Does mediolateral episiotomy reduce the risk of anal sphincter injury in operative vaginal delivery?
In a recent editorial, OBG Management Editor in Chief Dr. Robert L. Barbieri presented a draft checklist to guide clinicians during repair of third- and fourth-degree perineal lacerations. He also invited the journal’s readers to modify the checklist as they saw fit—and plenty of you responded! Here is a selection of the suggestions we received.
In a recent editorial, OBG Management Editor in Chief Dr. Robert L. Barbieri presented a draft checklist to guide clinicians during repair of third- and fourth-degree perineal lacerations. He also invited the journal’s readers to modify the checklist as they saw fit—and plenty of you responded! Here is a selection of the suggestions we received, with Dr. Barbieri’s reply.
How I adjusted my surgical protocol for the repair of severe perineal lacerations
I appreciate the clinical pearls offered by Dr. Robert Barbieri in his editorial on the repair of severe perineal lacerations. In response, I plan to change my protocol to initiate antibiotics prior to repair.
I would also offer this tip: When addressing the rectal mucosa, try to stay on a submucosal level, and perform a post-repair rectal exam to ensure that the mucosa has not been violated by a suture and to reduce the risk of rectovaginal fistula.
I repair the internal sphincter using an interrupted technique. And I place only three sutures in the external sphincter, at 8, 12, and 4 o’clock.
Martin E. Kanoff, DO
Sewell, New Jersey
A few pearls on checklist design
I am a big proponent of checklists and use them daily in my professional and personal life. However, as Atul Gawande, MD, MPH, mentioned in his book The Checklist Manifesto, checklists can’t teach a pilot how to fly a plane—that is best achieved through simulation. Dr. Gawande also noted that checklists should be short and to the point, usually containing no more than 10 items, and should highlight things more likely to be overlooked.
For the repair of perineal lacerations, a checklist might include:
The items followed by a question mark are of uncertain value.
Ideally, each checklist should undergo validation via dry runs and team training. In my experience, it is not as difficult to design a checklist as to design a system where checklists get executed entirely and correctly.
Alex Shilkrut, MD
Safety Director, Department of Obstetrics and Gynecology, Metropolitan Hospital, New York, New York
A question about sphincters
I am grateful for Dr. Barbieri’s excellent editorial on using a checklist. I was taught that three sphincters require attention in 4th-degree lacerations: the internal anal sphincter, the external anal sphincter, and the superficial transverse perineal muscle. Would Dr. Barbieri agree?
John Lavin, MD
QUICK POLL RESULTS
Ensure adequate anesthesia
I appreciate the checklist. I would add to it an explicit statement that the patient must be well-anesthetized, up to and including any readministration of epidural anesthesia or intravenous conscious sedation.
Marcie Richardson, MD
My experience repairing severe perineal lacerations
Dr. Barbieri’s column provided an excellent and timely summary! I have been repairing severe perineal lacerations consistently since I was taught a technique during my first year of residency in 1976. Since 1980, I have been at a community hospital with an average of 400 deliveries per year. In more than 33 years, I have had only one repair fail (knock wood!). It was readdressed without problems 1 month later after a low-residue diet, bowel prep, and other preparatory strategies. Interestingly, the patient delivered another 10-lb infant vaginally several years later with no problems, after a cesarean had been advised and declined.
Here is my rationale for the repair of severe lacerations:
Start using a mediolateral incision when episiotomy is indicated
Don’t waste valuable time waiting for coagulation studies to return from the lab—use your clinical judgment and start transfusing clotting factors...