QuestionSBA
QuestionChoice
Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician. This is usually the obstetric registrar, however may also be performed by a consultant.
49979
c
Surgical repair by the obstetric consultant
QuestionChoice
A one-off dose of broad-spectrum antibiotics is often given at the time of repair of perineal tears.
49980
d
One week course of broad-spectrum antibiotics
QuestionChoice
First-degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly. This tear is a second-degree tear, which does require repair.
49981
e
Conservative management
QuestionChoice
Episiotomy is generally regarded as the same anatomical involvement as a second-degree tear, i.e. involving the perineal muscles and fascia but with the anal sphincter intact. Second-degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.
49977
a
Suturing of the perineum by an experienced midwife
QuestionChoice
Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician.
49978
b
Surgical repair in theatre by the obstetric FY2
Concept
Chapter
# Classification

Perineal tears are the most common maternal obstetric injuries and can be classified into four categories:

1. First degree tear
   - Tear limited to the superficial perineal skin or vaginal mucosa only
2. Second degree tear
   - Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
3. Third degree tear
   - 3a: less than 50% of the thickness of the external anal sphincter is torn
   - 3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
   - 3c: external and internal anal sphincters are torn, but anal mucosa is intact
4. Fourth degree tear
   - Perineal skin, muscle, anal sphincter and anal mucosa are torn

# Management

Management of a perineal tear depends on the degree of severity and classification of the tear, thus full assessment of the extent of the trauma is required before any intervention.

First degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly.

Second degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.

Third and fourth degree tears require surgical repair by an experienced clinician and should take place in an operating theatre under regional or general anaesthetic.

Broad-spectrum antibiotics and laxatives should be given post-operatively.

Although some bleeding is expected with a tear, any excessive bleeding from the genital tract should prompt further investigation.
88
90
Perineal tears
Topic
38
Obstetrics
10032
A 39-year-old multiparous woman has been in the second stage of labour for more than three hours, and has been actively pushing for over an hour. The foetal head can be seen at the peak of each contraction. A cardiotocograph shows decelerations with each contraction, which recover.

A decision is made to perform an instrumental delivery. Local anaesthetic is infiltrated into the perineum and an episiotomy is performed. The forceps are applied and a live female infant is delivered after two contractions.

The midwife examines the woman's perineum following active management of the third stage of labour. The episiotomy is neat, and extends only to the perineal muscles and fascia, the anal sphincter is intact.

What is the correct management?
a