Repair of FourthDegree Perineal Lacerations Rhonda A Sparks

Repair of Fourth-Degree Perineal Lacerations Rhonda A. Sparks, MD University of Oklahoma Family Medicine Residency Program, Oklahoma City, Oklahoma Andrea D. Beesley, Ph. D Mid-Continent Research for Education and Learning, Aurora, Colorado Andrew D. Jones, MD Exempla Saint Joseph Family Medicine Residency Program, Denver, Colorado 1

Overview Definition of fourth-degree perineal laceration Review of relevant anatomy Description of how anatomical structures are represented in the model Description of the steps of the repair Practice repairing lacerations in the model Peer assessment 2

Objectives The learner will be able to identify the structures involved in perineal lacerations using the sponge model. The learner will be able to recall and perform the steps in the repair of perineal lacerations using the sponge model and according to the task checklist. 3

A. Jones & A. Beesley Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. Fourth-Degree Laceration 4

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. The Model: Vaginal Wall 5

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. The Model: Hymenal Ring 6

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. The Model: Perineum 7

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. The Model: Rectal Sphincter 8

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. The Model: Rectal Mucosa 9

Procedure: Setting up Needle driver Forceps A. Jones Lighting 5. 0 -3. 0 Vicryl or Chromic suture Needle driver Forceps Suture scissors Allis clamps Gilpi retractor 4 x 4’s 1% lidocaine Pudendal tray Allis clamp 10

Procedure: Anesthesia Does the patient have epidural anesthesia? Consider a bolus if needed Attempt local anesthesia with 1% lidocaine without epi Pudendal anesthesia if local inadequate 11

Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright Mc. Graw-Hill Companies, Inc. Visualize! 12

Reapproximate rectal mucosa Anchor suture in vertex of tear Running or interrupted stitch SUPERIOR to rectal mucosa—avoid passing suture into mucosa 13

Reapproximate rectal mucosa A. Jones 14

Reapproximate rectal sphincter Identify and grasp with Allis on both sides Interrupted or figure of 8 stitches in four points 1. 2. 3. 4. Posterior Inferior Superior Anterior Get the fibrous sheath while suturing 15

Reapproximate rectal sphincter Clamping the rectal sphincter 16 A. Jones Completed repair

Reapproximate perineal and vaginal mucosa Repair vaginal sidewall to hymenal ring Deep repair from hymenal ring to anal verge Subcuticular repair from anal verge to hymenal ring 17

Repair of vaginal sidewall to hymenal ring A. Jones 18

Repair of perineum A. Jones 19

Completed repair A. Jones 20

Finishing up Check hemostasis Add interrupted sutures as needed Cleanse with warm saline 21

Time for practice! Complete one practice repair while your partner holds the model Switch places Complete another repair while your partner hold the model and checks off the checklist Switch places 22