Women and Children S Directorate Meeting

POWYS LOCAL HEALTH BOARD Cover sheet

Rev Date

Ref: Jan06 Care of the perineum during and August 2009 PLHB after birth GNP Mat 0013

Responsible Officer Approved by Date

Head of Midwifery Women and Children’s Directorate 27th April 2006 meeting Senior Nurses 24th April 2006 Clinical Governance and Risk August 2006 Management Committee

Care of the perineum during and after birth

PLHB GNP Mat 0013 Policy for care of the perineum during and after birth – Powys Midwife Led Care. Author: Head of Midwifery, Approved: Clinical Governance and Risk Management Committee, August 2006, review: August 2009. Page 1 of 7

Introduction It is estimated that over 85% of women will sustain some degree of perineal trauma following a vaginal delivery. 60-70% of these will require some form of perineal suturing (RCOG 2002). Routine episiotomy is not recommended as a method of preventing extended perineal trauma, however midwives should use their clinical judgement regarding it possible use. Perineal suturing is an integral part of the midwives role. Perineal repair should be performed as soon as possible using an aseptic technique, ensuring adequate analgesia and with full explanation to the woman.

Definition

 First degree involves skin only  Second degree involves perineal muscle and skin, this would include episiotomy  Third degree partial or complete disruption of the anal sphincter.  Fourth degree involves complete disruption of the external and internal anal sphincter and mucosa. (RCOG 2002).

Local guideline for all midwives working in Powys.

Responsibilities

The overall aim must be ensure safe and effective care is provided to women whilst allowing them to make an informed choice regarding perineal care during and after birth.

Qualifications/Training

All Midwives working within Powys hold a recognised midwifery qualification, no additional qualifications are required to carry out this policy if the midwife received appropriate training during her preparation as a midwife. Midwives will be required to attend yearly midwifery updates. This will include care of the perineum.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the IR1 reporting system.

Action

Key Points

 Identify and control bleeding points  eliminate dead space  avoid inserting too many sutures too close together.

The use of Vicryl Rapide is the recommended material as this has been shown to aid perineal wound healing and cause less pain in the postnatal period. (Mackrodt et al, 1998; Kettle, 1998). Literature reviews strongly suggest a continuous, subcuticular technique to be superior to the

PLHB GNP Mat 0013 Policy for care of the perineum during and after birth – Powys Midwife Led Care. Author: Head of Midwifery, Approved: Clinical Governance and Risk Management Committee, August 2006, review: August 2009. Page 3 of 7 interrupted suture technique for the closure of skin (Enkin et al, 1995; Kettle and Johanson, 2000b; Jackson, 2000).

There is little research evidence to support not suturing second degree tears; therefore midwives should discuss this lack of evidence with the woman when discussing perineal suturing. McCandlish (2001) suggests that, seeking to reduce morbidity associated with suturing, by not suturing, is not justified in the absence of robust evidence. There is reliable evidence that restricted suturing of the skin may be an appropriate strategy to offer some women (Gordon et al, 1999).

1 Explain procedure to the woman and her partner to obtain informed verbal consent and ensure their understanding of procedure to be performed. 2 Check number of swabs and instruments prior to commencing procedure. 3 Assist the woman into the lithotomy position to facilitate inspection of the laceration and aid its’ repair. 4 Cleanse the vulva using a clean technique, water is an acceptable solution for cleansing. 5 Inspect the vulva and vagina and determine extent of episiotomy/tear. Transfer to DGH if perineal trauma appears extensive or the midwife feels the repair merits the expertise of a more experienced practitioner.

6 If analgesia is required 10ml Lignocaine 1% should be used to infiltrate the perineum. If the perineum was infiltrated with Lignocaine prior to episiotomy it should be effective for 1 hr and further analgesia may not be required. 7 Lubricate and insert the tampon into the vagina above the level of the wound to be repaired. Attach an artery forceps to the tail and clamp onto abdominal 8 The vaginal mucosa is sutured using Vicryl Rapide sutures. Insert and anchor suture first above the apex to ensure good apposition. Use a continuous stitch to repair the vaginal mucosa to the level of the introitus. The sutures are inserted into the epithelium and sub- mucosa only and should not be pulled too tight. 9 The perineal muscle is sutured using Vicryl Rapide sutures. Deep interrupted or continuous sutures are used but should be kept to the minimum to achieve haemostasis. 10 The perineal skin should be repaired using Vicryl Rapide and the subcuticular suturing technique is most suitable. The bite of tissue is taken below the skin surface beginning at the distal end of the wound and ending at the introitus. A thread is left longer when suturing the vagina and is used with the suture from the subcuticular repair to secure the suture. 11 Remove the tampon and inspect the vagina to confirm satisfactory repair has been achieved. 12 Perform a digital rectal examination to ensure the sutures have not extended into the rectum. 13 Check swabs and needles to ensure all swabs and instruments are accounted for.

Record Keeping.

Ensure perineal care element of the All Wales Clinical pathway for Normal labour is completed in full.

Contraindications to a Midwife Suturing

The midwife must acknowledge her limitations, as in all areas of practice (NMC, 2004) and refer extensive perineal damage and third and fourth degree tears for repair by a senior obstetrician (Johnson and Walker, 2000). This will require emergency transfer to the relevant DGH. The health and wellbeing of the woman may be seriously affected in both the short and long term if the repair is poorly completed (Sleep et al, 1984).

REFERENCES Clement, S. & Reed B (1999) To stitch or not to stitch? A long term follow up study of women with unsutured perineal tears. Practising Midwife 2 (4) pp20 – 28. Enkin M. Keirse. M. Renfrew. M. Neilson. J. (2000) A Guide to Effective Care in Pregnancy and Childbirth. Oxford Medical Publications. Oxford. Gordon,B. Mackrodkt C. Fern E. et al (1998) The Ipswich Childbirth study, 1. A randomised evaluation of two-stage postpartum perineal repair leaving the skin unsutured. British Journal of Obstetrics and Gynaecology. 105 (4) pp435- 440. Jackson K. (2000) The bottom line: care of the perineum must be improved. British Journal of Midwifery. 8 (10) pp609 – 614.

Johnson R and Walker. (2000) Skills for Midwifery Practice. Churchill Livingstone. London.

Kettle, C. (1998) Suture Materials used for perineal repair following childbirth. British Journal of Midwifery. 6 (12) pp760. Kettle C. Johanson R. (2000b) Continuous versus interrupted sutures for Perineal repair. (Cochrane review). The Cochrane Library.Oxford. Mackrodt C. Gordon B. Fern E. Ayers S. Truesdale A. Grant. A. (1998) the Ipswich Childbirth study 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. British Journal of Obstetrics and Gynaecology. 105 pp441 - 445 McCandlish R. Albers L. Sandland D. (2000) suturing versus Non Suturing of perineal lacerations. Birth. 28 pp73 - 74 McCandlish M. (2001) Routine Perineal Suturing: Is it time to stop? Midirs Midwifery Digest 11 (3) pp296 - 300. Royal College of Obstetricians and Gynaecologists (2002) Methods and Materials used in Perineal repair. RCOG. London. Sleep J. Grant A. Garcia J. Elbourne D. Spencer J. Chalmers I. (1984) West Berkshire perineal management trial. British Journal of Medicine 289 pp587-590. Nursing and Midwifery Council (2004) Code of Professional Conduct. NMC: London. Nursing and Midwifery Council (2004) Midwives Rules and Standards. NMC: London Walker R. & Jay A. (2001) Perineal care and repair workshop ENB Approved Study day. Hatfield.