Perineal trauma: classification and repair principles

6 steps

First to fourth degree, by what is torn. First and second degree are repaired in the room; third and fourth in theatre by an experienced operator.

Consent and trauma-informed practice

Explain the tear and the repair; analgesia before touching; the patient can ask to stop and have more analgesia

The sequence

6 steps

01
Classify
First degree: skin and vaginal epithelium only. Second: perineal muscles, sphincter intact. Third: anal sphincter (3a under 50 percent of the external sphincter, 3b over 50 percent, 3c internal sphincter too). Fourth: anorectal mucosa.
02
Repair the vagina
A continuous suture from the apex of the vaginal tear to the hymenal ring.
03
Repair the muscle
Continuous or interrupted sutures to approximate the perineal muscles without tension.
04
Close the skin
A subcuticular continuous suture, or leave the skin if well apposed.
05
Check
A rectal examination for sutures in the rectum; a swab and needle count; document the degree and the repair.
06
Third and fourth degree
Theatre, regional or general anaesthesia, a trained operator; the sphincter is repaired end to end or by overlap; antibiotics, laxatives, physiotherapy and follow-up in a perineal clinic.

Consent, analgesia (local infiltration or a working epidural), good light, lithotomy, a rectal examination before and after repair
Absorbable suture; count swabs and needles