetion.  Warn about suture migration, de-brief about findings and repair, document about the methods used.  Patient needs a week course of antibiotics and 2 weeks course of laxatives to avoid wound infection and wound dehiscence.  Perineal hygiene and pelvic floor exercise to be informed and supported by physio referral.  Patient needs to be reviewed at the pelvic floor clinic by a dedicated consultant around 6 weeks time.

Posted by shazard S.
Good day Dr. Paul, i posted an essay please mark it. Thx so much.
Posted by shazard S.
Good day Dr. Paul, i posted an essay please mark it. Thx so much.
NA Posted by naila A.

The women should be informed of her condition and need of detailed examination and treatment should be explained to her.  General condition of the woman should be assessed. Her pulse blood pressure and state of hydration and need of analgesia should be assessed. I/V line should be obtained and blood for FBC, group and save serum should be obtained. If there is significant blood loss, volume replacement should be urgent and resuscitation measures should be instituted. Rapidly bleeding vessels should be given immediate attention.

      Woman should be informed of need of repair under general or regional anesthesia. The structures involved and need of examination of vagina, perineum and rectum should be explained to her. The detail of the procedure should be explained to her and consequences of not repairing should also be explained. Small risk of fecal or flatus incontinence should be explained to her. Frequent risk of post partum discomfort, dyspareunia, wound infection and urinary tract infection should be explained. If possible she should be given the opportunity to meet anesthetist.  Her family or partner should also be explained about her condition.

 b)  The procedure should be carried out in operation theater. The procedure should be carried out by an experienced practitioner or under supervision of an experienced practitioner. Good light and correct instruments should be available. Urinary catheter should be inserted. I/V antibiotics such as metronidazole and cephalosporin should be given. Adequate exposure of tissues and systematic examination is required to assess the extent of damage. Proper visualization of apex is required for appropriate repair. This is the most common site for fistula formation. If internal anal sphinter is identified it is repaired with monofilament PDS 3-0 suture with interrupted stitches. External anal sphinter is identified and mobilized as it may have retracted into the surrounding tissues and should be repaired either with 2-0 vicryl or PDS 3-0 suture. An end to end repair or overlapping technique both can be used with equal success. Surgical knots should be buried beneath superficial perineal muscles. Good repair of perineal muscles is required with vicryl 2-0 for the support of sphinter. Skin should be closed with subcuticular stitching with vicryl 2-0. It is associated with better results and less perineal pain as compared to interrupted sutures. The procedure should be completed by final examination of repair and rectal examination. Instruments and swabs should be counted. Urinary catheter should be retained for overnight.   

 

Answer to essay 358 Ritu M Posted by Ritu M.

Evaluation begins with a brief history about parity , previous 3rd degree tears ,instrumental delivery. A systematic examination should be performed after verbal consent in lithtomy postion with good light and adequate analgesia , nitrousoxide and air and local anaesthesia. with pervaginal and perrectal examination to assess the degreeof tear , appropriate  classification and to rule out 4th degree tear and assess amount of pervaginal bleeding.The patient should be conselled about the extent of perineal tear and written consent abtained for appropriate repair in theatre by trained personnel with good light , adequate regional anaethesia or general anaethesia and   complicaions such as incontinence of flatus and faeces which may be common , infection , bleeding , implications on fututre deliveries , secondory repair or sacral neuromodulation for persistent symptoms.should be explained . IV access should be obtained and bloods taken for FBC and group and save .Inform the anaethetist for a review and theatre team .

Intraopertively a reexamination should be performed after cleaning  and draping with P/V and perrectal examination to accurately classify the degree of tear ., remembering to change the gloves to prevent infection . Antibiotics such as IV cefuroxime and metronidazole should be administered  prophylactically . External anal sphincter ends identified and repaired with 3"0 polydiaxone  PDS suttures by ened to end anastomosis or overalpping techniqueas both are equally effective . Internal anal sphincter should idendified and approximated with interrupted sutures with 3"0 PDs or 2"0 poly galactin may cause less irritaion and discomfort .Surgigal knots shouldbe burried under the perinal muscles to prevent knot migration under the skin . vaginal mucosa , perineal muscles and perineal skin are sutured with continous sutures 2"0 vicryle rapide, with  subticular sutures to perineal skin .  P/R  and P/V examination is perforemed post procedure and swab and instrument count checked . Post procedure debefring  is carried out . antibiotics ceflexin and metronidazole recommendedfor 7 days and laxatives for 2 weeks to prevent wound infection and dehiscence . Pelvic floor exercises  recommended for 6 to 12 weeks and patient  should be seen in a specilaist  perineal care clinic  in 6-12 weeks .If symptoms of incontintence perisist she may be referred to a colorectal surgeon or specilaist gynaecologist for anal manometry and endonal ultrasound . A small number of women may be require referral to a colorectal surgeon for secondary repair .