Perineal Lacerations and Episiotomies 1

Classification and Repair of Perineal Lacerations and Episiotomies

I. First Degree Laceration

A. A first degree perineal laceration extends only through the vaginal and perineal skin.
B. Repair: Place a single layer of interrupted 3-O chromic or Vicryl sutures about 1 cm apart.
II. Second Degree Laceration and Repair of Midline Episiotomy
A. A second degree laceration extends deeply into the soft tissues of the perineum, down to, but not including, the
external anal sphincter capsule. The disruption involves the bulbocavernosus and transverse perineal muscles.
B. Repair
1. Proximate the deep tissues of the perineal body by placing 3-4 interrupted 2-O or 3-O chromic or Vicryl
absorbable sutures. Reapproximate the superficial layers of the perineal body with a running suture extending
to the bottom of the episiotomy.
2. Identify the apex of the vaginal laceration. Suture the vaginal mucosa with running, interlocking, 3-O chromic
or Vicryl absorbable suture.
3. Close the perineal skin with a running, subcuticular suture. Tie off the suture and remove the needle.
III. Third Degree Laceration
A. This laceration extends through the perineum and through the anal sphincter.
B. Repair
1. Identify each severed end of the external anal sphincter capsule, and grasp each end with an Allis clamp.
2. Proximate the capsule of the sphincter with 4 interrupted sutures of 2-O or 3-O Vicryl suture, making sure the
sutures do not penetrate the rectal mucosa.
3. Continue the repair as for a second degree laceration as above. Stool softeners and sitz baths are prescribed
post-partum.
IV. Fourth-Degree Laceration
A. The laceration extends through the perineum, anal sphincter, and extends through the rectal mucosa to expose
the lumen of the rectum.
B. Repair
1. Irrigate the laceration with sterile saline solution. Identify the anatomy, including the apex of the rectal mucosal
laceration.
2. Approximate the rectal submucosa with a running suture using a 3-O chromic on a GI needle extending to the
margin of the anal skin.
3. Place a second layer of running suture to invert the first suture line, and take some tension from the first layer
closure.
4. Identify and grasp the torn edges of the external anal sphincter capsule with Allis clamps, and perform a repair
as for a third-degree laceration. Close the remaining layers as for a second-degree laceration.
5. A low-residue diet, stool softeners, and sitz baths are prescribed post-partum. §

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