Assessment of perineal trauma

A systematic approach is essential in order to identify the full extent of trauma, the type of the required repair, who should carry out the repair, and where it should take place.

Prior to clinical examination it is important to ensure the following (95):

1. Verbal informed consent for a vaginal and rectal examination.

2. Effective analgesia

3. Adequate lighting

4. Comfortable position of the woman; the lithotomy position is usually necessary.

A clinical examination is undertaken for the assessment of vaginal and perineal tears:

• Parting the labia enables visualization and inspection of the tear.

Use of a Sims speculum is helpful to identify the extent and apex of the vaginal tears. The cervix can also be examined for tears if there is clinical suspicion.

• A digital rectal examination is important to assess the integrity of the anal sphincter muscles and rule out buttonhole tears. Anal sphincter injury can still be present with intact perineal skin. The anal sphincter is palpated using the index finger and thumb circumferentially.

• Examination under anaesthesia using pudendal or regional block may be required if complete examination is precluded by discomfort.

Once a tear is diagnosed, repair should be undertaken by a trained healthcare professional in a suitable environment.

Improvements in clinical diagnosis of severe perineal trauma have been documented following standardized training. Improved diagnosis will increase the chances of optimal repair. Third-degree tears repairs undertaken by doctors who have followed a structured training programme appear to result in a lower incidence of per­sistent sphincter defects (96).

The use of ultrasonography has enabled the accurate visualization of the anal sphincter complex, revealing a high incidence of pre­viously unrecognized occult anal sphincter trauma after delivery. Transvaginal or transperineal ultrasonography and MRI of the pelvis with or without three- dimensional reconstruction are imaging tech­niques helpful in identifying the types of LAM injuries (97).