2015昆士兰-临床指南会阴护理

1、Perineal Queensland Clinical Guideline: Perineal careDocument title: Publication date: Document number:Document supplement:Amendments: Amendment date: Replaces document: Author:Audience:Review date: Endorsed by:Perineal care April 2012 MN12.30-V2-R17The document supplement is int

2、egral to and should be read in conjunction with this guideline.Full version history is supplied in the document supplement. March 2015MN12.30-V1-R17Queensland Clinical GuidelinesHealth professionals in Queensland public and private maternity services April 2017Queensland Clinical Guidelines Steering

3、 CommitteeStatewide Maternity and Neonatal Clinical Network (Queensland) Email: G.auURL: .au/qcgContact: State of Queensland (Queensland Health) 2015This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence

4、. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visi

5、t /licenses/by-nc- nd/3.0/au/deed.enFor further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email G.au, phone (07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Of

6、ficer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email ip_.au, phone (07) 3234 1479.Refer to online version, destroy printed copies after usePage 2 of 29DisclaimerThis guideline is intended as a guide and provided for information purposes only. The inform

7、ation has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.The guideline is not a substitute for clinical j

8、udgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances may be appropriate.This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: Providing care within the

9、context of locally available resources, expertise, and scope of practice Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management Advising consumers of their choices in an environment that i

10、s culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary Ensuring informed consent is obtained prior to delivering care Meeting all legislative requirements and professional standards Applying standard precautio

11、ns, and additional precautions as necessary, when delivering care Documenting all care in accordance with mandatory and local requirementsQueensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence)

12、for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.Queensland Clinical Guideline: Perineal careFlo

13、w Chart: Perineal carePerineal morbidity - risk reductionmeasuresAntenatal prevention measures Risk assess, provide education re:o Perineal massageo Pelvic floor muscle exerciseso Perineal stretching devices risks & benefits (support womans choice) Offer deinfibulation of FGM2nd stage labour, injury

14、 reduction Restrict episiotomy use to specific indicationso Attention to correct mediolateral angle Offer perineal massage/perineal warm packs Slow birth of fetal head at time of crowning Perform deinfibulation of FGM When able, use vacuum extractor over forceps2nd stage labour, painreduction Offer

15、warm perineal packs Hands-on technique reduces mild (but not intense) perineal pain up to 10 days post birthPostpartum perineal assessmentTear classification and repair Assess for risk factors Obtain informed consent and support woman Ensure adequate pain relief Ensure timely repair by appropriately

16、 skilled practitionerIntact: No separation of skin at any siteFirst degree tear: Involves skin only e.g. fourchette, perineal skin or vaginal mucous membrane, but not the underlying fascia and muscle (includes graze)Visual inspection Periurethral area, labia, proximal vaginal walls Extent of tear Ab

17、sence of anterior anal puckering Repair if wound not apposed/haemostatic Or, if womans preference to minimise painSecond degree tear (and episiotomy): Involves perineal muscles but not the anal sphincter Repair with dissolvable sutures, using continuous, non-locking technique for all layers, with su

18、bcuticular suture for skin Check rectally for any suture material Offer pain relief (PR NSAID/Paracetamol)Vaginal exam Place index finger and third finger high into vagina, separate walls, sweep downwards, check cervix, vaginal vault/side walls/floor and posterior perineum Note tearing and identify

19、apex of injuryThird degree tear3a 50% of external anal sphincter thickness torn 3c Both internal and external anal sphincter thickness tornFourth degree tear: Involves anal sphincter complex (external and internal and anal sphincter) and anal epithelium/rectal mucosa Repair in theatre by an expert p

20、ractitioner, under anaesthetic Use overlapping or end-to-end techniques Repair internal anal sphincter separately with interrupted sutures Bury knots to prevent knot migration Offer pain relief (NSAID/Paracetamol)Rectal exam(If concerns or tear extends to anal margin) Place index finger into anus as

21、k woman to squeeze, the separated ends of a torn external anal sphincter will retract backwards and a gap will be felt anteriorly If unable to squeeze, place index finger into anus and thumb into vagina and use a pill- rolling motion to check for inconsistencies in the anal sphincter muscle bulk Che

22、ck integrity of anterior anal wall Note detection of internal anal sphincter traumaPostnatal perineal careAdd for genital haematoma Observe for:o Excessive pain/pelvic pressureo Signs of shocko Urinary retentiono Unexplained pyrexia Assess for haemodynamic resuscitation & surgical care Give prophyla

23、ctic IV antibiotics Monitor T, P, BP for recurrence If packing remove at 12-24 hours If drain remove when loss minimal For vulval site apply cool packs Treat anaemia If muscle trauma refer to gynaecologist/physiotherapistAll perineal injury Inspect daily (and if excessive pain) Apply cool packs Offe

24、r regular oral analgesia (NSAID) Educate woman for self-care:o Perineal hygieneo Signs of infection or wound dehiscenceo Positions to reduce perineal oedemao Pelvic floor muscle exercises Advise 6 week GP or midwife review:o See GP earlier if signs of infection or wound dehiscence Advise GP review i

25、f experiencing dyspareuniaAdd for anal sphincter injury Administer:o Prophylactic IV antibiotics - assess need for postnatal antibioticso Laxatives & stool softener for 10 days (with high fibre diet & fluids) Advise woman re:o Morbidity riskso Benefits of follow-upo Options in subsequent births Refe

26、r to physiotherapist for PFME Refer to Continence Clinic, where available Review at 6 weeks with obstetrician:o Consider endoanal ultrasound & anal manometryQueensland Maternity and Neonatal Clinical Guideline: MN12.30-V2-R17 PerinealcareRefer to online version, destroy printed copies after usePage

27、3 of 29Queensland Clinical Guideline: Perineal careAbbreviationsDefinition of termsRefer to online version, destroy printed copies after usePage 4 of 29CrowningWhen the widest part of the fetal head (biparietal diameter) has passed through the pelvic outlet.1Deinfibul

28、ationA surgical procedure to reverse infibulation, i.e. to open the vaginal introitus.2DyspareuniaPain on vaginal penetration and/or pain on intercourse or orgasm.FourchetteThe labia minora extend to approach the midline as low ridges of tissue that fuse to form the fourchette.Hands-onThe accoucheur

29、s hands are used to put pressure on the babys head in the belief that flexion, will be increased, and to support (guard) the perineum, and to use lateral flexion to facilitate the delivery of the shoulders3 modification includes use of the modified Ritgens manoeuvre.4Hands-poised (or off)The accouch

30、eur keeps hands poised, prepared to put light pressure on the babys head in case of rapid expulsion but not to touch the head or perineum and allows spontaneous delivery of the shoulders3 modification includes hands-on to birth the shoulders.5,6InfibulationA type of female genital mutilation that in

31、volves the excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening.2ObstetricianLocal facilities may as required, differentiate the roles and responsibilities assigned in this document to an “obstetrician” according to their specific practitioner group requir

32、ements; for example to general practitioner obstetricians, specialist obstetricians, consultants, senior registrars and obstetric fellows.Pelvic floor muscle exercisesExercises aimed at strengthening abdomino-pelvic and pelvic floor muscles.Pelvic floor muscle trainingA program of exercises used to

33、rehabilitate the function of the pelvic floor muscles.Perineal injuryIncludes perineal soft tissue damage, tearing and episiotomy.Perineal tearsIncludes perineal tearing but not injury such as bruising, swelling, surgical incision (episiotomy).ReinfibulationA procedure that reinstates infibulation.2

34、Restrictive use episiotomyWhere episiotomy is not used routinely during spontaneous vaginal birth but only for specific conditions (e.g. selective use in instrumental deliveries or if fetal compromise).7Modified Ritgens manoeuvreLifting the fetal chin anteriorly by using the fingers of one hand plac

35、ed between anus and coccyx, and thereby extending the fetal neck, while the other hand is placed on the fetal occiput to control the pace of expulsion of the fetal head. The modification in the manoeuvre is used during a uterine contraction rather than between contractions.8Sitz bathWarm bath to whi

36、ch salt has been added.9Slow birth of fetal headRefers to measures taken to prevent rapid head expulsion at the time of crowning (e.g. counterpressure to the head (as needed) and minimising active pushing, it does not include measures such as fetal head flexion or the Ritgen manoeuvre).ACHSAustralia

37、n Council of Healthcare StandardsCTComputed tomographyFGMFemale genital mutilationIAPIntraabdominal pressureIVIntravenousNSAIDNon-steroidal anti-inflammatory drugsPFMEPelvic floor muscle exercisesQueensland Clinical Guideline: Perineal careTable of Contents1Introduction1.4Definition of per

38、ineal injury6Perineal tear classification6Counselling of women7Clinical training723Risk factors for anal sphincter injury8Antenatal risk reduction3.4Digital perineal massage9Pelvic floor muscle exercises9Perineal stretching device10Deinfibulation for female genital mutilation114Intrapartum

39、 risk reduction4.24.3Intrapartum clinical measures12Perineal techniques for the second stage of labour13Intrapartum interventions14Uncorroborated clinical measures155Postpartum perineal examination and repair5.2Perineal examination16Systematic perineal assessment16Perineal repair

40、176Puerperal genital haematoma186.16.2Diagnosis of puerperal haematoma18Treatment and care of puerperal haematoma197Postpartum perineal care7.3.1Minimising pain and the risk of infection20Promoting perineal recovery21Follow-up22Prognosis following repair of anal sphincter injury22Referenc

41、es23Appendix A: Pelvic floor muscle exercises27Appendix B: Female genital mutilation classification and country28Acknowledgements29List of TablesTable 1. Types of perineal injury6Table 2. Types of perineal tearing6Table 3. Digital perineal massage9Table 4. Pelvic floor muscle exercises9Table 5. Peri

42、neal stretching device10Table 6. Care considerations for female genital mutilation11Table 7. Intrapartum clinical measures12Table 8. Second stage of labour perineal techniques13Table 9. Intrapartum interventions14Table 10. Uncorroborated clinical measures15Table 11. Systematic perineal assessment16T

43、able 12. Perineal repair17Table 13. Diagnosis of puerperal genital haematoma18Table 14. Care of puerperal genital haematoma19Table 15. Postnatal measures to reduce perineal pain and infection risk20Table 16. Postnatal measures to promote perineal recovery21Table 17. Post perineal repair follow-up22R

44、efer to online version, destroy printed copies after usePage 5 of 29Queensland Clinical Guideline: Perineal care1IntroductionPerineal injury is the most common maternal morbidity associated with vaginal birth.10 Anal sphincter injury is a major complication that can significantly aff

45、ect womens quality of life.11In Queensland in 201012:Genital tract trauma affected 71.5% of women giving birth vaginallyThe majority of tears were minor, involving only the perineal skin or underlying muscles Where trauma was reported, 2.4% involved the anal sphincterFor women birthing vaginally the

46、 overall risk of anal sphincter injury (3rd and 4th degree tears) was 1.7%1.1Definition of perineal injuryAnatomically the perineum extends from the pubic arch to the coccyx and is divided into the anterior urogenital triangle and the posterior anal triangle.13 Types of perineal injuries are defined

47、 in Table 1.Table 1. Types of perineal injury1.2Perineal tear classificationPerineal injuries sustained during childbirth are most often classified by the degree to which the perineum tears. The perineal tear definitions in Table 2 are aligned with the Australian Council on Healthcare Standards (ACH

48、S) Obstetric Clinical Indicators (Version 6, 2010).11Table 2. Types of perineal tearingRefer to online version, destroy printed copies after usePage 6 of 29TypeDefinitionIntactNo tissue separation at any site15First degreeInjury to the skin only11,16 (i.e. involving the fourchette, p

49、erineal skin and vaginal mucous membrane; but not the underlying fascia and muscle17 sometimes referred to as a graze)Second degreeInjury to the perineum involving perineal muscles but not involving the anal sphincter11,13,17Third degreeInjury to perineum involving the anal sphincter complex11,16: 3

50、a: Less than 50% of external anal sphincter thickness torn 3b: More than 50% of external anal sphincter thickness torn 3c: Both internal and external anal sphincter tornFourth degreeInjury to perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium11,1

51、6 (i.e. involving anal epithelium and/or rectal mucosa)TypeDefinitionAnterior perineal injuryInjury to the labia, anterior vagina, urethra or clitoris13Posterior perineal injuryInjury to the posterior vaginal wall, perineal muscles or anal sphincter that may include disruption to the anal epithelium

52、13EpisiotomyA surgical incision intentionally made to increase the diameter of the vulval outlet to aid delivery13Female genital mutilationA cultural or non-therapeutic procedure that involves partial or total removal of female external genitalia and/or injury to the female genital organs14Queenslan

53、d Clinical Guideline: Perineal care1.3Counselling of womenTo reduce the risk of morbidity and to promote collaborative care:Inform women antenatally of the overall risks of perineal injury associated with vaginal birth refer to Section 1Provide antenatal and intrapartum counselling to women who may

54、be at increased risk of anal sphincter injuryProvide emotional support, reassurance and adequate information prior to undertaking repair procedures10o Encourage presence of womens preferred support person(s)o Encourage women to report ineffective pain reliefGive written information and fully inform

55、women, particularly when there is anal sphincter injury, about16,18:o The nature and extent of the injuryo Details of short and any long term morbidity and treatmento Benefits and importance of required follow upCounsel women undergoing deinfibulation and seek involvement from health care profession

56、als experienced in the care of women with female genital mutilation also refer to Section 3.4Utilise interpreter services for women from a non-English speaking background Document outcomes of discussions in the womans recordFor counselling of women prior to discharge refer to Section 71.4Clinical trainingAppropriately trained health care professionals are more likely to provide a consistently high standard of perineal assessment and repair.7,16,19 Perineal assessment training is important because: