PERINEUM, Rupture of.
Lacerations of the perineum at childbirth should be immediately sutured; this may be done while waiting for the placenta to he expelled from the uterus. When the rupture is an incomplete one—i.e., not extend ing through the sphincter ani—the torn surfaces should be carefully sponged clear of blood with mops of cotton-wool soaked in r in 2,000 Perchloride of Mercury lotion before suturing. A large half-circle needle is the most convenient to use, and three of these, threaded with strands of stout silkworm gut, should be boiled and in readiness. The first suture is introduced near the anal end of the tear. It passes through the skin, takes a deep bite under the torn surface, and emerges just short of the apex of the laceration in the vagina ; it then passes in the reverse order underneath the other half of the torn surface and pierces the skin opposite its point of entry. Further sutures, if required to close the wound, are passed in the same way at successively higher levels. Before tying the sutures, the wound should again be sponged clear of blood and clot. and care should be taken that a fragment of membrane is not included in the loop of the suture. If the rupture has been a complete one, extending into the rectum, the rectal wall should be sutured with a continuous catgut suture, just missing the mucous membrane, and special care should be taken to bring together the two ends of the sphincter ani, which can be readily identified on either side of the anal margin. When that has been done the remainder of the laceration is sutured with silkworm gut exactly as in the case of incomplete rupture. It is easier to insert the sutures if the patient is on her hack with the legs held well apart, but the operation may be done quite well with the patient on her side, provided an assistant holds up the right leg and buttock. If for any reason the suturing of a torn perineum is omitted at the confinement, it can be undertaken with fair hope of success during the first days of the puerperium, provided the torn surfaces are neither sloughing nor suppurating.
The successful result of a suture of the perineum depends as much on the nurse as on the operator. Bathed as it is in a highly albuminous and decomposable fluid—the lochia—and exposed to constant risk of con tamination from the anus, only the strictest attention on the nurse's part can insure the absence of suppuration. The nurse should be specifically told to keep in the room a basin of i in 2,000 Perchloride with a dozen cotton-wool mops lying in it. Every 4 hours for the first three days the genitals should be exposed and the wound washed free from lochia with the mops dripping from the solution. The same precaution should he repeated each time the bladder or bowels act. From the fourth day to the tenth the wound need only be bathed night and morning, and after defecation or micturition. On the tenth day the sutures may he removed.
There is no need to hobble the patient by a bandage round the knees, which has no effect in promoting union.
It is a mistake to bind up the bowels in these cases. An aperient should be given on the second night, even where the tear has extended into the rectum, but special care should he taken in this case to cleanse away all particles of faeces from the anus with mops of cotton-wool soaked in antiseptic.
A torn perineum which has not been sutured or which has failed to unite leaves the patient with a gaping vulva and some protrusion of the anterior and posterior vaginal walls, if the levator ani has been injured, as is usually the case. If the tear has been a complete one, the discomfort of the patient is increased by more of less loss of control over the bowel. The operative treatment of these injuries is a large question, the discussion of which would be out of place here. Lawson Tait's operations for the relief of incomplete rupture and that for complete rupture may be briefly described.
Perineorrhaphy (Lawson Tait).—An incision is made along the skin margin of the scar in the perineum. This incision is U-shaped when completed, and corresponds to the junction of the lower half of the vulval opening. The posterior wall of the vagina is then seized with forceps and is dissected up with scissors from the anterior wall of the rectum for a distance of r to 2 inches, care being taken neither to buttonhole the vagina nor to cut into the wall of the rectum. The oval-shaped raw surface thus produced is united by silkworm-gut sutures which pass transversely across it, being introduced through the skin margin on one side, passing deep under the surface of one half of the raw area to emerge just short of the middle line, where they are immediately reintroduced to emerge again on the opposite side at a point corresponding to their point of entry. About four silkworm-gut sutures are required, and the wound is treated as described under immediate suture. This method provides a skin apron which protects the exposed vaginal walls.
For complete rupture, an incision is made along the line of scar at the junction of the rectal and vaginal mucous membranes, and the incision is carried backwards on either side of the anus, and thence upwards on either side of the vulval opening. The vagina is dissected up from the rectum for an inch above the apex of the tear in its wall, and the dissection is carried backwards to expose the torn ends of the sphincter ani, whose position may he identified by two small dimples in the skin on either side of the anal margin. The rectal wall is then sutured with catgut, and special care taken to insure apposition of the ends of the sphincter. The operation is then completed as described above for Lawson Tait's perin eurrhaphy. The after treatment is as for immediate suture.—R. J. J.