Third- and Fourth-Degree Laceration Repair

Chapter 18 Third- and Fourth-Degree Laceration Repair



Common indications


Third- and fourth-degree perineal lacerations occur when the head of the infant applies excessive tension to the perineal body and the posterior fourchette during delivery. Episiotomies are rarely cut to the third degree, but the extension of second-degree episiotomies to third- or fourth-degree lacerations is relatively common. The third-degree laceration results in the tearing of the external and internal rectal sphincters, and the fourth-degree tear involves the rectal mucosa (Figure 18-1).


image

FIGURE 18-1 Anatomy.



Equipment


A standard delivery set with a Russian forceps, needle driver, a Gelpi retractor, and Alice clamps is ideal for this repair. Plan to repair the rectal mucosa with 4-O or 5-O chromic gut. The rectal fascia should be repaired with 3-O Vicryl or Dexon to provide tensile strength for at least 2 weeks. Repair the rectal sphincter with 2-O Vicryl or Dexon (Figure 18-2). The remaining final closure of the second-degree repair is reviewed in Chapter 15, which covers vaginal laceration and episiotomy repair.


image

FIGURE 18-2 Instruments.



Key steps



Fourth-Degree Repair



1. Inspection: Carefully inspect the laceration, and identify the rectal mucosa, the rectal submucosal fascia, and the internal rectal sphincter with its fibrous capsule. Grasp the torn ends of the rectal sphincter with the Alice clamps to prevent them from retracting into the capsule. Use the Gelpi retractor to open the laceration above the rectal mucosa to allow for clear, hands-free visualization of the area to be repaired.

2. Mucosal closure: Begin suturing the rectal mucosa by anchoring a stitch proximally above the mucosa tear, using 4-O or 5-O chromic gut. Begin a running stitch through the mucosal layer, taking fine bites about 2 mm from the edge of the tear and 2 mm between each suture. Run the entire length of the tear, and continue the repair through the anal skin past the pectinate line (Figure 18-3).

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Related posts:

  1. Excisional Biopsy
  2. Vacuum-Assisted Delivery
  3. Paracervical Block
  4. Vulvar Biopsy

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Dec 12, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Third- and Fourth-Degree Laceration Repair

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