C H A P T E R



C H A P T E R 1 5

Care of the perineum, repair and female genital mutilation

Ra nee Tha ka r, Abdul H Sulta n, Ma ureen D Ra ynor, Ca rol McCormick, Kinsi Cla rke

CHAPTER CONTENTS

Factors associated with reduced incidence of perineal trauma 312

Definition of perineal trauma 312

Episiotomy 313

Diagnosis of perineal trauma 313

Importance of anorectal examination 314

Female genital mutilation/genital cutting/female circumcision 314

Background 314

The role of the midwife 317

Repair of perineal trauma 318

Basic principles prior to repairing perineal trauma 318 First-degree tears and labial lacerations 318 Episiotomy and second-degree tears 318

Technique for perineal repair 318

Obstetric anal sphincter injuries (OASIS) 319

Technique for OASIS repair 320

Basic principles after repair of perineal tears 320

Postoperative care after oasis 320

Follow up 321

Medicolegal considerations 321

Training 321

References 324

Further reading 325

Useful websites 325

In the United Kingdom (UK), approximately 85% of women sustain some degree of perineal trauma following vaginal birth and it can be extrapolated that millions of women will be affected worldwide. Morbidity in the short and long term following trauma and repair can lead to major physical,

psychological, sexual and social problems affecting the woman's ability to care for her newborn baby and other members of the family. Midwives should be aware that suturing is a major and sometimes traumatic event for women (Green et al 1998). The repair of the perineum is an important part of the continuing care of a woman during labour and birth (Kettle 2012). The permanent presence of midwives who are trained and continually developing expertise in perineal repair, minimizes the problems associated with the rotation of inexperienced junior medical staff (Draper and Newell 1996) and provides continuity of care for women.

This chapter presents an overview of key issues relating to perineal care during labour and childbirth. It is important that the reader has knowledge and understanding of the anatomy and physiology of the pelvic floor (see Chapter

3) prior to engaging with this chapter.

The chapter aim s to:

• draw on the evidence base to identify some of the factors associated with a reduced incidence of perineal trauma during the second stage of labour

• examine the standard classification used to describe the different types of perineal trauma

• discuss the systematic assessment necessary in order to accurately diagnose perineal trauma

• highlight the significance of female genital mutilation and the inherent consequences for birth and women's psychosexual wellbeing and health more broadly

• consider the basic principles involved in repairing perineal trauma

• examine the midwife's role and medicolegal considerations involved in perineal trauma.

Factors associated with reduced incidence of perineal trauma

Many studies have compared interventions to prevent perineal trauma during the second stage of labour, starting with antenatal considerations such as diet and nutrition as well

as the recommended antenatal perineal massage for nulliparous women (Beckmann and Garref 2006). Coupled with this there are some well-documented risk factors associated with more complex perineal trauma (third- and fourth-degree tears)

such as fetal macrosomia, Asian ethnicity, persistent occipitoposterior position, instrumental births and nulliparity (Groutz et al 2011; Chan et al 2012) . Box 15.1 summarizes some of the factors that might lead to a reduction in perineal trauma.

Box 15.1

St r a t e g ie s t o pr e v e nt / m inim iz e pe r ine a l t r a um a dur ing la bo ur

|Influencing factors The evidence |

|Antenatal perineal massage but not perineal massage during the second stage of labour |Beckmann M M, Garrett A J 2006 (Cochrane review ) and NICE 2007 |

|Use of w arm perineal compresses during the second stage of labour |Aasheim et al 2011 (Cochrane review ) |

|Restricted use of episiotomy |Carroli and Mignini 2009 (Cochrane review ) |

|Upright birth positions – freedom of w oman to choose |Gupta et al 2004 (Cochrane review ) and NICE 20007 |

|Non-directed pushing (w oman using her ow n urges to bear dow n w ithout coaching from the midw ife or |NICE 2007 |

|doctor) | |

Definition of perineal trauma

Perineal trauma may occur spontaneously during vaginal birth or when a surgical incision (episiotomy) is intentionally made to facilitate birth.

It is possible to have an episiotomy and a spontaneous tear (e.g. extension of an episiotomy).

Anterior perineal trauma is defined as injury to the labia, anterior vaginal wall, urethra or clitoris.

Posterior perineal trauma is defined as any injury to the posterior vaginal wall or perineal muscles and may include disruption of the anal sphincters.

In order to standardize definitions of perineal tears, the classification outlined in Table

15.1 is recommended (Royal College of Obstetricians and Gynaecologists [RCOG] 2007; National Institute for Health and Clinical Excellence [NICE] 2007). (See Chapter 3 for details of pelvic floor anatomy) (Fig. 15.1.)

Table 15.1

Classification of perineal trauma

|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 external anal sphincter (EAS) thickness torn |

| |3b: More than 50% of external anal sphincter thickness torn |

| |3c: Both external anal sphincter and internal anal sphincter (IAS) torn |

|Fourth degree |Injury to perineum involving the anal sphincter complex and anal epithelium |

|Isolated button hole injury of rectum |Injury to the rectal mucosa w ithout injury to the anal sphincters |

Source: NICE 2007, RCOG 2007

[pic]

FIG. 15.1 Classification of perineal trauma depicted in a schematic representation of the anal sphincters (modified from Sultan and Kettle 2007).

Episiotomy

The traditional teaching that episiotomy is protective against more severe perineal lacerations has not been substantiated (Carroli and Mignini 2009), and therefore the liberal use of ‘prophylactic’ episiotomy is no longer recommended.

However, there are still valid reasons to perform an episiotomy. A variety of episiotomy techniques are described in the literature (Kalis et al 2012), but two types of episiotomy are most frequently used:

• Midline episiotomy: Advantages of the midline episiotomy are that it does not cut through muscle, the two sides of the incised area are anatomically balanced, making surgical repair easier, and blood loss is less than with mediolateral episiotomy.

• A major drawback is that extension through the external anal sphincter and into the rectum can occur.

• For this reason midline episiotomy is not recommended in the UK.

• Mediolateral episiotomy: The right mediolateral episiotomy is the technique approved for use by midwives in the UK.

• The incision is made starting at the midline of the posterior

fourchette and aimed towards the ischial tuberosity to avoid the anal sphincter.

In addition to the skin and subcutaneous tissues, the bulbospongiosus and the transverse perineal muscles are cut.

Diagnosis of perineal trauma

Following every vaginal birth a thorough assessment should be performed to exclude genital trauma.

The healthcare professional should explain to the woman what they plan to do and why, offer inhalational analgesia and ensure that if there is pre-existing epidural analgesia, it is effective.

There must be good lighting and the woman should be positioned so that she is comfortable and the genital structures can be seen clearly.

If this is not possible then it is vital to explain to the woman the rationale for the examination and why it is necessary to place her in a comfortable position, i.e. lithotomy (NICE 2007).

In the UK, modern birthing beds in the hospital sefing mean that the use of lithotomy poles in midwifery practice to support women's legs during examination of the genital tract or to repair perineal trauma is not always warranted.

However, supported lithotomy (i.e. use of poles) is necessary to aid the diagnosis and repair of complex trauma to the genital tract.

When supported lithotomy position is to be employed, clear explanation should be provided to the woman in a sensitive manner.

The midwife should be mindful that use of lithotomy poles may conjure up images associated with previous sexual abuse or female genital mutilation/female cufing (Kettle and Raynor 2010). Visualization, effective analgesia and systematic assessment of perineal trauma can be even more challenging at a homebirth, not least because of poor lighting and the use of sefees or low bedroom furniture.

When faced with such complexities it is perfectly acceptable for midwives afending home births to transfer women into the hospital sefing for thorough assessment, especially if the repair is judged not to be straightforward or the midwife does not have the requisite skills/competence to perform the repair.

Importance of anorectal examination

Informed consent must be obtained for a vaginal and rectal examination. If the digital assessment is restricted because of pain, adequate analgesia must be given prior to examination. Following inspection of the genitalia, the labia should be parted and a vaginal examination performed to establish the full extent of the vaginal tear. When multiple or deep tears are present it is best to examine and repair in the supported lithotomy position, as previously stated.

A rectal examination should then be performed to exclude anal sphincter trauma. Figure 15.2 shows a partial tear along the external anal sphincter which would have been missed if a rectal examination was not performed. Every woman should have a rectal examination prior to suturing in order to avoid missing isolated tears such as a ‘bufon hole’ of the rectal mucosa (NICE 2007). Furthermore, a third- or fourth-degree tear may be present beneath apparently intact perineal skin, highlighting the need to perform a

rectal examination in order to exclude obstetric anal sphincter injuries (OASIS) following every vaginal birth (Sultan and Kefle 2007) (Fig. 15.3). Following diagnosis of the tear it should be graded according to the recommended classification (NICE 2007; RCOG 2007), as delineated earlier in Table 15.1.

[pic]

FIG. 15.2 A partial tear (arrow) along the external anal sphincter which would have been missed if a rectal examination was not performed (Sultan and Kettle 2007).

FIG. 15.3 A third- or fourth-degree tear may be present beneath apparently intact perineal skin highlighting the need to perform a rectal examination in order to exclude obstetric anal sphincter injuries (OASIS) following every vaginal delivery (Sultan and Kettle 2007). (a) An apparent intact

perineum. (b) A ‘bucket handle tear’ is demonstrated behind the intact perineal skin. (c) The torn external anal sphincter.

In order to diagnose OASIS, clear visualization is necessary and the injury should be confirmed by palpation.

By inserting the gloved index finger in the anal canal and the thumb in the vagina, the anal sphincter can be palpated by performing a pill-rolling motion.

If there is still uncertainty, the woman should be asked to contract her anal sphincter (in the absence of an epidural) and if the anal sphincter is disrupted, there will be a distinct gap felt anteriorly.

If the perineal skin is intact there will be an absence of puckering on the perianal skin anteriorly.

This may not be evident under regional or general anaesthesia. As the external anal sphincter (EAS) is normally in a state of tonic contraction, disruption results in retraction of the sphincter ends.

The internal anal sphincter (IAS) is a circular smooth muscle that appears paler (similar to raw fish) (Fig. 15.4) than the striated EAS (similar to raw red meat) (Sultan and Kettle 2007) (Fig. 15.5).

[pic]

FIG. 15.4 The IAS is a circular smooth muscle that appears pale (similar to raw fish).

[pic]

FIG. 15.5 The EAS is striated muscle and appears red in colour (similar to raw red meat).

Female genital mutilation/genital cutting/female

circumcision

Background

Partly as a result of immigration and refugee movements, women who have undergone female genital mutilation (FGM) now present all over the world.

Therefore healthcare professionals in all countries need to be familiar with the practice of genital cufing and its implications, particularly for childbirth and safeguarding of the next generation, as well as to be proactive in eradicating this harmful cultural practice altogether.

The language used by midwives and doctors when dealing with genital cufing is important as parents understandably resent the suggestion that they have mutilated their daughters.

As a result, the word ‘cufing’ has increasingly come to be used to avoid alienating communities (World Health Organization [WHO] 2013).

There has been great debate amongst holy men as to whether, particularly type one, genital cufing (sometimes referred to as Sunna circumcision) is required in the Muslim faith, but it is clear that female genital cufing is not linked to the Bible or the Koran.

It is in fact condemned by many Islamic scholars.

Genital cufing predates both the Koran and the Bible, appearing in the 2nd century BC. It is a cultural practice, not a religious one.

In countries when there is a mixture of Christians and Muslims it is practised by both faiths (WHO 2001, 2008, 2013).

What actually happens to the girls and women varies from ritualistic herbs rubbed into the genitalia to complete removal of the clitoris and labia minora, and stitching (or closing by other means, usually thorns) of the labia majora.

The WHO (2001) define FGM as any procedure that intentionally alters or causes injury to the external female genital organs for non-medical reasons and describes four types, as depicted in Fig. 15.6.

Type 1: Clitoridectomy is partial or total removal of the clitoris and/or, in some cases, only the prepuce (the fold of skin surrounding the clitoris).

Type 2: Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are ‘the lips’ that surround the vagina).

Type 3: Infibulation: narrowing of the vaginal opening through the cutting of the labia minora and suturing or closing of the outer, labia majora, with or without removal of the clitoris.

Type 4: Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

In practice, however, it is ohen difficult to be clear about the classification. Uneven cufing, scarring and defects in suture lines are very common findings, therefore every woman who has undergone genital cufing should be assessed by an experienced practitioner and dealt with individually.

[pic]

FIG. 15.6 Types of female genital mutilation.

The age at which girls undergo genital cufing varies enormously according to their community. The procedure may be carried out when the girl is a newborn, during childhood, adolescence, at marriage or during the first pregnancy. Most commonly it is performed on girls between four and eight years of age (WHO 2001, 2008).

Girls are usually compliant when they have the procedure carried out as they believe they will be outcasts if they are not cut. Mothers and other family members believe they are doing the best for their children, as women are thought to be unclean and immoral

unless they had been cut. In most cultures that practise FGM the girls/women would be unmarriageable if uncut. So deep-rooted is this cultural tradition that it is the opinion of some that a woman will not be promiscuous or unfaithful if she derives lifle or no pleasure from sexual intercourse (Elnashar and Abdelhady 2007). Despite being aware of the dangers associated with genital cufing, it is this very strong belief that makes parents ensure their daughters are cut in accordance with their cultural custom and tradition.

Anaesthetics and antiseptic treatment are not generally used and the practice is usually carried out using basic tools such as circumcision knives, scissors, scalpels, pieces of glass and razor blades. Ohen iodine or a mixture of herbs is placed on the wound to tighten the vagina and stop the bleeding.

Immediate complications include severe pain, shock, haemorrhage, tetanus, sepsis and urinary retention. Inexperienced or very old cufers may inadvertently cause injury to adjacent tissue. Late complications include sexual dysfunction with anorgasmia, keloid scar formation, dermoid cysts and psychological issues. There is an increasing trend for medically trained personnel to perform FGM in hospitals and institutions (Hassanin et al 2008). There are no known health benefits associated with FGM.

In the UK the Prohibition of Female Circumcision Act 1985 makes it an offence to carry out FGM or to aid, abet or procure the service of another person. The Female Genital Mutilation amendment to the Act 2003 makes it against the law for FGM to be performed anywhere in the world on UK permanent residents of any age and carries a maximum sentence of 14 years imprisonment (Home Office 2004). Europe and many other countries also have laws against FGM.

The role of the midwife

In order to have a robust plan of care during labour, identification of women from countries that practise FGM is essential antenatally. NICE (2008) highlights the importance of antenatal screening of these women. This should be performed in a timely manner so that referral and consultation with a practitioner who can address both the physical needs of the woman plus the safeguarding and legal issues for the unborn child in a sensitive manner can take place.

Antenatally, physical examination is necessary to assess the extent of genital cufing and make a birth plan, also to identify whether antenatal surgery (deinfibulation) would be beneficial before 20 weeks of pregnancy. Most women would prefer a deinfibulation in labour but a plan to deinfibulate during labour means all staff must have adequate training and experience in performing the procedure, which in most hospitals is an unrealistic expectation. Even women who have given birth before or have had a previous deinfibulation should be examined as they may have suffered trauma at the last birth and some women will have undergone a reinfibulation (being ‘closed’ again), usually in their country of origin.

There is contradicting evidence as to whether FGM is associated with prolonged or obstructed labour (De Silva 1989; Al-Hussaini 2003; Millogo-Traore et al 2007 ). However,

during the second stage of labour the reduced labia and inelastic anterior tissue may be scarred and adherent to the labial vault and/or urethra, and therefore the birth process can cause significant anterior trauma to these structures. A low threshold for a right mediolateral episiotomy should be discussed with the woman antenatally, particularly if the type of cufing has leh scar tissue that may prevent progress or cause additional trauma in the form of an anterior tear in the second stage of labour (RCOG 2009).

A proforma including a predrawn diagram, akin to that outlined in the RCOG (2009) guideline, should be completed for the identification of the type of FGM and the agreed birth plan as part of good note-keeping. The impact of FGM is very profound, as captured by the personal narrative at the end of the chapter (Box 15.2).

Repair of perineal trauma

Basic principles prior to repairing perineal trauma (NICE 2007; Sultan and Thakar 2007)

The skills and knowledge of the operator are important factors in achieving a successful repair. Ideally the repair should be conducted in a timely manner by the same midwife who afended the woman in labour. This ensures seamless continuity of care, as the midwife would have established a good rapport and trust with the woman. The woman should be referred to a more experienced healthcare professional if uncertainty exists as to the nature or extent of trauma sustained. Having fully informed the woman why a detailed examination is required and to gain her consent, an initial systematic assessment of the perineal trauma must be performed including a sensitive rectal examination to exclude any trauma to the IAS/EAS is not missed (NICE 2007).

In order to reduce maternal morbidity, repair of the perineum should be undertaken as soon as possible to minimize the risk of bleeding and oedema of the perineum as this makes it more difficult to recognize tissue structures and planes when the repair eventually takes place. Perineal trauma should be repaired using aseptic techniques. Equipment should be checked and swabs and needles counted before and aher the procedure.

A repair undertaken on a non-cooperative woman, due to pain, is likely to result in a poor repair. Ensure that the wound is adequately anaesthetized prior to commencing the repair. It is recommended that 10–20 ml of lidocaine 1% (maximum dose 3 mg/kg) is injected evenly into the perineal wound. If the woman has an epidural it may be ‘topped- up’ instead of injecting local anaesthetic.

The issue of obstetric anal sphincter injuries is addressed in more detail later in the chapter, but it is worth noting here that repair of such trauma should be undertaken in theatre, under general or regional anaesthesia. In addition to providing pain relief, this provides the added advantage of relaxing the muscles, enabling the operator to retrieve the ends of the torn sphincter and identify the full length of the anal sphincter prior to repair. An indwelling catheter should be inserted for at least 12 hours to avoid urinary retention.

In the case of FGM, if a woman undergoes a deliberate traumatic deinfibulation in labour without antenatal preparation she may ask to be reinfibulated (closed again), but any repair carried out aher birth, whether following spontaneous laceration or deliberate defibulation, should be sufficient to oppose the raw edges of the perineal trauma and control bleeding. It must not result in a vaginal opening that makes intercourse difficult or impossible, as this would be in breach of the law. The WHO (2001, 2008, 2013) recommends suturing of raw edges to prevent spontaneous reinfibulation but an individual assessment should be made.

First-degree tears and labial lacerations

Women should be advised that, in the case of first-degree trauma, the wound should be sutured in order to improve healing, unless the skin edges are well opposed (NICE 2007). If the tear is leh unsutured, the midwife or doctor must discuss the implications with the woman and obtain her informed consent. Details regarding the discussion and consent must be fully documented in the woman's case notes.

Labial lacerations are usually very superficial but may be very painful. Some practitioners do not recommend suturing, but if the trauma is bilateral the lacerations can sometimes adhere together over the urethra and the woman may present with voiding difficulties. It is important to advise the woman to part the labia daily during bathing to prevent adhesions forming. This is particularly important when caring for women with type 3 FGM.

Episiotomy and second-degree tears

Although the repair of these tears was previously carried out using the interrupted technique, the continuous suturing technique for perineal skin closure has been shown to be associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin), the reduction in pain is even greater (Kefle et al 2007). The perineal muscles should be repaired using absorbable polyglactin material which is available in standard and rapidly absorbable forms. A recent Cochrane review has shown that there are few differences in short-term and long-term pain, between standard and rapidly absorbing synthetic sutures, but more women need standard sutures to be removed (Kettle et al 2010).

Technique for perineal repair

Technique is important, as is the suturing material used (Kettle and Fenner 2007).

Suturing the vagina (Fig. 15.7a)

Using 2/0 absorbable polyglactin 910 material (Vicryl rapide®), the first stitch is inserted above the apex of the vaginal skin laceration to secure any bleeding points. The vaginal laceration is closed using a loose, continuous, non-locking technique ensuring that each

stitch is inserted not more than 1 cm apart to avoid vaginal narrowing. Suturing is continued down to the hymenal remnants and the needle is inserted through the skin at the fourchette to emerge in the centre of the perineal wound.

[pic]

FIG. 15.7 Continuous suturing technique for mediolateral episiotomy (Kettle and Fenner 2007): (a) loose continuous non-locking stitch to the vaginal wall; (b) loose, continuous non-locking stitch to the perineal muscle; (c) closure of skin using a loose subcutaneous stitch.

Suturing the muscle layer (Fig. 15.7b)

The muscle layer is then approximated aher assessing the depth of the trauma and the perineal muscles (deep and superficial) are approximated with continuous non-locking stitches. If the trauma is deep, two layers of continuous stitches can be inserted through the perineal muscles.

Suturing the perineal skin (Figure 15.7c)

To suture the perineal skin the needle is brought out at the inferior end of the wound, just under the skin surface. The skin sutures are placed below the skin surface in the subcutaneous tissue, thus avoiding the profusion of nerve endings. Bites of tissue are taken from each side of the wound edges until the hymenal remnants are reached. A loop or Aberdeen knot is placed in the vagina behind the hymenal remnants.

A vaginal examination is carried out to ensure that the vagina is not narrowed and a rectal examination carried out to ensure that sutures have not been inadvertently placed through the anorectal epithelium.

Obstetric anal sphincter injuries (OASIS)

The quoted rate of OASIS is 1% of all vaginal births (RCOG 2007), although a more recent analysis reveals the rate to be 3.2% in consultant-led units (unpublished data). However, ‘occult’ OASIS (i.e. defects in the anal sphincter detected only by anal endosonography) has been identified in 33% of primiparous women following vaginal birth (Sultan et al 1993). More recent work has shown that these defects were not really occult but could have been identified by an adequately trained doctor or midwife (Andrews et al 2006a). The most plausible explanation for what was previously believed to be an ‘occult’ OASIS is either an injury that has been missed, recognized but not reported, or, wrongly classified as a second-degree tear (Sultan and Thakar 2007).

Technique for OASIS repair (Sultan and Thakar 2007)

In the presence of a fourth-degree tear, the torn anorectal epithelium is sutured with a continuous 3/0 Vicryl suture. When torn (Grade 3c tear/fourth-degree), the internal anal sphincter tends to retract and can be identified lateral to the torn anal epithelium. It should be repaired with mafress sutures using 3-0 PDS (Polydioxanone) or modern braided sutures such as 2/0 Vicryl (polyglactin – Vicryl®). To repair a torn external anal sphincter, the ends are grasped using Allis forceps and the muscle is mobilized. When the EAS is only partially torn (Grade 3a and some 3b) then an end-to-end repair should be performed using two or three mafress sutures. Haemostatic ‘figure of eight’ sutures must not be used to repair the mucosa or sphincter muscle. If there is a full-thickness EAS tear (some 3b, 3c or fourth-degree), either an overlapping or end-to-end method can be used with equivalent outcome. The limited data available from the Cochrane review on the topic showed that compared to immediate primary end-to-end repair of OASIS, early primary overlap repair appears to be associated with lower risks of faecal urgency and anal incontinence symptoms and deterioration of anal incontinence over time. However, as the experience of the surgeon was addressed in only one of the three studies reviewed, it would be inappropriate to recommend one type of repair over the other (Fernando et al 2006). Aher either technique of repairing the external sphincter the remainder of the tear is closed using the same principles and suture material outlined in the repair of episiotomy.

Basic principles after repair of perineal tears (NICE 2007; Sultan and Thakar 2007)

Aher repair, complete haemostasis should be achieved. A rectal and vaginal examination should be performed to confirm adequate repair, to ensure that no other tears have been missed and that a suture is not inadvertently placed through the rectal mucosa. Confirm that all tampons (if used) or swabs have been removed.

Detailed notes should be made of the findings and repair. Completion of a pre- designed proforma and a pictorial representation of the tears can prove very useful when notes are being reviewed following complications, audit or litigation. An accurate detailed account of the repair should be documented in the woman's case notes

following completion of the procedure, including details of suture method and materials used.

The woman should be informed regarding the use of appropriate analgesia, hygiene and the importance of a good diet and daily pelvic floor exercises. It is important that the woman is given a full explanation of the injury sustained and contact details if she has any problems during the postnatal period. In presence of OASIS women should be advised that the prognosis following EAS repair is good, with 60–80% being asymptomatic at 12 months (RCOG 2007). In the case of FGM, the woman and her partner must be advised about the legalities regarding reinfibulation and safeguarding issues if the baby is female.

Postoperative care after OASIS

Broad-spectrum antibiotics should be given intraoperatively (intravenously) and continued orally for 3 days. Severe perineal discomfort, particularly following instrumental delivery, is a known cause of urinary retention, and following regional anaesthesia it can take up to 12 hours before bladder sensation returns. A Foley catheter should be inserted for at least hours unless medical staff can ensure that spontaneous voiding occurs at least every 3–4 hours without undue overdistension of the bladder.

The degree of pain following perineal trauma is related to the extent of the injury and OASIS is frequently associated with other more extensive injuries, such as paravaginal tears. In a systematic review, Hedayati et al (2003) found that rectal analgesia such as diclofenac is effective in reducing pain from perineal trauma within the first 24 hours aher birth and women used less additional analgesia within the first 48 hours aher birth. Diclofenac is almost completely protein-bound and therefore excretion in breast milk is negligible. In women who had a repair of a fourth-degree tear diclofenac should be administered orally as insertion of suppositories may be uncomfortable and there is a theoretical risk of poor healing associated with local anti-inflammatory agents. Codeine based preparations are best avoided as they may cause constipation leading to excessive straining and possible disruption of the repair. It is of utmost importance that constipation is avoided as passage of constipated stool or indeed faecal impaction may disrupt the repair. Stool soheners (Lactulose) should be prescribed for the first 10–14 days postpartum and the dose titrated to keep the stools soh. The addition of isphagula husk (Fybogel) should be avoided as it has been shown to be non-beneficial (Eogan 2007). It is recommended that women with OASIS be contacted by a healthcare provider 24 or 48 hours aher hospital discharge to ensure bowel evacuation has occurred (Sultan and Thakar 2007).

Follow-up

Special designated multidisciplinary clinics should be available for women with perineal problems to ensure that they receive appropriate, sensitive and effective management. All women who sustain OASIS should be assessed by a senior obstetrician at 6–12 weeks

aher birth (RCOG 2007). If facilities are available, follow-up of women with OASIS should be in a dedicated clinic with access to endoanal ultrasonography and anal manometry, as this can aid decision on future mode of birth ( RCOG 2007; Scheer et al 2009).

In the clinic a genital examination is performed looking specifically for scarring, residual granulation tissue and tenderness. Where facilities are available, women would undergo anal manometry and endosonography. The women are assessed by the physiotherapists and advised to continue pelvic floor exercises while others with minimal sphincter contractility may need electrical nerve stimulation.

If a perineal clinic is not available, women with OASIS should be given clear instructions, preferably in writing, before leaving the hospital. In the first six weeks following birth, they should look for signs of infection or wound dehiscence and call with any increase in pain or swelling, rectal bleeding, or purulent discharge. Any incontinence of stool or flatus should also be reported. Under such circumstances referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasound and manometry should be considered (RCOG 2007).

Medicolegal considerations

Although creating a third- or fourth-degree tear is seldom found to be culpable, missing a tear is considered to be negligent. It is essential that a rectal examination is performed before and aher any perineal repair and findings must be carefully documented in the notes. Delay in repairing in theatre, poor note-keeping, repair by untrained personnel, poor lighting and inadequate exposure, inadequate anaesthesia, failure to recognize extent of the tear, use of wrong suture material, forgofen swab in the vagina, deviation from recommended safe practice, failure to inform and counsel the woman, failure to inform the general practitioner, inappropriate follow-up and advice regarding subsequent pregnancy are common issues raised at litigation. In the UK a recent report by the National Health Service Litigation Authority (NHSLA 2012) demonstrated that during the review period, from 1 April 2000 to 31 March 2010, the NHSLA received 441 claims in which allegations of negligence were made arising out of perineal damage (principally third- and fourth-degree tears) caused during labour. The total value of those claims, including both damages and legal costs, was estimated to be £31.2 million. Allegations of negligence included failure to consider a caesarean section or perform or extend the episiotomy, and failure to diagnose the true extent and grade of the injury including failure to perform a rectal examination. Failure to perform the repair and the adequacy of the repair itself were also raised as allegations in this cohort of claims (NHSLA 2012).

Training

Throughout the centuries, midwives have received very lifle formal training in the art of perineal suturing. In June 1967, midwives working in the United Kingdom were

permifed by their then regulatory body, the Central Midwives Board (CMB), to perform episiotomies, but they were not allowed to suture perineal trauma. In June 1970 the Chairman of the CMB issued a statement that midwives who were working in ‘remote areas overseas’ may be authorized by the doctor concerned to repair episiotomies, provided they have been taught the technique and were judged to be competent, but the final responsibility lay with the doctor. It was not until 1983, however, that perineal repair was included in the midwifery curriculum in the UK, when the European Community Midwives Directives came into force and the CMB issued the statement that midwives may undertake repair of the perineum provided they received the necessary instruction and are deemed competent to undertake the procedure (Thakar and Kefle 2010). Tohill and Kefle (2013) have provided evidence-based guidelines for midwives on how to suture correctly.

However, it has been reported that there is a lack of general knowledge on the agreed classification of perineal trauma and that midwives feel inadequately prepared to assess or repair perineal trauma (Mutema 2007). It has also been demonstrated that practitioners require more focused training relating to performing mediolateral episiotomies. Andrews et al (2006b) carried out a prospective study over a 12-month period of women having their first vaginal birth to assess positioning of mediolateral episiotomies. The depth, length, distance from the midline, the shortest distance from the midpoint of the anal canal, and the angle subtended from the sagifal or parasagifal plane were measured following suturing of the episiotomy. Results of the study demonstrated that no midwife and only 13 (22%) doctors performed a truly mediolateral episiotomy and that the majority of the incisions were in fact directed closer to the midline (Andrews et al 2006b). The current recommendation is that all relevant healthcare professionals should afend training in perineal/genital assessment and repair, and ensure that they maintain these skills (NICE 2007).

Box 15.2

A pe r so na l pe r spe ct iv e o f F GM

Kinsi Clarke

When I was asked if I minded sharing a short personal account on the effects of FGM for inclusion in a textbook for midwives, I was quite hesitant because the effects of FGM can be different for each woman and girl. But then I realized that is the whole point – how it affected me is what was asked.

I was born in one of the East African countries where the practice of FGM was, and still is, very prevalent; around 95 to 98 per cent. I remember very clearly the day I had to face my fate and join a long list of women (older sister, mother, grandmother, great grandmother, aunties, cousins, etc.) who went through the same process. There was never any doubt or question that I, along with all my sisters, would undergo FGM. It was always a matter of when, not if.

I was about 8 years old when the day arrived. A few days earlier I was told that I

would be made clean, proper and a real girl going into womanhood. I was shown a lifle bag, containing a present for me, a new dress, which I would be allowed to wear on the day. The day before it happened, my mum said I would not need to do any household chores the following day and I could sleep longer in the morning, and enjoy a special breakfast, just for me. I was gefing really excited about all these special treats and the promise of being the centre of afention all day. Lifle did I know what it all meant.

I woke up late that morning, had a full wash, which was itself a treat, put on my new dress and had a specially prepared breakfast including a small glass of milk. It must have been approaching midday when a strange looking old woman arrived with dusty and dirty looking sack of unknown contents. My mum, my aunty and a neighbour were already present. My family lived in the bush where water had to be fetched on the back of a camel once a fortnight from a village 20 miles away. We lived in a small hut made of straw and twigs in the middle of the open land. So there was no running water, no hygienic environment, and no sanitized equipment. I was told to empty my bladder (and bowels if necessary) and then join the ladies. I sat down in the middle, had my dress pulled up towards my shoulders and the first thing I can remember was a razor blade. I remember the old lady showing it to my mum, presumably reassuring her that it was clean and not too rusty. I remember feeling alarmed and frightened by the sight of the razor blade, and mum reassuring me and telling me to be a brave girl like so and so, and to fill my mouth with my dress and keep gripping it with my teeth all the time.

Things became rather too blurred too quickly. The first cut was so sharp and the pain so indescribable I remember my whole body convulsing violently and the women using all their strength to keep me still. I can't say how long it lasted. I think I might have fainted or was paralysed by the pain but I do not remember struggling too long. I had type III FGM where all the inner and external genitalia including major labia were removed and then sewn up. The gap that was leh open for me to pass water was the size of the head of a cofon bud. I know this because I once went to see a doctor later, when I was growing up and had an infection, and I remember him struggling to put a cotton bud into the hole.

Recovery was very painful. I was ‘stitched-up’ using 16 long thorns, 8 in each direction in an alternate pafern. The tips of the thorns were broken off once they were in place to prevent them pricking my groin. However it was impossible not to feel the heads of the thorns whichever side I lay on. My legs were tied together and I was told to lie on my side, not on my back or front, to aid the process of the two edges sealing together. I was not allowed much food, just a very small amount of porridge and milk every other day. This was to prevent or minimize bowel movement which could put pressure in the sewn-up area and cause the sides to become undone. Passing water was unbearable and I remember how much I hated it and tried to avoid it by not drinking much. I was told to force myself to urinate once a day, otherwise the bladder (I was told) would eventually burst, open everything up, and I would have to go through the whole thing all over again.

The threat of undergoing the same thing again was so terrifying that I eventually

had to let the water trickle through, stopping it every so ohen to catch my breath and bite my dress again. I was aware that a lot of girls didn't heal properly first time and they had to face being stitched-up again, but mine sealed up all the way and there was no need to repeat it. It was 8 days later when the old lady came back, inspected her handiwork and declared it a success. She took the thorns out and told me to start walking with very lifle steps. She also loosened the rope that was tied around my legs, from the hips to the toes, to stop my legs parting. I remember that so well because it was the first time in days that I slept a normal, full night's sleep. The removal of the thorns made sleeping not just possible but so peaceful and thoroughly enjoyable. Another week passed before I was allowed to remove the rope around my legs altogether and walk slowly with short steps on my own.

As I said at the start, FGM probably affects every woman and girl differently. I am not medically trained but I heard many stories of girls dying during the operation. I have been lucky to the extent that I am alive and well.

I remember gefing vaginal infections three or four times in my late teens and early 20s. It was always impossible for the doctor to see what was going on down there due to the almost total closure of the vagina but they used to give me oral antibiotics which did not always work. It used to itch like mad and smell too during those episodes and I wanted to rip it open so that I could wash and scratch it well!

When I was 18, I remember once asking my aunt who looked aher me, if I could have it opened and leave it that way. She said it was possible if the hospital could give us a certificate stating I was opened on medical grounds necessitating internal treatment. However, said my aunty, my advice would be not to open yourself (literally and figuratively) to accusations which would damage your reputation irrevocably and would inevitably lessen your chances of a good marriage. I took her advice.

Nonetheless, in my case, I would say the effects have been more psychological than physical. Of course I have mutilated genitals, which is a daily reminder of the brutal way my clitoris and other parts were removed. It still takes me a lot longer to pass water than the average ‘intact’ woman, despite being fully ‘opened-up’ for 17 years. However, the greatest impact has been the loss of my childhood and the loss of my womanhood. Loss of a childhood because FGM ended who I was: a happy, carefree, playful and a popular child who was full of excitement and of the possibilities of what the future might bring. I emerged as traumatized, subdued, passive, docile, quiet and indifferent young person who was neither a child nor a woman. I do not remember playing or behaving like a child aher that day. Nor was I expected to be one. This was the passage to womanhood, to prosperity, to a good marriage and motherhood.

The irony, for me, is that what should have completed me as a woman deprived me of the very thing.

In my country women are inspected and opened-up on their wedding night. It's every husband's duty to have intercourse with his new bride soon aher the flesh is cut open, to prevent the raw edges sealing up again. I heard many horror stories from my friends of how painful having sex with their new husbands was. Those were girls who had no anaesthetic during the actual procedure of deinfibulation and who then had to

face obligatory ‘lawful’ intercourse with their husbands soon aher the flesh was sliced opened; in many cases, with another razor blade. Any husband who hesitated to carry out his duty would be considered weak and cowardly, given that an inspection would take place in the morning to prove that the groom had ‘had his way’, as indicated by the amount of fresh blood on the sheets.

Again I was lucky, or shall I say shrewd, in that I didn't face this second ordeal of bridal duty because, at the age 25, I married my husband who was from outside my culture and country. A kind, compassionate and understanding husband whose main concern was my welfare and comfort. I underwent deinfibulation by a qualified surgeon, under hygienic conditions, and I was allowed to heal naturally. Nonetheless, I found sexual intercourse extremely painful and unpleasant. Having lost all sensitive parts of my genitals, compounded by the tightness of shrunken muscles that had been sewn up for 17 years, made sex not an enjoyable experience, but an activity to be avoided. This aversion to intimacy naturally led to me not conceiving a child and thus not becoming a mother, the very thing FGM was supposed to prepare me for. Of course this had a significant impact on my relationship with my husband and my self- image as a woman, but we are fortunate in that sex is not an essential part of our relationship for either of us. On the plus side, I did not have to face further complications in connection with childbirth.

I would have done anything to have my body leh intact as it was and to have experienced a normal sex life. For most women sex is probably a pleasurable part of a fulfilled life, but, for me, this was something I never had the chance to find out. It is difficult to quantify or to explain how FGM affected me; it has been a life-long physical and psychological pain which will remain with me for as long as I live. I made a conscious decision not to resent or hate my dear mum (who has now sadly passed away) and others who, I am sure, in their own minds, were doing me a good deed. And yet I cannot get the anger and the sense of being robbed of something precious, the sense of betrayal by the very people I trusted most, out of my head.

I could write a book on the visible and invisible damage caused to me by the imposition of type III FGM at such a tender age, so could every other victim; but, as midwives supporting women and girls living with the physical and mental scaring of FGM, I hope this short account will give you some sense of what it is like for us.

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