|Royal Society of Medicine Forum: Are you sitting comfortably? Issues around perineal trauma. |
This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Wednesday 5th June 2002. The meeting was chaired by Rona McCandlish, Professor of Midwifery, University of Southampton.
This report first appeared in the RCM Midwives Journal.
Describing perineal trauma.
Mrs. Katie Yiannouzis, Consultant Midwife with a special interest in labour, King’s College Hospital, London.
Materials and methods for perineal repair.
Christine Kettle, Research Fellow, Department of Obstetrics, North Staffordshire Hospital.
76 midwives took part in 1995. The responses were: 84% had not received formal training; 93% agreed that they needed more training; 38% did not feel confident to perform perineal repair unless supervised. 71% had received supervision on the basis See one, do two, now you’re on your own, and 20% of doctors and 48% of midwives considered that their training in perineal repair had been adequate.
The plan thereafter was to introduce a training programme prior to undertaking research, and to repeat the audit to assess benefit. Only midwives entered the subsequent study as their technique had become standardised by the speaker’s input.
The null hypothesis was: The suturing techniques and materials used for perineal repair following spontaneous vaginal delivery have no effect on the amount of pain and superficial dyspareunia experienced by women in the short or long-term postpartum period.
The interventions employed were either interrupted or continuous suture, and either Vicryl or Vicryl Rapide 2/0 suturing material; this requires training in the use of square surgeon’s knots. The main outcome measures were pain at ten days and superficial dyspareunia at three months postpartum. The sample was 1,542 women requiring suture of a second degree perineal tear or episiotomy by a midwife following spontaneous vaginal birth. Data collection was by questionnaires at two and ten days postpartum, three months and one year. The response rate to these was excellent. (The continuous method of repair was described and illustrated).
There was a significant reduction in pain associated with the continuous suture method (p<0.0001), and a non-significant reduction in pain associated with the use of Vicryl Rapide. Neither method nor material improved later superficial dyspareunia. There was significantly less need for the removal of suture material at three months with the continuous method and when Vicryl Rapide was used 3.
The continuous method prevents one woman in six from suffering early postpartum pain; its worldwide use would reduce such pain for millions of women.
In 1999 of 79 midwives 6% had not received formal training (compared with 84% in 1995); 54% requested further training (93%); 18% did not feel confident undertaking perineal repair unsupervised (38%); 54% were supervised for more than four repairs before being left unsupervised. The conclusion is that there is now more supervision and more satisfaction with training, which needs to be ongoing and available for all levels of staff.
Training and development.
The education and training of all involved professionals is systematic and multidisciplinary, with a rolling program of workshops, a study day, and a training video; support is continuous and supervision is logged, and a formal perineal repair record has become an accepted part of the intrapartum notes.
MOMS has improved performance through learning from adverse incidents and by the application of the foregoing principles. Feedback on performance is both positive and negative; it is understood that learning and the maintenance of skills are lifelong processes. The training programme should involve all levels of staff, and must include awareness and increased recognition of third and fourth degree tears, with training for registrars in their repair. The subject deserves national guidelines to reduce harm and litigation, with sensitive treatment, prompt reporting of untoward incidents, the development of a blame-free culture, rapid handling of complaints, and support for women, who might themselves be involved in the development of the service. It is clear that audit should be repeated continuously.
Advances in care such as these could well be broadcast widely and the principles applied throughout health care.
|1. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair (Cochrane Review). In Cochrane Library, Issue 1. Oxford: Update Software; 2002. Updated quarterly.|
2. Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. In Cochrane Library, Issue 1. Oxford: Update Software; 2002. Updated quarterly.
3. Fleming N. Can the Suturing Method make a Difference in Postpartum Perineal Pain? Journal of Nurse-Midwifery 1990; 35(1): 19-25
Have I missed a third degree tear? The identification, treatment and follow-up of women who experience perineal trauma.|
Mr. Abdul Sultan, Consultant Obstetrician and Gynaecologist, Mayday University Hospital, Croydon.
This presentation highlights large areas of ignorance and differences of opinion among consultants concerning obstetric anal sphincter injury (OASI), its identification and management.
· Repair by a trained doctor, in the operating theatre and using regional or general anaesthesia.|
· Both internal and external anal sphincters to be visualised and repaired if necessary, using monofilament sutures (3/0 PDS – Polydioxanone or Vicryl).
· A Foley catheter to be inserted.
· Antibiotics and lactulose and Fybogel to be prescribed.
· Detailed notes to be kept and an explanation of the procedure to be given to the mother.
· The general practitioner to be informed and hospital follow-up arranged.
1.Sultan AH, Kamm MA, Hudson CN. Obstetric perineal tears: an audit of training. ObstetGynaecol 1995;15:19-23.|
2.Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I and II. Obstet Gynecol Survey 1995; 50:806-802.