Perineal tear involving perineal body and rectovaginal septum during spontaneous vaginal delivery

摘要

A 35-year-old primigravid woman presented at term in spontaneous labor and progressed to full dilation 12 hours after admission. Active pushing initially commenced with the woman on her hands and knees and then in the left lateral position. With further pushing, the perineal body began to thin out and tear, with the vertex subsequently beginning to appear through the tear. The vaginal introitus remained intact as the fetal head began to emerge through the tear. Further damage to the perineum was averted by pushing the head back through the tear and redirecting it through the vagina with the help of a right mediolateral episiotomy. A healthy neonate was born weighing 4250 g. The duration of the second stage of labor was 85 minutes.Examination under anesthesia revealed a large tear in the perineal body, and rupture of the external and internal anal sphincters, the rectovaginal septum, and the posterior vaginal wall. The rectal mucosa was intact. Repair was carried out by first suturing the internal sphincter with interrupted 2-0 polyglactin 910 sutures. We decided not to open the intact skin over the perineum because there was good access to the sphincter muscles through the tear. The superficially torn external sphincter was reinforced by side-to-side approximation with 2-0 polydioxanone sutures. Next, the posterior vaginal wall with the rectovaginal septum was reattached to the perineal body with interrupted polydioxanone sutures. The tear was then closed with polyglactin 910 sutures for the deeper layers and Vicryl Rapide (Ethicon, Somerville, NJ, USA) for the skin. The episiotomy was sutured in layers. A rectal examination revealed a satisfactory repair. The woman was discharged from hospital on the third day and given antibiotics for 7 days and laxatives for two weeks.