Why is it important to check for sutures in the rectum after second-degree tear repair?

Checking for Sutures in the Rectum After Second-Degree Tear Repair

A rectal exam is essential after second-degree perineal laceration repair to detect any inadvertently placed sutures in the rectum, which could lead to infection, rectovaginal fistula formation, and significant patient morbidity. 1

Importance of Rectal Examination

• A systematic evaluation including visual inspection, thorough perineal exam, and digital rectal examination should be performed after all vaginal deliveries, especially following perineal laceration repair 1
• Rectal examination improves detection of obstetrical anal sphincter injuries (OASIS) and is therefore critical to perform after all vaginal deliveries 1
• The rectal exam specifically checks for:
  • Inadvertent placement of sutures through the rectal mucosa 1
  • Undiagnosed extension of the tear into the anal sphincter complex 1
  • Integrity of the repair and proper tissue approximation 1

Consequences of Missed Rectal Sutures

• Sutures penetrating the rectal mucosa can create a tract between the rectum and vagina, potentially leading to:
  • Rectovaginal fistula formation requiring surgical repair 2
  • Fecal contamination of the wound leading to infection 1
  • Wound breakdown and dehiscence 1
  • Prolonged healing time and increased patient discomfort 1
  • Need for additional surgical procedures 2

Proper Technique for Second-Degree Tear Repair

• Second-degree tears involve the perineal skin, vaginal epithelium, and perineal muscles 1
• Repair should proceed in layers:
  1. Vaginal epithelium and muscularis
  2. Perineal body musculature
  3. Rectovaginal fascia and perineal skin 1
• Continuous non-locking suturing techniques are recommended as they:
  • Distribute tension more evenly across the suture line 1
  • Result in less pain for up to 10 days postpartum 1
  • Reduce analgesic use 1
  • Decrease need for suture removal 1

Prevention of Rectal Suture Placement

• Ensure adequate lighting and exposure during the repair 1
• Use proper surgical instruments and appropriate suture material 1
• Maintain awareness of anatomical planes during repair 1
• Perform the repair in a systematic fashion from deep to superficial structures 1
• Consider moving to an operating room setting if visualization is inadequate 1

Post-Repair Protocol

• Perform a digital rectal examination after completing the repair to check for any sutures penetrating the rectal mucosa 1
• If sutures are detected in the rectum, they must be removed and the repair redone properly 1
• Document the laceration type, repair technique, and confirmation of no rectal sutures 1
• Count all surgical instruments, sponges, and sutures pre- and post-operatively 1
• Provide appropriate postoperative care instructions to the patient 1

Quality Improvement Considerations

• Institutional guidelines and checklists should include verification of rectal examination after perineal repair 1
• Provider education should emphasize the importance of rectal examination after repair 1
• Documentation should specifically note that rectal examination was performed and no sutures were palpable in the rectum 1

Remember that maintaining and improving provider knowledge and repair skills is vital to providing optimal perineal care and preventing short- and long-term complications from obstetrical perineal trauma 1.