Systematic assessment: Video with ”patient”

 Systematic assessment: Video with ”patient”
When inspection for perineal tears after childbirth, it is important to use a systematic approach. (0:20) Initially, the vulva is inspected. The vulva consists of the labia majora on each side of the vagina, here and here. The lateral edges of the labia majora are not easily recognized – where they become regular skin. (0:45) On the inside of the labia majora, it is easy to see where they become the labia minora that demarcate the vestibule on either sides. (0:58) At the anterior apex of the labia minora, the two lips meet to form a crescent-­‐shaped skin-­‐fold, the clitoral hood, which partially covers the clitoral glans. The frenulum is the inverted-­‐V shaped fold that is immediately posterior to the clitoral glans. (1:20) The posterior commissure is formed by the meeting of the labia minora as they encircle the lowermost border of the vagina. The posterior commissure also marks the anterior border of the perineum. The uppermost edge of the anal opening marks the posterior border of the perineum. (1:41) The hymenal ring forms the boundary between the tissues of the vestibule and the mucosal tissues of the vaginal walls). The hymenal ring is usually easy to see. (2:01) The urethra is located posterior to the frenulum. It is seen opening here. It is very important to know if the tear involves the urethra and the urethral meatus. Those are the first details to inspect. (2:27) Next, check for tears of the labia minora, and for vaginal tears. Right after childbirth the vaginal introitus will naturally be more open than in a nullipara, making it much easier to inspect the vaginal wall. Here we can clearly see the hymenal ring and the terminal section of the vaginal wall. (3:00) Naturally it is important to inspect the muscles of the perineum. When the patient tightens the muscles, the area will lift up if the muscles are intact. When the woman is completely relaxed, resting her bum and muscles, and the skin is stroked in the area, the ano-­‐cutaneous reflex is activated: notice how the sphincter will contract in a circle around the anus. ______________________________________________________
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Systematic assessment: Video with ”patient”
(3:45) Next it is necessary to do a rectal exam to examine the sphincter ani, and to diagnose tears between the vagina and the rectum. The distance between the vagina and the rectum is only 1 centimetre, and sometimes even less. Therefore it is important to find out if a vaginal tear involves the mucosa and muscles around the anus. (4:20) Before doing a rectal exam, it is necessary to prepare and inform the woman. It is important to use lots of gel on the examining finger and again have the patient relax. You may ask her to push down lightly against your finger as you introduce a fingertip into her anus. This will help to relax her sphincter muscles. . (4:45) Then inspect the area from 2 o’clock to ten o’clock for the sensation of muscle-­‐tissue between the fingers. That is felt here, and the substance is almost visible to the eye. Have the woman squeeze – here it is easy to feel the sphincter contracting all around the finger. (5:20) Check for the sensation of muscle higher on the perineum -­‐ which is clearly felt in this case. Again, the woman is asked to squeeze. Here you can see that the area lifts and I can feel that superficial transverse perineal muscle contract in the direction of the perineum. (5:47) Lastly, the palpation is further up in the area of the bulbocavernosus muscle. Also here I can feel a good muscular substance. Again, I ask the woman to squeeze, and I can almost see-­‐-­‐-­‐-­‐-­‐ relax again-­‐-­‐-­‐-­‐ that the area of the labia here-­‐-­‐-­‐-­‐ and squeeze again -­‐-­‐-­‐ the area lifts and I can feel the muscle working against my finger. (6:20) Finally, the finger is gently pushed a bit further into the rectum in order to lift the terminal section of the vagina so as to inspect for vaginal tears and thus assess how deep the tear is. Holding the finger in the rectum while suturing a deep tear is also helpful, because it prevents the stitches from going too deep and into the lumen of the rectum. The rectal finger helps you in making sure you are stitching the deepest layers of the tear, for instance the internal sphincter or the recto-­‐vaginal fascia. ______________________________________________________
Copyright GynZone Denmark 2012
www.gynzone.net