1. Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur
2. Anatomy
A. 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.
4. 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.
5.
6. 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.
7.
8.
9.
10. 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
11. 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.
12.
13. 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.
14. 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
15. Nerve Supply is primarily via pudendal nerve
(S2,S3,S4) and its branches.
18. 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.
19. 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.
22. 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.
23. 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.
24. 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.
28. Complications if left untreated:
Infection
Hemorrhagic Shock
Cosmetic disadvantage
3rd and 4th degree tears if left untreated may lead to fecal
incontinence.
29. 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.
30. Repair ofchronic complete perineal
laceration
1. Layered method of repair
2. Warren flap procedure
3. 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
31. 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.
32. 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.
33. 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-o’clock 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.
34. 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.
35. (II). Warren Flap Operation for
complete third degree tear
A. 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.
36. 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.
37. 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.
38. C. Ends of external anal sphinter are approximated end
to end or overlapping.
D. Genital hiatus is narrowed by bringing puborectalis
muscles closer .
39. 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.
40. 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 2–3 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 6–8 weeks. Antibiotics should be
utilized if infection is noted
41. 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.
42. 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.
