Perineotomy

Perineotomy is a mini-operation performed during natural childbirth, usually without anesthesia. Its essence is that the laboring woman is dissected shallowly and quickly perineum along the midline to exclude lacerations from spontaneous ruptures, since the wound from a smooth small incision heals much faster than a laceration. This manipulation helps avoid birth trauma to the infant, prevents stretching of the pelvic floor, and is a stimulation of labor.

Indications for the procedure

The decision to perform a perineotomy is made in the following cases:

• high probability of perineal tears (pronounced asynclitism, large fetus, scarring of perineal tissues caused by tears in previous deliveries, etc.);
• the threat of brain injury to the child;
• need to accelerate the second period of labor, caused by pre-eclampsia, bleeding in labor, secondary uterine hypotonia, the presence of chronic kidney, heart, ophthalmologic pathologies;
• acute fetal oxygen deprivation;
• to reduce the pressure of the pelvic floor musculature on the head of a premature infant as it passes through the birth canal in the case of preterm labor;
• the threat of pelvic floor distension.

Preparation

Before dissection, the perineum is treated with antiseptic agent and, if there is time and necessity, local anesthesia - infiltration (freezing) or novocaine/ lidocaine blockade of the sciatic-rectal area (pudendal).

Technique of the perineotomies

If the manipulation is necessary, blunt-tipped medical scissors are used. Between exertions, the blunt-tipped blade is inserted under finger control between the vaginal wall and the surface of the erupting fetal head in the direction of the future incision - from the posterior commissure of the labia majora toward the anus. The incision is made at its peak (at maximum stretching of the perineal tissues). The peak of pushing is determined when the area of the baby's head with a diameter of three to four centimeters appears from the genital slit.

The perineal tissues are cut along the midline, where there is a minimum of blood vessels and nerve endings, to a depth of at least three centimeters to prevent further tearing of the perineum. The incision should not reach the anus.

After the birth of the baby almost immediately begin to restore the integrity of the damaged tissues, that is, perform perineorrhaphy.

Perineotomy and episiotomy

The prevention of intrapartum brain injury to the infant and spontaneous lacerations in the mother can be prevented by perineal incision surgery. This minor obstetric surgery is called an episiotomy.

Depending on the direction of dissection, there are several types of this intervention:

• Perineotomy is the most preferable because the incision is made vertically along the midline, it is the least painful and heals faster than the others, but it is not suitable for women in labor with a "low" perineum;
• modified medial episiotomy - supplemented by a transverse dissection slightly above the anus;
• Mid-lateral episiotomy (not perineotomy) - the incision is made at an angle of 45º to the midline, it can be lengthened if necessary, as there is no risk of obstructing the anus;
• Lateral episiotomy - cut the perineum at the same angle, but 2 cm higher; rarely used, because at this localization of the incision is the most painful, long and poorly healed suture;
• Schuchardt dissection (radical lateral episiotomy) - more complex and traumatic than the previous one, used in complicated labor.

J-shaped and anterior episiotomy is performed when indicated.

Perineotomy and perineorrhaphy are successive stages of obstetric intervention. Quality restoration of the integrity of the perineal tissues is very important for the woman in labor.

There are several suturing techniques, however, the layer-by-layer technique is preferred, as it achieves the most accurate juxtaposition of the wound edges. First, separate catgut sutures are placed on the vaginal mucosa from the corner of the wound to the posterior commissure in centimeter increments. From the edge of the incision, the needle is pricked at a distance of 0.5-1cm. Next, the muscle tissue is sutured with catgut immersion sutures, after which single-row sutures or staples are used to match the incised skin.

The method of suturing the vagina with a wraparound continuous suture is also used, the perineal muscles and skin are sutured, as in the previous case, with separate sutures, each of which is knotted.

There is a well-known method of restoring tissue integrity developed by Schuthe, in which the individual eight-point sutures simultaneously capture all tissue layers in the wound. The sutures are 1 cm apart. This method is more complicated - it is more difficult to match tissues and control the tension of threads, which is fraught with impaired blood circulation and the development of inflammatory processes.

Perineorrhaphy is performed under local anesthesia or, if the woman in labor was given epidural anesthesia, components that anesthetize the superficial tissues are added.

Perineotomy in labor is preferable to spontaneous rupture. The woman in labor has less blood loss, the smooth incision is easier to close and heals faster, and there are fewer cosmetic defects and fibrous tissue overgrowths.

Contraindications to the procedure

Perineotomy is not performed on women in labor with a short (low) perineum because of the risk of the dissection becoming a rupture with injury to the rectum.

Consequences after the procedure

During labor, a perineotomy may lead to further perineal tearing, exacerbating obstetric trauma.

Immediate possible adverse effects after the procedure include:

• pain in the area of the surgery;
• allergies to suture material;
• infection of the postoperative wound;
• hematomas and bleeding at needle puncture sites;
• involuntary urination, difficult defecation;
• divergence of wound edges, sutures, their cutting through;
• vaginal-rectal fistula formation;
• discomfort during sexual intercourse.

Later complications after the procedure may include weakening of the pelvic floor muscles, prolapse and prolapse of the vagina and/or uterus, growth of gross scar tissue, and chronic perineal pain.

Care after the procedure

Fulfillment of all medical recommendations significantly reduces the risk of complications, contributes to the restoration of anatomy and functionality of the perineum.

1. The perineotomy suture and the entire perineal area should be washed from front to back using antiseptic solutions recommended by the physician.
2. Blot and dry after washing with a soft cotton cloth, do not rub or press.
3. Treat the perineal area with prescribed antiseptics, later with healing gels or creams.
4. In pain, you can use analgesics prescribed by a doctor, at the first signs of inflammation - anti-inflammatory drugs.
5. Free air circulation promotes healing of the postoperative wound - natural and not too tight underwear should be worn. If possible, remove it for a while, removing the pads to allow the wound to air out and dry.
6. Choose breathable, non-fragranced sanitary pads. They should be changed more often.
7. The nails on your hands should be kept short during grooming to avoid traumatizing the wound.
8. Sitting on the traumatized perineum is not recommended at first to avoid suturing and/or divergence of the sutures.
9. To prevent constipation, you should drink more, eat mostly liquid food with a loosening effect. If necessary, use laxatives.
10. After using the toilet, it is necessary to wash your face every time.
11. Sitting baths with herbs, weak pink manganese solution will also promote wound healing.
12. It is recommended to do exercises to strengthen the pelvic floor muscles, some can be done immediately after childbirth.

Sex after perineotomy does not promote wound healing. It is recommended to abstain from sexual intercourse for about a month. The period of abstinence may vary depending on the woman's condition.