Hi...this presentation was created for better understanding of anatomy of perineal muscles and perineal body...to aid better understanding of episiotomies.

1. DR.JUHI LOYA(RATHI)

6. 1) SUPERFICIAL COMPARTMENT

7. ♦Closed compartment 
infection or bleeding within it
remains contained

9. INTERIOR OF ANAL CANAL
Divided by pectineal line & Hilton’s line into
3 areas
1. Upper (15 mm)
2. Intermediate (15 mm)
3. Lower (8 mm)
(Anal verge)
Pectinate / dentate line
Hilton’s line

10.  UPPER HALF(2/3)
 Mucous membrane of upper
half of anal canal is derived
from hindgut entoderm.
 It is lined by columnar
epithelium
 It is thrown into vertical folds
called anal columns, which
are joined together at their
lower end by semilunar folds
called anal valves(remains of
proctodeal membrane).
 Nerve supply is derived from
autonomic hypogastric plexus.
It is sensitive to stretch only.
 LOWER HALF(1/3)
 Mucous membrane of lower half
is derived from ectoderm of anal
pit.
 It is lined by stratified squamous
epithelium.
 There are no anal columns
• The nerve supply is from
somatic inferior rectal nerve.; it
is thus sensitive to pain,
temperature, touch and
pressure.

12.  Striated muscle in a state of tonic
contraction.
 Innervation by pudendal nerve.
 Upto 30% resting pressure.
 Most of the squeeze pressure
 Contraction mintained for <2 mins
 Reflex contraction with sudden
increase in intra-abdominal
pressure.
 Relaxes during straining
 Damage results in fecal
incontinence.

13.  1) Subcutaneous part
2) Superficial part
3) Deep part

14.  Smooth muscle
 Autonomic control
 Contributes upto 70% of
resting pressure.
 Sympathetic -superior rectal
and hypogastric plexus
 Parasympathetic fibres
 Damage results in passive
soiling and flatus incontinence.

15. The median raphe of levator ani between the anus and
vagina, is reinforced by the central tendon of the
perineum.
IMPORTANCE:Support perineal organs

19.  Lacerations of perineum are the result of overstreching
or too rapid streching of the tissues, especially if they
are poorly extensile and rigid.
 Perineal injuries are more common in primigravida than
multigravida.

20. 1)Obstetrical causes
2)Non Obstetrical causes

21.  Malpresentations such as breech
 Contracted pelvic outlet
 Prolonged labour
 operative vaginal deliveries( forceps or vaccum)
 Macrosomic babies
 Occipitoposterior delivery
 Precipitate labour
 Epidural analgesia
 Induction of labour

22. RIGID PERINEUM:
• Elderly primigravida
• Vulval oedema
• Previous perineal tear
• Scarred perineum due to previous surgeries.
Non-obstetric causes: Rape,
Molestation
Fall
Accidental injuries like RTA, bull
horn injuries etc.

23.  First degree: Injury to perineal skin only.
 Second degree: Injury to perineum involving perineal muscles but
not involving the anal sphincter.
 Third degree: Injury to perineum involving the anal sphincter
complex:
3a: Less than 50% of EAS thickness torn.
3b: More than 50% of EAS thickness torn.
3c: Both EAS and IAS torn.
 Fourth degree Injury to perineum involving the anal sphincter
complex (EAS and IAS) and anal epithelium.

24.  Involve the fourchette,
perineal skin, and vaginal
mucous membrane but not
the underlying fascia and
muscle.
 These included periurethral
lacerations

28. Severe perineal trauma incidence was 3% (338/10408),
primiparas :5.4% (239/4405)
multiparas 1.7% (99/5990)
Occipito posterior (OP) delivery (OR 3.35, 95% CI 1.75-6.41) and
prolonged second stage (OR 1.98, 95% CI 1.46-2.68),
gestational diabetes (OR 1.78, 95% CI 1.04-3.03)
birth weight >4000g (OR 1.86, 95% CI 1.10-3.15).
-Goldbar and associates (1993) found that 21 of 390 or 5.4% with fourth degree
laceration experienced significant morbidity.
-Stock and coworkers (2013) 7% of 909 high order lacerations had complications
Risk factors for severe perineal trauma during vaginal childbirth: a Western
Australian retrospective cohort study.Hauck YL1, Lewis L2, Nathan EA3, White
C4, Doherty DA5.2015

29. A surgical cut made at the
opening of the vagina during
childbirth, to aid a difficult
delivery and prevent rupture of
tissues.

30. ♦Straight surgical incision
♦Postoperative pain is less and healing improved
♦It prevented pelvic floor complications that is, vaginal
wall support defects and incontinence

31. AT the time of crowning.
Performed too early,
bleeding from the
episiotomy may be
considerable.
Performed too late,
lacerations will not be
prevented.

33. Median episiotomy
J shaped
Mediolateral episiotomy
• Right (RML)
• Left (LML)

35. 

37. “The long held belief's that postoperative
pain is less and healing improved with an
episiotomy compared with a
tear,however,appeared to be
incorrect”,Larsson 1991

38. “ Another commonly cited but unproven
belief was that it prevented pelvic floor
disorders.
Number of observational studies showed that
routine episiotomies is assosiated with
increase chances of anal sphincter sand
rectal tears.”
Angioli2000,Nager 2001,Rodriguez
2008

39. “Carroli and Migini 2009 reviewed the
Cochrane Pregnancy and child birth Group
trial Registry.
There were lower rates of posterior
perineal trauma,surgical repair and healing
complication in women managed with
restrictive use of episiotomy.”

40. Alperin and associates reported that
“episiotomies performed for the first
delivery conferred a five fold risk of
second degree or higher order laceration
with the second delivery”.

41. Americal College of Obstetrics &
gynaecology 2013 has concluded
“Restricted use of episiotomy is preferred
to routine use.”

42. ♦Episiotomy is equivalent to second degree tear and studies
indicate that episiotomy may decrease the incidence of
anterior tears, but not posterior tears, rather may be
associated with increased risk of 3rd & 4thdegree perineal
tears (7, 8).
♦In a study conducted by F.C.R. Williams et al, it was
found that the rate of 3rd degree tear was 5 times higher in
women with episiotomy as compared to tear.
Episiotomy Vs Perineal Tear –A Comparative Study Of Maternal and Fetal OutcomeDr Rumi Bhattacharjee, M.D. Obst& Gynae, Assistant Prof.,Dept. of
Obst.&Gynae,Pramukh Swami Med 2013

43. 1. Episiotomy only protects against anterior perineal
tears, but does not provide protection against anal
sphincter muscle tears, pelvic muscle damage or
incontinence in the mother, nor does it prevent
neonatal complications.
1. Women who undergo episiotomy have more blood loss,
delayed wound healing and more pain after
childbirth.
CONCLUSION:

44. LOE 1a :Systemic Review of 6 RCTs
♦Restrictive use results in:
-Less posterior trauma
-Less suturing
-Fewer healing complications
-But more anterior trauma
♦No differences in severity of trauma or pain
GOR A: Use episiotomy sparingly.

46. Usually done after delivery of the placenta
Hemostasis and anatomical restoration without excessive suturing

47. Proper lighting
Good analgesia
Good assistance
Good exposureand proper examination
Identifying missing apex on lacerations

48.  Adequate analgesia
 Prefer blunt needle
 Chromic catgut 2-0
 Rapidly absorbed synthetic sutures
 Slowly absorbed sutures may require removal due to pain or
dyspareunia
 Continuous or interrupted suture

49.  All tears that are bleeding
should be identified and
ligated separately.
 The stitching starts from the
apex of vaginal mucosa
using polyglactin stitch with
continuous or interrupted
sutures.
 The muscles are stitched
using the same stitch taking
full thickness of the muscle
and achieving hemostasis.
 The skin is stitched with
interrupted sutures.

50. Results: The study revealed the pain at 48 hours postpartum and
day 10 was more in interrupted group ( 83% versus 37% and 57%
versus 28% respectively) which was found to be statisitically
significant.(p = 0.0005)
Conclusion: The continuous suturing techniques for perineal
closure, compared to interrupted methods, are associated with less
pain at 48 hours and 10th day postpartum.
Outcome of Continuous Versus Interrupted Method of Episiotomy Stitching
RUBINA IQBAL, AYESHA INTSAR, SAMINA KHURSHEED, SHEHNEELA ZAFAR

52. .Prevalence-Primigravida 2.8%
Multigravida 0.4%

53. Immediate:
Perineal Pain
Perineal hematoma
Urinary retention due to painful perineum
Urinary incontinence
Anorectal dysfunctions like fecal incontinence
Bleeding Traumatic PPH - hemorrhagic shock.
Delayed:
Infected perineum- perineal abscess
Uterovaginal prolapse
Urinary incontinence (stress and urinary fistula)
Fecal incontinence ( rectovaginal fistula)
Dyspareunia
Feeling of slack vagina during coitus

54. 1. Timely episiotomy primigravida
operative delivery (vacuum and forceps)
Breech delivery
Breech extraction done after IPV
rigid perineum
1. Proper support of perineum at the time of crowning and expulsion of
head.

55. ¥ Written consent
¥General anesthesia/spinal anesthesia/epidural
analgesia
¥Operation theatre
¥Trained obstetrician
¥Good light,Good assisstance
¥Proper instrument and sutures

56. 1. Anaesthesia a)General
b)Local
1. Examine
2. Assistant to massage the uterus.

57.  Immediately (within 24 hours)
 If >24 hours then repair at 6 weeks.
As accurate an approximation as possible of all the tissues should be
secured and no dead spaces are left.

58. 1. Good light
2. Operation theatre
3. Anesthesia
4. Stepwise manner
5. Quantify

59. 1. Sterile drapes & gloves
2. Irrigation solution
3. Needle holder
4. Metzenbaum scissors
5. Suture scissors
6. Forceps with teeth
7. Allis forceps

60. 9. 10ml syringe with 22 guage needle
10. 1% lidocaine
11.3-0 polyglactin 901 (Vicryl) suture on CT-1 needle
Vaginal mucosa
for perineal muscle
skin sutures
14. 2-0 polydiaxone sulfate (PDS) suture on CT-1 needle.
(external sphincter sutures)

61. ♦Appears band of skeletal muscle with fibrinous
capsule.
♦Traditionally - end to end technique
♦Allis clamps placed on each end of external anal
sphincter.
♦Use 2 polydiaxanone (PDS),a delayed absorbable
monofilament sutures.
♦End to end repairs have poorer anatomic and
functional outcomes than overlapping technique.

62. 1. Identified as a glistening,white,fibrous
2. Between the rectal mucosa & the external anal
spincter.
3. Retracted laterally, & placement of Allis clamps
on the muscle ends
4. Closed with continous 2-0 polyglactin 910
sutures.

63.  Change to sterile gloves
 antiseptic solution
 Repair
 The rectum- interrupted 3-0 or
4-0 sutures 0.5 cm apart to
bring together the mucosa.
 Place the suture through the
muscularis (not all the way
through the mucosa).

64.  Cover the muscularis layer- the
fascial layer with interrupted
sutures.
 antiseptic solution
 Repair the skin - interrupted (or
subcuticular) 2-0 sutures
starting at the vaginal opening .

65. ♦If the sphincter is torn
grasp
Repair the sphincter with
interrupted stitches of 2-0
suture.
♦ antiseptic solution
♦Examine the anus with a gloved finger to
ensure the correct repair of the rectum and
sphincter.

70. As per RCOG green top guidelines
“Repair of external anal sphincter,either an
overlapping or end to end method can be used
with equivalent outcome however the IAS can
be identified,it is advisable to repair separately
by interrupted sutures.”

71. 3.Torn anal epithelium repaired with interrupted vicryl withknot tied towards the
anal mucosa.
4. Internal anal sphincter interrupted polydiaxone sutures(PDS) by end to end
approximation.
5.External anal sphincter
<50% End to end repair 3-0,2-0 vicryl
>50% Muscle should be pulled across to overlap before suturing it.
with 3-o PDS in double breast fashion with enabling overlapping of sutures if not
then end to end anastomosis.

72. 1. When repair of EAS muscle is being performed either
monofilament sutures such as polydiaxonone or modern
braided sutures such as vicryl used.
2. When repair of IASmuscle is being performed,PDS 3-0
and 2-0 vicryl causes less irritation and discomfort.
1. When obstetrical anal sphincters repair are being
performed,burying of surgical knots beneath the
superficial perineal muscles is recommended to prevent
knot migration to skin.
A
C

73. 1. The use of broad spectrum antibiotics is recommended following
repair of OASIS to reduce the risk of postoperative infection and
wound dehiscence.
2. postoperative laxatives
3. Bulking agents should not be give with laxatives
4. Physiotherapy and pelvic floor exercises 6-12 weeks after repair.
5. Follow up
6. If patient is experiencing incontinence or pain on follow up refer to a
special gynaecologists or colorectal surgeon and anorectal
manometryshould be considered.

74. Women should be advised that 60-80% of
women are asymptomatic 12 months following
delivery and EAS repair.

75.  Chronic perineal pain
 Dyspareunia
 Urinary & fecal
incontinence

76. A perineal tear is always contaminated with faecal material. If closure is
delayed more than 12 hours, infection is inevitable. Delayed primary
closure is indicated in such cases.
1)For first and second degree tears,
leave the wound open
2)For third and fourth degree tears,
close the rectal mucosa with some supporting tissue
and approximate the fascia of the anal sphincter with 2 or 3 sutures; close
the muscle and vaginal mucosa and the perineal skin 6 days later.

77.  Infection
 Hemorrhagic Shock
 Cosmetic disadvantage
 3rd and 4th degree tears if left
untreated may lead to fecal
incontinence.
 Pain out of proportion can be
sign of vulvar, paravaginal,
ischiorectal hematoma or
cellulitis.

78. Needs urgent surgical
intervention.

80. LOE 4 :Prospective cohort
Compared women who were coached to push versus
women who were given no instructions.
Sutured trauma-63% vs 39% in coached compared to
not coached groups.
GOR D:Insufficient evidence to recommend style of
pushing for prevention of perineal trauma.

81. LOE1:Systematic Review & RCTs
Use of Vacum Extraction compared to forceps results in:
-Less maternal trauma
-Less pain at 24 hours
-More cephalohematomas & retinal hemorrhage
GOR A : Use of VE over forceps,whenever possible,but be aware of
possible neonatal harms.

82. 1. LOE 2a:Use of epidural anesthesia also
increases perineal trauma,likely increasing
fetal malposition and operative vaginal
deliveries,based on systemic review of
cohort studies (Lieberman,2002,6 studies)
2. Epidural analgesia was found to be
protective (Jango 2014)

83. LOE 2b : 2 small RCT (Lundquist 2000,Flemming 2013)
-Women who did not have standard suturing of trauma were likely to report at 2-
3 days postpartum.
-”Burning sensation”
-”Soreness”
-Better wound healing at 6 weeks in sutured group,reported by Fleming
GOR b:There some evidence that non suturing perineal trauma can be
harmful.Patients should have the benifitof suturing until there are large enough
trials to definitively exclude such harm.

84. LOE Ib
Women in the NSAID group (diclofenac and indomethacin used in
RCT)
-Experienced less pain 24 hours after birth
-Required less supplemental analgesia in first 24 hours.
GOR A :there is fair evidence to adopt the use of NSAID
suppositories to reduce postpartum.
Indomethacin 50mg availablein US
A single dose of 200mg PR used in the RCT.

85. 1. Kneeling versus sitting position has no effect on increase in
chances of OASIS while standing might increase the risk of
OASIS.
2. A retrospective analysis of 814 women (650 standing, 264
sitting, any parity) in which women standing for their delivery
had a nearly 7-fold increase in OASIS (2.5% vs 38%).
3. A 2012 RCT comparing traditional method of delivery versus
“alternate” method of delivery “Gasquet” position – with upper
hip flexed, foot on stirrup higher than knee) showed no
difference in rate of OAS.
Gareberg B, Magnusson B, Sultan B, Wennerholm U-B, Wennergren M,
Hagberg H. Birth in standing position: a high frequency of third degree
tears. Acta Obstet Gynecol Scand 1994;Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair,SOGC clinical
practical guideline Dec 2015

86. LOE Ib
●Lower risk oF third degree tear in massage group
●No difference in 1st and 2nd degree tear
●2nd stage 10 mins less in massage group.
GOR A:Perineal massage during labour,may be
helpful,especially for primiparous women.

87. 1. All women should be counselled for risk of developing anal
incontinence or worsening of symptoms with subsequent
vaginal delivery.
1. Theres is no evidence to support prophylactic episiotomy in
subsequent pregnancies.
1. All women who sustained an obstetrical anal injuries and who
are symptomatic and have abnormal endoanal manometry
should have option of elective cesarean birth.

88. WHEN TO REPAIR:
after 6 weeks of delivery

89. 1. Layered method of repair.
2. Warren flap procedure
3. Noble-Mangert-Fish operation
If anorectal mucosa is intact & injury is largely limited to sphincters
and perineal body complex,repair consists of anal sphincteroplasty
and perrineorrhaphy.

91.  anorectal mucosa
 closed using a continuous or
interrupted suture of 3-0 delayed
absorbable material. A
submucosally placed suture is
ideal.
 internal anal sphincter
it also serves to imbricate and
isolate the mucosal layer and take
tension off it helping it heal and
seal against infection.

92.  Overlapping approach
 The ends are widely mobilized
with the scar tissue left on,
taking care not to dissect
beyond the 3 and 9-o’clock
position bacause pudendal
innervation enters laterally.

93.  Restoration of narrower gental hiatus
by bringing the puborectalis muscles
closer together.
 delayed- absorbable sutures
 It is extended till midportion of
vagina to produce excellent
anatomical support to rectum and
anal canal.
 the superficial transverse perineal
muscles and bulbocavernosus.
 redundant vaginal mucosa is excised
and remaining mucosa is
approximated in midline with a
continuous 2-0 or 3-0 delayed
absorbable suture. It followed by
subcuticular closure of perineal skin.

94. A. The length of the flap should
measure a minimum of 3 cm to
provide sufficiet vaginal
mucosa.
B. Taking care not to injure the
bowel the bowel wall, the flap
of mucosa is dissected free
from above downwards,
stopping short of the margin
between the vaginal and anal
mucosa. The flap is turned
down to hang over the anus.

95. C. External anal sphincter ends are then dissected free and approximation or overlapping type external anal
sphincteroplasty is then performed.
D. The fascia overlying the medial aspect of puborectalis muscles is identified and is brought together with a series
of interrupted sutures using 0 or 2-0 delayed absorbable sutures.
E. Margins of vaginal mucosa and graft are approximated in the midline by a continuous locking stich of 3-0
delayed absorbable suture.

96. A. ‘butterfly appearence’ across
the perineum.
B. The initial incision is outlined
around the margins of this area
following the margin of anal
mucosa along tha anatomical
defect in rectovaginal septum.
C. Sharp dissection is done to
separate tha anal wall from
vaginal mucosa.
D. External anal sphincter
remnants are sharply mobilized
and separated from underlying
anal wall.

97. C. Ends of external anal sphinter are approximated end to end or
overlapping.
D. Genital hiatus is narrowed by bringing puborectalis muscles closer
.

98. E. Transverse perineal muscles and
inferior margins of
bulbocavernosus are
reapproximated.
F. vaginal mucosa is trimmed
continuous locking stich of 3-0
delayed absorbable suture.
E. This suture is carried over the
perineal body as a subcuticular
stich and perianal skin is
approximated in midline.