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Guideline: Perineal care - Queensland Health

Maternity and NeonatalClinical GuidelineQueensland Health clinical Excellence Queensland Perineal care Queensland clinical Guideline: Perineal care Refer to online version, destroy printed copies after use Page 2 of 39 Document title: Perineal care Publication date: June 2018 Document number: Document supplement: The document supplement is integral to and should be read in conjunction with this guideline. Amendments: Full version history is supplied in the document supplement. Amendment date: September 2020 Replaces document: Author: Queensland clinical Guidelines Audience: Health professionals in Queensland public and private maternity and neonatal services. Review date: June 2023 Endorsed by: Queensland clinical Guidelines Steering Committee Statewide Maternity and Neonatal clinical Network ( Queensland ) Contact: Email: URL: Disclaimer This guideline is intended as a guide and provided for information purposes only.

• Restrict use of mediolateral episiotomy to clinical indications • If previous OASIS or multiple risk factors, *experienced accoucheur where possible ... • Rectal examination ... requirements; for example to general practitioner obstetricians, specialist obstetricians, consultants, senior registrars and obstetric fellows.

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Transcription of Guideline: Perineal care - Queensland Health

1 Maternity and NeonatalClinical GuidelineQueensland Health clinical Excellence Queensland Perineal care Queensland clinical Guideline: Perineal care Refer to online version, destroy printed copies after use Page 2 of 39 Document title: Perineal care Publication date: June 2018 Document number: Document supplement: The document supplement is integral to and should be read in conjunction with this guideline. Amendments: Full version history is supplied in the document supplement. Amendment date: September 2020 Replaces document: Author: Queensland clinical Guidelines Audience: Health professionals in Queensland public and private maternity and neonatal services. Review date: June 2023 Endorsed by: Queensland clinical Guidelines Steering Committee Statewide Maternity and Neonatal clinical Network ( Queensland ) Contact: Email: URL: Disclaimer This guideline is intended as a guide and provided for information purposes only.

2 The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: Providing care within the context of locally available resources, expertise, and scope of practice Supporting consumer rights and informed decision making in partnership with healthcare practitioners,including the right to decline intervention or ongoing management Advising consumers of their choices in an environment that is culturally appropriate and whichenables comfortable and confidential discussion.

3 This includes the use of interpreter services wherenecessary Ensuring informed consent is obtained prior to delivering care Meeting all legislative requirements and professional standards Applying standard precautions, and additional precautions as necessary, when delivering care Documenting all care in accordance with mandatory and local requirementsQueensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. Recommended citation: Queensland clinical Guidelines Perineal care.

4 Guideline No. Queensland Health . 2020. Available from: State of Queensland ( Queensland Health ) 2020 This work is licensed under Creative Commons Attribution-NonCommercial-NoDerivatives Australia. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit For further information, contact Queensland clinical Guidelines, RBWH Post Office, Herston Qld 4029, email For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health , GPO Box 48, Brisbane Qld 4001, email phone (07) 3234 1479. Cultural acknowledgement We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander Elders past, present and emerging.

5 Queensland clinical Guideline: Perineal care Refer to online version, destroy printed copies after use Page 3 of 39 Flow Chart: Antenatal and intrapartum Perineal care Queensland clinical Guidelines: Antenatally: Assess for risk factors Offer information about:o Risk of Perineal injury in vaginal birtho Antenatal and intrapartum risk reduction measuresHistory of FGM? Refer to clinician *experienced in FGM Assess degree of FGM Consider deinfibulationHistory of oasis ? Refer/consult with obstetrician Counsel about mode of birth at: o First visit o Around 36 weeks Inform of risk factors for recurrence: o High grade of previous tearo Birth weight > 4 kgo Instrumental birth Indications for elective CS:o Current symptoms of anal incontinenceo Psychological and/or sexual dysfunctiono Sonographic evidence of anal sphincter defect ( defect > 30 degrees)o Low anorectal manometric pressures ( incremental squeeze pressure < 20 mmHg)o Previous fourth degree tearo Woman s request Support woman to make own decisionIntrapartum risk reduction strategies for all women: Offer in second stage.

6 O Perineal warm compresseso Intrapartum Perineal massage Support woman to give birth in position they find most comfortableo Inform of benefits of all-fours, kneeling, lateral and standing positionso Avoid prolonged periods in birth stool, sitting, lithotomy and squatting positions Closely observe perineum during second stage Promote slow and gentle birth of fetal head, shoulders and body Communicate clearly, especially in final stages of second stage Use hands on or hands poised technique according to clinical situation Restrict use of mediolateral episiotomy to clinical indications If previous oasis or multiple risk factors, *experienced accoucheur where possible If instrumental birth required:o Consider vacuum rather than forcepso Strongly consider use of mediolateral episiotomy, especially with forcepsRisk factors for oasis Asian ethnicity First vaginal birth (including if previous CS) Birthweight > 4 kg OP position Instrumental birth Shoulder dystocia Prolonged second stage Midline episiotomy Previous oasis Woman elects vaginal birth?

7 Elective CSYesYesNoNoYes*Experienced clinician: The clinician best able to provide the required clinical care in the context of the clinical circumstances and local and HHS resources and structure. May include clinicians in external facilities. CS: caesarean section, FGM: female genital mutilation, HHS: Hospital and Health Service, kg: kilogram, mmHg: millimetre of mercury, oasis : obstetric anal sphincter injuries, OP: occipto-posterior position, >: greater than, <: less than Queensland clinical Guideline: Perineal care Refer to online version, destroy printed copies after use Page 4 of 39 Flow Chart: Perineal assessment and repair Queensland clinical Guidelines: Ensure privacy Seek consent prior to assessment and repair Communicate clearly and sensitively Position woman to optimise comfort and clear view of perineum ensuring adequate lighting Perform assessment and repair as soon as practicable while minimising interference with mother-baby bonding Ensure adequate analgesia throughout assessment and repair Ensure clinician competent to perform assessment and repair refer to more experienced clinician as requiredPerform systematic assessment Visual assessmento Periurethral area, labia, proximal vaginal wallso Extent of tearo Presence or absence of anterior anal puckering Vaginal examinationo Cervix, vaginal vault, side walls.

8 Floor and posterior perineumo Note extent of tearingo Identify apex Rectal examinationo Insert index finger into rectum and ask woman to squeeze while feeling for any gaps anteriorlyo If unable to squeeze ( epidural), assess using pill-rolling motion checking for inconsistencies in anal sphincter muscleo Check integrity of anterior anal wallo Note detection of IAST raumaidentified?Repair not required Classify injury Use repair technique appropriate for injury Use local and/or regional anaesthesia as appropriateYesGeneral principles for Perineal assessment and repair If haemostasis evident and structures apposed, suturing not required Repair skin with continuous subcuticular sutures or consider surgical glue Avoid large volumes of local anaesthetic for clitoral tearsFirst degree repair Repair muscle with continuous, non-locked sutures Use absorbable synthetic suture material If skin apposed after suturing muscle layer, suturing of skin is not required If skin not apposed after suturing muscle layer.

9 Suture the skin Second degree repair Undertake repair in theatre except in exceptional cases Avoid figure of eight sutures Trim suture ends and bury knots in deep Perineal muscle to avoid suture migration Repair of EAS:o Use monofilament or modern braided sutureso Full thickness EAS tear, use overlapping or end-to-end methodo Partial thickness EAS tear, use end-to-end method Repair of IAS:o Repair separately with interrupted or mattress sutureso Do not attempt to overlap IAS Repair of anorectal mucosa:o Use 3-0 polyglactin sutureo Avoid polydioxanone sutureso Use either continuous or interrupted sutures OASISP erineal tear classificationFirst degree: Injury to the skin or vaginal epithelium onlySecond degree: Injury to the perineum involving Perineal muscles but not involving the anal sphincterThird degree: Injury to perineum involving the anal sphincter complex 3a: Less than 50% of EAS torn 3b: More than 50% of EAS torn 3c: Both EAS and IAS tornFourth degree: Injury to perineum involving the EAS, IAS and anal epitheliumRectal buttonhole tear: Injury to rectal mucosa with an intact IAST hird and fourth degree tears collectively known as OASISNoEAS: external anal sphincter.

10 IAS: internal anal sphincter, oasis : obstetric anal sphincter injuries Queensland clinical Guideline: Perineal care Refer to online version, destroy printed copies after use Page 5 of 39 Abbreviations AOR Adjusted odds ratio APM Antenatal Perineal massage CT Computed tomography CI Confidence intervals CS Caesarean section EAS External anal sphincter FGM Female genital mutilation GP General Practitioner HHS Hospital and Health Service IAP Intra-abdominal pressure IAS Internal anal sphincter IPM Intrapartum Perineal massage IV Intravenous NSAID Non-steroidal anti-inflammatory drugs PFMT Pelvic floor muscle training oasis Obstetric anal sphincter injury or injuries OR Odds ratio OT Operating theatre PR Per rectum RCT Randomised controlled trial RR Relative risk USS Ultrasound scan Definition of terms Accoucheur Clinician directly assisting with birth of baby.


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