Third and Fourth Degree Repair of the Perineum

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  • Repair of episiotomy wound
  • Repair of third- or fourth-degree perineal lacerations
  • Complex or unusual lacerations may require surgical intervention.
  • Needle holder
  • Nontraumatic forceps
  • Vaginal retractor(s)
  • Allis clamps
  • Ring forceps
  • Gauze sponges
  • 2-0 and 3-0 glycolic polymer sutures on a large, curved cutting or tapered point needle
  • 10-mL syringe with a 1½-inch, 27-gauge needle and 10 mL 1% lidocaine without epinephrine (if effective regional anesthesia is not in place)
H4>Perineal Anatomy
  • The perineal body is the central tendon that lies between the vagina and the rectum.

Perineal Injury

  • A first-degree perineal laceration is a laceration that is confined to the vaginal and perineal epithelium.
  • A second-degree perineal laceration is a tear that extends to the perineal body.
  • A third-degree perineal laceration is a tear that extends into the anal sphincter.
  • A fourth-degree perineal laceration is a tear that extends into the rectal mucosa.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Many women will desire analgesia.
  • Apply ice packs for the first 24 hours after delivery.
  • Warm sitz baths can provide comfort beyond the immediate postpartum period.
  • Discuss with the patient potential complications.
  • Hematoma formation with acute swelling and pain is unusual but not rare.
  • Infection is probably the most serious threat to episiotomy recovery.
  • Rectovaginal and urogenital fistulae may result from direct trauma or from infection or necrosis associated with suturing.
  • Local pain or wound breakdown and dyspareunia usually are self-limited.
  • Bartholin's duct cysts, inclusion cysts, and endometriosis at the wound site are encountered rarely but may require surgical repair.
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