PowerPoint Presentation
RUPTURE PERINEUMPrepared by :Christine Surbakti -
406147010Marcelly Raymando - 406147011Melani Sugiarti Wijaya
Kangmartono - 4060147014
OBSTETRI AND GYNECOLOGY CLERKSHIP TARUMANAGARA UNIVERSITYRSUD
CIAWI, BOGORPeriod 29 th December 2014 s/d 7th March 2015
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DefinitionLacerations of perineum are the result of
overstreching or too rapid streching of the tissue especially if
they are poorly extensile or rigid. Laceration of the perineum is a
wound or irregular tear of the perineal tissues during
childbirth.
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ANATOMYPerineum Perineum is a diamond-shaped space that lies
below the pelvic floor.Is bounded by : Superiorly : Pelvic floor
Laterally : the pelvic outlet consisting of subpubic angle,
ischiopubic rami, ischial tuberosities, sacrotuberous ligaments and
coccyx Inferiorly : skin and fascia
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This area is divided into two triangles by transverse muscles of
perineum and base of urogenital diaphragm :Anterior
trianglePosterior triangleMost of the support of perineum is
provided by pelvic floor and urogenital diaphragm
ETIOLOGITear in perineum commonly occur at childbirth
:Malpresentations such as breechThe head of the fetus is born too
soonLabor is not headed properlyPreviously on peineum there is a
lot of scar tissue
RISK FACTORRisk Factor for more complex laceration include
:Midline EpisiotomyNulliparity ( Primigravida )Longer second-stage
laborPrecipitous deliveryPersistent occiput posterior
postitionOperative vaginal deliveryAsian RaceIncreasing Fetal
birthweight
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EPIDEMIOLOGYOne in three women occurring spontaneous laceration
in the first childbirth.Seven in ten women reported using
episiotomy in their first childbirthIt estimates that 85% of women
who have a vaginal delivery will have some degree of perineal
trauma and that 60-70% will require suturing.
CLASSIFICATIONDegrees of Perineal Rupture :First-degree
lacerations involve the fourchette, perineal skin, and vaginal
mucous membrane but not the underlying fascia and muscle. These
included periurethral lacerations, which may bleed profusely.
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Second-degree lacerations involve, in addition, the fascia and
muscles of the perineal body but not the anal sphincter. These
tears may be midline, but often extend upward on one or both sides
of the vagina, forming an irregular triangle.
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Third-degree lacerations extend farther to involve the external
anal sphincter.
Fourth-degree lacerations extend completely through the rectal
mucosa to expose its lumen and thus involves disruption of both the
external and internal anal sphincters.
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SIGN AND SYMPTOMSBleeding in a State where the placenta is born,
uterine contractions and well, it is certain that the bleeding
wounds of the street comes from the birth. Signs that threatens to
tear the perineum, among others:the perineum Skin started flaring
and tense.the perineum Skin colored pale and shinythere is bleeding
out of the holes of the vulva, is an indication of a tear in the
vaginal mucosa.when the skin of the perineum at the midline begins
to tear, among the fourchette and the sphincter ani.
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EPISIOTOMYepisiotomy is incision of the pudendumthe external
genital organs.The incision maybe made in the midline, creating a
median or midline episiotomy. It may also begin off the midline and
directed laterally and downward away from the rectum, termed a
mediolateral episiotomy.
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Episiotomy should be considered for indications such as shoulder
dystocia, breech delivery, macrosomic fetuses,operative vaginal
deliveries, persistent occiput posterior positions, and other
instances in which failure to perform an episiotomy will result in
significant perineal rupture
EXAMINATION1. Routine ExaminationAlmost all clinicians examine
perineum area after childbirth process to detect tears can be
appear. Some clinicians also recommend having all labor, followed
by routine rectal examination and inspection of the walls of the
vagina and cervix. Routine examination of the rectal to detect the
septal aims on mucosa recta, anal sphincter, and perineum by using
one finger into the rectum.
2. Peri-ruleIs a standard tool for assessing the perineum tear
stadium two objectively made of plastic scale.
MANAGEMENTLacerations should be repaired immadietly if possible,
and certainly within hours of deliveryFirst step is to define the
limits of the lacerations, which includes vagina as well as
perineumAs accurate an approximation as possible of all tissues
should be secured and no dead spaces are left
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There are many ways to repair a perineal lacerations, but the
concept is still the same:The suture material commonly used is 20
chromic catgut.For shallow wound it can be repair with one stitch;
for deep wound it can be repair with two or more.Each stitch should
be reach to the base of the woundThird degree laceration need a
special technique.
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Initially the walls of the rectum is sewn inverted with simple
gut. The needle cannot be penetrate the rectum wall and into the
rectum lumen then the layer is closed with fascia stitch on it.
After that, the end of the sphincter ani is searched and connected
with two or three stitch using chromic cat gut. Finally it is sewn
like second degree laceration
Fourth-Degree Laceration Repair
Education in patients also need to be provided, can be :Clean
the wound after defecation/urinationAvoid the use of toilet paper,
perfume, or powder on the genital areaRest the pelvic area with no
sexual intercourse, inserting tamponCheck if pain increases or
settled more than 1 week.Check if excessive bleeding
occursSpecifically for III and IV degree tears, avoid constipation,
as well as consume a diet low in fiber, low residue, as well as a
stool softener.In 6 weeks post partum, if the tear heal normally,
physical examination on perineum indicated normal then the patient
can continues her sexual activity.
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Post operative treatment Administering of antibiotics given to
patients with ruptured perineum Control of pain in the days after
birth, usually by administering NSAIDMaintain hygiene perineum
PREVENTIONThe incidence of severe perineal trauma can be
decreased by minimizing the use of episiotomy and operative vaginal
deliveryProper support of perineum at the time of crowning and
expulsion of head
COMPLICATIONSInfectionCosmetic disadvantage3 and 4 degree tears
if left untreated may lead to fecal incontinence
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PROGNOSISThe majority of patients with an episiotomy or tear
will heal very well, with the disappearance of pain 6 weeks after
delivery and minimal scarring, however the stool incontinence may
occur in the short term and long term on 10% of patients with
fourth degree laceration, although already done well handling. If
there are no complications, no required care and monitoring for
long a period of time