Suturing Perineal

Lacerations
Anatomy of the Female External Reproductive Organ
FEMALE REPRODUCTIVE SYSTEM
EXTERNAL PARTS: THE VULVA
1. MONS PUBIS OR MONS
VENERIS = Thick pad of fat
that covers & protects the
symphysis pubis. Hairless &
smooth in childhood, it is
covered by dark & curly
hair called escutcheon after
puberty. Hair pattern is
triangular with base up.
2. LABIA MAJORA = 2
greater folds (lips) of fat
& areolar tissue arising
from the mons
anteriorly and merge
into the perineum
posteriorly; outer
portion is covered with
skin and pubic hair.
3. LABIA MINORA = 2
lesser folds (lips) of skin
located between the labia
majora and uniting
anteriorly to form the
prepuce and encloses the
clitoris, and posteriorly
forming the fourchette.
4. CLITORIS = Small
erectile structure;
contains nerve endings,
sensitive to temperature
and touch. It is the seat
of sexual arousal and
excitement in females.
It is the most sensitive
part of a woman’s body.
It is also the structure
that guides to the
urinary meatus for
female catheterization.
5. URETHRAL ORIFICE
(os)= The external opening
of the urethra. Lies 2.5
cm below the clitoris; on
either side are the
openings of the Skene’s
glands (paraurethral
glands). The shortness of
the female urethra makes
women more susceptible
to UTI than men.
VESTIBULE = A space
enclosed by labia
minora laterally,
prepuce anteriorly
and fourchette
posteriorly; has 6
openings: a urethral
os, a vaginal os, 2
outlets of the
Bartholin’s glands & 2
outlets for the Skene’s
glands.
VAGINAL ORIFICE /
INTROITUS = External
opening of the vagina,
covered by a thin membrane
( Hymen) in virgins. Located
lateral to the vaginal
opening on both sides are
the Bartholin’s Glands
(vulvovaginal glands). The
Grafenberg or G-spot is a
very sensitive area located at
the inner anterior aspect of
the vagina.
BARTHOLIN’S
GLANDS (Vulvovaginal
Glands). It lubricates
the external vulva
during coitus and the
alkaline ph of their
secretion helps to
improve sperm
survival in the vagina.
SKENE’S GLANDS
(Paraurethral Glands);
The secretions of which
help to lubricate the
external genitalia.
 Lacerations
of the birth
canal
Perineal lacerations-
are injuries or tears
in the vaginal canal
and outlet that
occur during delivery
of the baby.
Based on RA 7392
Art. III Sec. 23. Practice of Midwifery Defined
 Suture perineal lacerations to control
bleeding
 Repair lacerations up to 2nd degree
 Refer more extensive lacerations to the
hospital
 Follow principles of surgical repair in doing
suturing.
 Muscles of the
Perineum
1.Bulbocavernosus
Muscle
2.Transverse
Perineal Muscle
3.Levator Ani
Muscle
4.External Anal
Sphincter
Commonly torn sites
during childbirth
1.Clitoris
2.Labia Minora
3.Vagina
4.Fourchette
Complications of Perineal
Lacerations

1.Chronic perineal pain

2.Dyspareunia
3.Urinary incontinence
4.Fecal incontinence
Classifications of Perineal Lacerations

1.First degree
2.Second degree
3.Third degree
4.Fourth degree lacerations
First Degree
Perenial
laceration

• Vaginal mucous
membrane
• Fourchette
• Perineal skin
 Second Degree
Perenial
laceration
• Vaginal mucous
membrane
• Fourchette
• Perineal skin
• Muscles of the
perineal body
Third Degree
Perenial
laceration
• Vaginal mucous
membrane
• Fourchette
• Perineal skin
• Muscles of the
perineal body
• Anal sphincter
Fourth Degree
Perenial laceration
• Vaginal mucous
membrane
• Fourchette
• Perineal skin
• Muscles of the
perineal body
• Anal sphincter
• Rectal mucosa &
Predisposing Factors for Perineal Lacerations

1.Face presentation
2.Rigid & scarred perineum
3.Precipitate Labor/Delivery
4.Rapid breech extraction
5.Big baby
Principles of Surgical Repair

1.Asepsis & antisepsis

2.Adequate hemostasis
3.Anatomic restoration
4.Use suture materials with minimum tissue
reaction
Sutures
Materials used to
stitch tissue
together & hold
them until
healing has taken
place. Consist of
a needle with an
attached length
of thread.
Types of Suture
Materials
1.Absorbable
2.Non-absorbable
 Absorbable
A.Plain type A
Suture
B.Chromic Surgical
Gut
C.Polyglycolic Acid
A.Plain type A Suture
B. Chromic Surgical Gut
C. Polyglycolic
Acid
Non-absorbable
A.Cotton
B.Silk
C.Nylon
Selecting Sutures for Perineal Lacerations
1.Sterile
2.Easy to handle
3.Minimal tissue reaction/trauma
4.Have high tensile strength retention
5.Hold knot securely
6.Absorbable
Surgical Needles
Types of Needles
1.Round
2.Taper point
3.Cutting
 Interlocking
Interrupted Stitch Running
Suture Stitch
Suturing Techniques
Simple interrupted sutures
Continuous running stitch
Interlocking stitch
Subcuticular Closure
 Pointers in Perineal Repair
1.Repair the lacerations in layer.
2.Close the deeper tissues with interrupted suturing.
3.Repair the vagina by suturing above the angle of the
wound (apex) using continuous interlocking or
interrupted technique.
4.Close the skin with simple interrupted or subcuticular
sutures.
5.Use smaller sizes of materials (2-O or 3-0)
6.Avoid making the sutures too tight.
7.Check the rectal lumen after.
8.Remove gauze from the vagina (if you put one) when
you finish repair.
Essential Instruments and Supplies
Needle holder
Tissue forceps
Scissors
Mosquito forceps
Gloves
Disposable syringe (3cc or 5cc) with needle
Lidocaine 1% or 2% solution
Gauze sponge
Size 2-O suture with needle
Adequate light or flash light
 Providing Local Anesthesia
 Use lidocaine to numb the sensation on the site of the repair.
 Ask the patient for any untoward reaction.
1.Fill the hypodermic needle with lidocaine.
2.Introduce the entire length of the needle to the repair site.
3.Aspirate the needle to make sure you did not hit a blood
vessel.
4.Slowly withdraw the needle while injecting the anesthesia.
5.Repeat the procedure to adequately anesthetize the repair site,
wait for 2 minutes before starting
 Steps in Perenial Repair
1.Clean hands with soap & water.
2.Clean the site for repair.
3.Put on sterile gloves.
4.Expose & explore the vagina & perineum.
5.Apply firm pressure on bleeding sites.
6.Clamp & tie bleeders using small forceps.
7.Infiltrate site for repair with Lidocaine using
local anesthesia technique.
8.Start suturing 1 cm above the apex of the
tear and continue downwards.
 Steps in Perenial Repair
9.Use either interrupted or continuous suturing
technique.
10. Stitch muscle to muscle, mucosa to mucosa.
11. Push the edges together to make sure that
they are correctly approximated.
12.Be sure the suture did not go through the
anus or rectum. Check it by inserting one
finger in the woman’s anus.
 Care of the Wound
For perineal pain & discomfort do the ff:
1.Give oral analgesic.
2.Apply ice pack initially.
3.Apply warm compress (after 1 day) to
lessen edema.
4.Inspect the perineum for hematoma.
 Complications of Wound Repair
1.Wound Infection 2. Hematoma
 Prevention of Perineal Tears
1.Instruct the woman on proper bearing
down effort.
2.Avoid sudden expulsion of the fetal head
during bearing down.
3.Maintain flexion of the fetal head to allow
smaller diameter to pass through the
perineum.
4.Control extension of the head.
5.Avoid external rotation of the baby before
delivery of the shoulders.