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			<div class="title_b">Post-Natal Care (NUCOG 12) &raquo; Notes</div>
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						<p>
	<span style="font-size: 14px;"><strong>PERINEAL CARE</strong></span></p>
<p>
	Classification of perineal tears<br />
	Perineal tears are common following vaginal delivery. There are classified as follows:</p>
<ul>
	<li>
		1<sup>st </sup>degree &ndash; tear involving vaginal mucosa or perineal skin only</li>
	<li>
		2<sup>nd</sup> degree &ndash; involves perineal muscles</li>
	<li>
		3<sup>rd</sup> degree &ndash; involves external anal sphincter (EAS). This is further divided into 3A (less than 50% of EAS), 3B (more than 50% EAS) and 3C (full thickness anal sphincter tear)</li>
	<li>
		4<sup>th</sup> degree &ndash; includes rectal mucosa</li>
</ul>
<p>
	<strong>Obstetric risk factors for anal sphincter injury</strong></p>
<p>
	Maternal factors</p>
<ul>
	<li>
		Primiparity</li>
	<li>
		Instrumental delivery &ndash; higher with forceps than vacuum extraction</li>
	<li>
		Prolonged second stage of labour</li>
	<li>
		Epidural analgesia</li>
	<li>
		Midline episiotomy</li>
	<li>
		Previous anal sphincter injury</li>
</ul>
<p>
	Fetal factors</p>
<ul>
	<li>
		Birth weight greater than 4kg</li>
	<li>
		Shoulder dystocia</li>
	<li>
		Persistent occipito-posterior position during labour</li>
</ul>
<p>
	3<sup>rd</sup> and 4<sup>th</sup> degree tears are repaired in theatre under regional anaesthesia.</p>
<p>
	A course of antibiotic and laxatives is usually prescribed in these circumstances. Give NSAIDS for analgesia if not contraindicated.</p>
<p>
	Postnatal physiotherapy for 6 &ndash; 12 weeks is offered to help prevent incontinence</p>
<p>
	<strong>Complications of perineal tears</strong></p>
<p>
	Early</p>
<ul>
	<li>
		Haemorrhage</li>
	<li>
		Pain - may interfere with maternal-neonate bonding</li>
	<li>
		Wound infection / breakdown</li>
</ul>
<p>
	Late</p>
<ul>
	<li>
		Faecal incontinence</li>
	<li>
		Urinary incontinence</li>
	<li>
		Persistent perineal pain / dyspareunia</li>
	<li>
		Fistula formation</li>
	<li>
		Psychological sequelae</li>
</ul>
<p>
	<strong>Care of the perineum</strong></p>
<ul>
	<li>
		Pelvic floor exercises and analgesia are important</li>
	<li>
		Use warm clean water to clean perineum. No difference in healing when alternative remedies such as adding salt and antiseptics to water are used.</li>
	<li>
		Wash perineum after every visit to the toilet</li>
	<li>
		Do not use hair dryer over perineum. Use of toilet paper to pad dry the stitches is adequate</li>
	<li>
		To help keep area dry, the use of breathable materials e.g. cotton briefs is better than synthetic materials</li>
	<li>
		If using sanitary pads, change them frequently to help prevent infection</li>
	<li>
		If there is swelling, can use cold ice packs to help reduce swelling and discomfort</li>
	<li>
		Local anaesthetic creams are available at chemists but are expensive</li>
</ul>
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			<div class="title_b">Post-Natal Care (NUCOG 12) &raquo; Notes</div>
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						<span class="s_title">PERINEAL CARE</span>
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						<p>
	<span style="font-size: 14px;"><strong>PERINEAL CARE</strong></span></p>
<p>
	Classification of perineal tears<br />
	Perineal tears are common following vaginal delivery. There are classified as follows:</p>
<ul>
	<li>
		1<sup>st </sup>degree &ndash; tear involving vaginal mucosa or perineal skin only</li>
	<li>
		2<sup>nd</sup> degree &ndash; involves perineal muscles</li>
	<li>
		3<sup>rd</sup> degree &ndash; involves external anal sphincter (EAS). This is further divided into 3A (less than 50% of EAS), 3B (more than 50% EAS) and 3C (full thickness anal sphincter tear)</li>
	<li>
		4<sup>th</sup> degree &ndash; includes rectal mucosa</li>
</ul>
<p>
	<strong>Obstetric risk factors for anal sphincter injury</strong></p>
<p>
	Maternal factors</p>
<ul>
	<li>
		Primiparity</li>
	<li>
		Instrumental delivery &ndash; higher with forceps than vacuum extraction</li>
	<li>
		Prolonged second stage of labour</li>
	<li>
		Epidural analgesia</li>
	<li>
		Midline episiotomy</li>
	<li>
		Previous anal sphincter injury</li>
</ul>
<p>
	Fetal factors</p>
<ul>
	<li>
		Birth weight greater than 4kg</li>
	<li>
		Shoulder dystocia</li>
	<li>
		Persistent occipito-posterior position during labour</li>
</ul>
<p>
	3<sup>rd</sup> and 4<sup>th</sup> degree tears are repaired in theatre under regional anaesthesia.</p>
<p>
	A course of antibiotic and laxatives is usually prescribed in these circumstances. Give NSAIDS for analgesia if not contraindicated.</p>
<p>
	Postnatal physiotherapy for 6 &ndash; 12 weeks is offered to help prevent incontinence</p>
<p>
	<strong>Complications of perineal tears</strong></p>
<p>
	Early</p>
<ul>
	<li>
		Haemorrhage</li>
	<li>
		Pain - may interfere with maternal-neonate bonding</li>
	<li>
		Wound infection / breakdown</li>
</ul>
<p>
	Late</p>
<ul>
	<li>
		Faecal incontinence</li>
	<li>
		Urinary incontinence</li>
	<li>
		Persistent perineal pain / dyspareunia</li>
	<li>
		Fistula formation</li>
	<li>
		Psychological sequelae</li>
</ul>
<p>
	<strong>Care of the perineum</strong></p>
<ul>
	<li>
		Pelvic floor exercises and analgesia are important</li>
	<li>
		Use warm clean water to clean perineum. No difference in healing when alternative remedies such as adding salt and antiseptics to water are used.</li>
	<li>
		Wash perineum after every visit to the toilet</li>
	<li>
		Do not use hair dryer over perineum. Use of toilet paper to pad dry the stitches is adequate</li>
	<li>
		To help keep area dry, the use of breathable materials e.g. cotton briefs is better than synthetic materials</li>
	<li>
		If using sanitary pads, change them frequently to help prevent infection</li>
	<li>
		If there is swelling, can use cold ice packs to help reduce swelling and discomfort</li>
	<li>
		Local anaesthetic creams are available at chemists but are expensive</li>
</ul>
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