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OB Experience Paper- Care for Perineal Injury Delainey Doughty
Davenport University- Midland Campus

Care for Fourth Degree Lacerations
The act of labor is both beautiful and mysterious all at the same time, women have been doing it since the beginning of time, if not so, none of us would be here today. Women who have never given birth or never witnessed another woman giving birth seem to feel the mystery more than the beauty, the unknown can be terrifying. As a woman, who has never had a child nor seen another woman delivering vaginally before, the first experience with a laboring (and delivering) mother was none the less terrifying. On our first day of maternal-child clinical, I got the honor of observing a mother deliver a full term, very healthy baby boy, although not without some bit of work and a tad bit of complication.

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When arriving on the floor, I found the nurse I was assigned to and listened intently as the off going nurse gave us report on a laboring patient. She told us that mom was a 41 week and 3 days nullipara (meaning she had never given birth), her membranes had ruptured spontaneously and that currently, she was 6cm dilated, 70% effaced and at a -2 station; the nurse warned me we would probably be in for the long haul. I followed her and met the patient and her support person, her husband, who were both very nice and very nervous. I also met the physician, a little fireball of a woman who was both kind and factual, advising them that labor was progressing along quite nicely, and she would be back to check at lunch, but her bet would be by 5 pm they would have their baby boy in their arms. Around noon, the physician came back to the hospital from lunch to check the patient, and she was 10cm dilated, 100% effaced and at zero station, she said she would change and be back, so we could start pushing. My heart felt like it was pounding out of my chest. However, it did not go as quickly as we thought, the mother pushed for what felt like forever (three hours to be exact) and asked for no pain medication. Once baby began to crown we hit another roadblock and his head kept sliding back in, the physician told mom she was going to make a small incision, an episiotomy, to aid in the delivery of the head. With a couple more pushes his head made his appearance, however, his shoulders were turned and before the physician could tell her to hold on, so she could make another incision to aid in the delivery of the shoulder he was out. Unfortunately, mom suffered from a 4th-degree laceration, thankfully she was so engulfed in the moment (skin to skin) with her very large (9lb 10oz) baby boy. The physician explained to mom what had happened despite her efforts (making the episiotomy) and that she had torn all the way through her anal sphincter. She applied a local anesthetic and carefully took her time sewing mom up, ending up with over 70 stitches. The did both an inner and outer layer of stitches meticulously ensuring that everything was put back as it should be.
Vaginal tears or lacerations are fairly common occurrences during a vaginal delivery, they happen when the infants head cannot easily pass through the vagina due to a lack of stretch (Vaginal tears in childbirth, 2018). Typically, vaginal tears are mild and heal without intervention within a few weeks, however, some tears can stretch all the way down through the anal sphincter (Vaginal tears in childbirth, 2018). These are serious intrapartum injuries that require medical intervention (Citation). Tears or lacerations that occur during vaginal delivery are categorized into first, second, third- and fourth-degree lacerations depending on the severity and tissue involved in the injury. A first-degree tear/laceration involves only the perineal skin, these are mild and rarely require stitches, women experience discomfort (Vaginal tears in childbirth, 2018). A second-degree tear involves the perineal skin and muscle, potentially causing injury deep into the vagina; these are painful and require stitches, healing within a few weeks (Vaginal tears in childbirth, 2018). A third-degree tear extends through the perineal tissue, muscle and extends into the anal sphincter (Vaginal tears in childbirth, 2018), these require more than a few stitches and can take more than a few weeks to heal; they also can lead to serious complications later (Vaginal tears in childbirth, 2018). A fourth-degree laceration is the most severe perineal injury, they require serious, potentially specialized repair (Vaginal tears in childbirth, 2018). A fourth-degree tear extends through the anal sphincter and into the rectal mucosa (Vaginal tears in childbirth, 2018). These tears can lead to serious complications later in life. Management of a fourth-degree tear will be explained below.
The incidence of fourth-degree tears, otherwise known as obstetric anal sphincter injury, have been on a rise in recent years, not only in the United States but all over the world. A study in Australia showed a rise from 4.1% to 5.3% in less than 10 years, and a large US hospital reported a rate of 16% in primiparous women (Ampt, Roberts, Morris, & Ford, 2015). Another Scandinavian study showed a 400% increase in women experiencing this type of injury over the past 40 years (Ampt, Roberts, Morris, & Ford, 2015). Not to mention the increase in rate of recurrence and the implications associated with vaginal deliveries after the first resulted in a fourth-degree laceration injury, some studies suggest women plan for cesarean birth after this type of injury, and others suggest women may even delay or feel apprehensive about subsequent pregnancies/births (Ampt, Roberts, Morris, & Ford, 2015). The risk factors associated with fourth-degree tear incidence include; primiparity, the use of instrumental assistance in delivery such as forceps or vacuum, infant sex and birth weight, gestation and maternal age, anesthesia/analgesic use and induction/augmentation (if any) method (Ampt, Roberts, Morris, & Ford, 2015).
Complications associated with fourth-degree tears or obstetric anal sphincter injury are quite extensive. These injuries are the major risk factor associated with anal incontinence in younger women (Cerro et al., 2016, p. 455). Not only is anal incontinence (both of stool and flatus) a long-term complication but also persistent perineal pain and pain during intercourse (dyspareunia), anal abscess and rectovaginal fistula (Vaccaro & Clemons, 2008, p. 1503). These injuries are also associated with psychological issues, such as impaired body image and reluctance about subsequent births (Ampt, Roberts, Morris, & Ford, 2015).

Typically, the repair of a fourth-degree tear should happen right away (the maximum repair can be postponed is 12 hours postpartum) (Pandit, 2018, p. 101). The repair should be made by someone with expertise and experience, it should be done with the patient in the lithotomy position (may be done in the surgical suite) using aseptic technique (Pandit, 2018, p. 103). The patient should be kept comfortable using pharmacological and non-pharmacological interventions, at this point the role of the nursing staff is to assist the physician, to monitor the patient (as they are postpartum) and provide care (pain management) as necessary. Once the patient has had their injury repaired, it is up to the nurse to manage the patient during their stay and to educate them on how to manage at home care.
There are several nursing diagnoses related to obstetric anal sphincter injury. There are many diagnoses that need to be included in the care plan of this patient; acute pain related to birth trauma, risk for infection related to perineal injury, impaired tissue/skin integrity, knowledge deficit, and risk for fear/anxiety. To manage each of these diagnoses, it is imperative that nurses put interventions into place. Prophylactic antibiotics should be hung to reduce the risk of infection, proper hygiene should be taught to the patient to prevent any contamination of the injury site and education should be provided to the patient regarding signs and symptoms of infection and when to return to the emergency room (such as fever, redness, purulent drainage, and foul-smelling discharge). During her stay, mom should be observed for signs and symptoms of infection and if indicated should be reported to the physician. The patient’s pain should be managed with pharmacologic and non-pharmacologic interventions; these include the administration of medications such as Motrin and Tylenol, cold (ice packs) compresses and witch hazel pads. The patient will require a lot of education on how to care for the injured area, sitz baths, or warm water soaks will help to soothe the injured tissue and alleviate pain, utilizing a spray bottle and dabbing the area after voiding/defecating will help to properly clean the affected area. Many patients may have anxiety after an injury such as this and may fear the act of having a bowel movement after repair. It is important to teach the patient not to bear down or strain, the patient should take a stool softener daily to aid in discomfort, but not to use enemas. They should be educated on the importance of drinking enough fluids each day and eating adequate amounts of fiber to aid in moving their bowels, and enough protein to help with repairing tissue. The nurse should also educate the patient that the injury may take a long time (greater than 6 weeks) to be fully repaired and that they should follow up in their gynecologist/family practice office to reduce the risk of complications such as rectal incontinence later in life.

Fourth-degree tears or obstetric anal sphincter injuries can lead to serious complications for mothers throughout their life. They can be traumatizing to her birthing experience (and to the fathers) as well as lead to serious complications later in her life. She may experience anal/rectal incontinence, pain during intercourse, and have risk of repeat tear during any subsequent births. As nurses, it is our job to educate our patients to ensure their pain is managed and they do not get infections or experience constipation when returning to home. By aiding in the management of the mothers care and education, we can ensure that she can get home, reap the benefit of her hard work, and enjoy motherhood.
References
Ampt, A. J., Roberts, C. L., Morris, J. M., ; Ford, J. B. (2015). The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study. BMC Pregnancy and Childbirth, 15(1). doi:10.1186/s12884-015-0469-4
Cerro, C. R., Franco, E. M., Santoro, G. A., Palau, M. J., Wieczorek, P., ; Espuña-Pons, M. (2016). Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms. International Urogynecology Journal, 28(3), 455-460. doi:10.1007/s00192-016-3136-z
Pandit, B. (2018). Chapter-11 Management of Third and Fourth-degree Perineal Tears. Smart Obstetrics ; Gynecology Handbook, 101-110. doi:10.5005/jp/books/13082_12
Vaccaro, C., ; Clemons, J. L. (2008). Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women. International Urogynecology Journal, 19(11), 1503-1508. doi:10.1007/s00192-008-0667-y
Vaginal tears in childbirth. (2018, October 8). Retrieved November 20, 2018, from https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/multimedia/vaginal-tears/sls-20077129

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