1. Prof. M.C.BansalMBBS., MS., FICOG., MICOG.Founder Principal
& Controller,Jhalawar Medical College & Hospital
Jjalawar.MGMC & Hospital , sitapura ., Jaipur
2. AnatomyA. Pelvic floor: Pelvic floor is a muscular diaphragm
that separates the pelvic cavity above from the perineal space
below. It is formed by the levator ani and coccygeus muscles, and
is covered by parietal fascia. The levator ani muscles on either
side arise from posterior surface of pubic symphysis, the white
line over fascia covering obturator internus and ischial
spine.
3. The levators sweep from the lateral pelvic wall downwards
and medially to fuse with the opposite side in the midline and form
a pubo-coccygeal raphe. Fibres of Levators are inserted from before
backwards and fuse with muscle fibres of urethra, the vaginal
walls, perineal body, anal canal, anococcygeal body and the lateral
borders of coccyx. Functions: To support the pelvic viscera. To
maintain effective intra-abdominal pressure. To facilitate anterior
rotation and downward and forward propulsion of the presenting part
during parturition. Serves as a support and voluntary sphicter of
urethra, vagina and anal canal. There are gaps in pelvic floor:- 1.
Urogenital hiatus- anterior gap through which urethra and vagina
pass. 2. Rectal hiatus- posterior gap through which anal canal
passes.
4. B. Urogenital diaphragm: The urogenital diaphragm is
external to pelvic diaphragm and includes the triangular area
between the ischial tuberosities and the symphysis. It is made up
of deep transverse perineal muscles, sphincter urethrae and
internal and external fascial coverings.
5. Anatomy contn..C. Perineum: Perineum is a diamond-shaped
space that lies below the pelvic floor.it is bounded by:
Superiorly: pelvic floor Laterally: the pelvic outlet consisting of
subpubic angle, ischiopubic rami, ischial tuerosities,
sacrotuberous ligaments and coccyx Inferiorly: skin and fascia
6. This area is divided into two triangles by transverse
muscles of perineum and base of urogenital diaphragm: Anteriorly-
Urogenital triangle. Posteriorly- Anal triangle Most of the support
of perineum is provided by pelvic and urogenital diaphragms.
7. Perineal Body: The median raphe of levator ani between the
anus and vagina, is reinforced by the central tendon of the
perineum. Bulbocavernosus, superficial transverse perineal and
external anal sphincter muscles also converge on the central
tendon. These muscles contribute to perineal body, which provides
much support to perineum.
8. Blood supply to perineum: Major blood supply is by internal
pudental artery and its branches- inferior rectal artery and
posterior labial artery. Posterior labial Inferior rectal
9. Nerve Supply is primarily via pudendal nerve(S2,S3,S4) and
its branches.
10. Pudendal block
11. Causes and Predisposing Factors: Lacerations of perineum
are the result of overstreching or too rapid streching of the
tissues, especially if they are poorly extensile and rigid.
Perineal injuries are more common in primigravida than
multigravida. Obstetric injuries: Malpresentations such as breech
Contracted pelvic outlet spontaneous labour operative vaginal
deliveries( forceps or vaccum) Macrosomic babies Non-obstetric
injuries: rape, molestation, fall, accidental injuries like RTA,
bull horn injuries etc.
12. Degrees of Perineal tear: First degree- limited to vaginal
mucosa and skin of the introitus. Second degree- extends to the
fascia and muscles of the perineal body. Third degree- trauma
involves the anal sphincter. Fourth degree - extends into the
rectal lumen, through the rectal mucosa. A rare type of tear is
central tear of the perineum when the head penetrates first through
the posterior vaginal wall, then through the perineal body and
appears through the skin of the perineum. It usually occurs in
patients with contracted outlet.
13. Symptomatology: Immediate: Bleeding Traumatic PPH -
hemorrhagic shock. Perineal Pain Perineal hematoma Urinary
retention due to painful perineum Urinary incontinence Anorectal
dysfunctions like fecal incontinence Delayed: 1. Infected perineum-
perineal abscess 2. Uterovaginal prolapse 3. Urinary incontinence
(stress and urinary fistula) 4. Fecal incontinence ( rectovaginal
fistula) 5. Dyspareunia 6. Feeling of slack vagina during coitus
Bleeding Disruption of anatomical continuity
14. On examination:
15. How to recognize: Put the patient in extended lithotomy
position. Arrange proper spottless bright light. Arrange for
vaginal pads instruments like ant. and post. vaginal retractors ,
urinary cathter, sponge holders, curved and straight artery clamps.
Vulva should be examined stepwise right from clitoris to the anus
downwards, laterally paraclitoral, paraurethral, paravaginal and
pararectal skin and muscles in every case after delivery. Perineal
tears may be associated with high vaginal circular tears and tears
in the fornix and cervix. One should suspect traumatic PPH due to
perineal tears when continuous bleeding p/v persisting even after
delivery of placenta when uterus is contracted and retracted. All
lacerations exceeding half inch in depth should be immediately
repaired and individual bleeder should be ligated separately.
16. Prevention: Timely episiotomy should be given in all
primigravida, vacuum and forceps delivery, breech delivery and
breech extraction done after IPV, rigid perineum in multigravida or
previous cases with history of perineal tears. Proper support of
perineum at the time of crowning and expulsion of head.
17. Repair Lacerations should be repaired immediately if
possible, and certainly within 24 hours of delivery. First step is
to define the limits of the lacerations, which includes vagina as
well as perineum. Best suture material is catgut for the vagina and
buried sutures; and fine mono-filament nylon for skin. As accurate
an approximation as possible of all the tissues should be secured
and no dead spaces are left. Method: The vaginal tear is repaired
first, care being taken to reach upper limit and to include the
underlying fascia as well as vaginal mucosa in the sutures.
18. Repair of complete perineal tear:
19. After care
20. Complications if left untreated: Infection Hemorrhagic
Shock Cosmetic disadvantage 3rd and 4th degree tears if left
untreated may lead to fecal incontinence.
21. Chronic perineal laceration In most cases of Chronic
perineal laceration with long standing disruption of anal sphincter
complex, classical symptoms are progressive loss of control of gas
and faeces from anus. If the puborectalis muscle is left intact and
is well innervated and functional, it can provide sufficient
muscular contraction to permit control of faeces when the patient
is constipated and when the stool is of normal consistency. Such
patients quickly learn this and remain in a constipated state to
decrease their symptoms.
22. Repair ofchronic complete perineallaceration1. Layered
method of repair2. Warren flap procedure3. Noble-Mangert-Fish
operation If the anorectal mucosa is intact and the injury is
largely limited to the anal sphincter complex and perineal body,
repair consists of anal sphinteroplasty with extensive
perineorrhaphy
23. 1. Layered method of repair:A. A transverse or crescent
perineal incision is used at the junction of posterior vaginal wall
and anal mucosa. lateral margins of incision are extended to the
region of perineal dimple created by the retracted external
sphincter. A midline incision is made along the lower half of the
posterior vaginal wall.B. Anterior rectal wall is separated in the
midline from the posterior vaginal wall with careful scissors
dissection. Dissection is carried laterally till the region of
external anal sphinter.
24. C. All scar tissue is excised from the margins of the
anorectal mucosa , and the defect in anal mucosa is closed using a
continuous or interrupted suture of 3-0 delayed absorbable
material. A submucosally placed suture is ideal. After mucosal
margins are approximated, a second supporting layer inverts the
initial mucosal suture line, this is internal anal sphincter
identified as white smooth layer of tissue between the anorectal
mucosal closure and external anal sphincter. This muscle is
responsible for most of the resting pressure in the anal canal. it
also serves to imbricate and isolate the mucosal layer and take
tension off it helping it heal and seal against infection.
25. D. External anal sphincteroplasty is done:In
approximation-type external anal sphincteroplasty, exetrnal anal
sphincter ends are completely trimmed of scar tissue and united in
the midline with interrupted 0 or 2-0 delayed absorbable sutures (
such as monofilament polydioxanone). 4-5 sutures are used to
approximate the sphincter muscle.In overlapping approach to the
external anal sphincter, the scarred ends of the torn sphinter are
used to hold the sutures that reconstitute the circumferential
sphincter. The ends are widely mobilized with the scar tissue left
on, taking care not to dissect beyond the 3 and 9-oclock position
bacause pudendal innervation enters laterally. The external
sphincter is brought together over the repaired internal sphinter
with two rows of two horizontal mattress sutures of delayed
absorbable type.
26. E. Restoration of narrower gental hiatus by bringing the
puborectalis muscles closer together. Dissection is carried out
laterally to the fascia overlying the medial border of
puborectalis. This fascia is brought together by a series of
interrupted , delayed- absorbable sutures. It is extended till
midportion of vagina to produce excellent anatomical support to
rectum and anal canal.F. Further support to perineal body is
provided by bringing together the disrupted ends of the superficial
transverse perineal muscles and bulbocavernosus. redundant vaginal
mucosa is excised and remaining mucosa is approximated in midline
with a continuous 2-0 or 3-0 delayed absorbable suture. It followed
by subcuticular closure of perineal skin.
27. (II). Warren Flap Operation for complete third degree
tearA. An inverted V-shaped incision is made in the posterior
vaginal mucosa, outlining the flap that is to be turned down. The
lower ends ot incision should be just lateral to the dimples caused
by retracted sphincter ends. The length of the flap should measure
a minimum of 3 cm to provide sufficiet vaginal mucosa.B. Taking
care not tot injure the bowel the bowel wall, the flap of mucosa is
dissected free from above downwards, stopping short of the margin
between the vaginal and anal mucosa. The flap is turned down to
hang over the anus.
28. C. External anal sphincter ends are then dissected free and
approximation or overlapping type external anal sphincteroplasty is
then performed.D. The fascia overlying the medial aspect of
puborectalis muscles is identified and is brought together with a
series of interrupted sutures using 0 or 2-0 delayed absorbable
sutures.E. Margins of vaginal mucosa and graft are approximated in
the midline by a continuous locking stich of 3-0 delayed absorbable
suture.
29. III. Noble Procedure:A. The torn perineal anal and rectal
tissues in patient with complete perineal tear form form a
butterfly appearence across the perineum. The wings of butterfly
are the dimples of the retracted ends of the external anal
sphincter. The initial incision is outlined around the margins of
this area following the margin of anal mucosa along tha anatomical
defect in rectovaginal septum.B. Sharp dissection is done to
separate tha anal wall from vaginal mucosa. External anal sphincter
remnants are sharply mobilized and separated from underlying anal
wall.
30. C. Ends of external anal sphinter are approximated end to
end or overlapping.D. Genital hiatus is narrowed by bringing
puborectalis muscles closer .
31. E. Transverse perineal muscles and inferior margins of
bulbocavernosus are reapproximated.vaginal mucosa is trimmed, if
necessary and margins of posterior vaginal wall are approximated
with continuous locking stich of 3-0 delayed absorbable suture.
This suture is carried over the perineal body as a subcuticular
stich and perianal skin is approximated in midline. Excess anal
mucosa is trimmed and vertical mattress sutures of 3-0 delayed
absorbable suture are used to approximate the broad surface of anal
submucosa to perianal skin.
32. Dehiscence of a vaginal laceration repair should be
evaluated for infection, irrigated, and debrided of necrotic
tissue. Sitz baths should be used liberally. If discovered in the
first 23 days after delivery, the wound can be resutured; however,
if the tissue is friable or has evidence of infection, a secondary
repair should be delayed for 68 weeks. Antibiotics should be
utilized if infection is noted
33. Why is an episiotomy only performedwith clear indication?
Third and fourth degree lacerations and anal incontinence of stool
or flatus are more common with an episiotomy than with a
spontaneous laceration What muscles are affected by seconddegree
lacerations? Bulbocavernous and ischiocavernous Laterally
Superficial transverse perineal muscle.
34. The prevalence of clinically recognized anal sphincter
lacerations varies widely and has been reported to occur in 0.6% to
20.0% of vaginal deliveries, with higher rates documented after
operative vaginal delivery. the perineal skin may be intact with an
underlying muscle tear not visible. Risk factors for both occult
and clinically recognized anal sphincter disruption include midline
episiotomy, operative vaginal delivery (both forceps and vacuum),
persistent occiputo- posterior head position, prolonged second
stage of labor (>2 hours), and delivery of macrosomic
infants.