Managing Complications in Pregnancy and Childbirth: - IAWG

P-90 Repair of vaginal and perineal tearsMANAGEMENT OF NEGLECTED CASESA perineal tear is always contaminated with faecal material. If closure isdelayed more than 12 hours, infection is inevitable. Delayed primaryclosure is indicated in such cases.• For first and second degree tears, leave the wound open.• For third and fourth degree tears, close the rectal mucosa withsome supporting tissue and approximate the fascia of the analsphincter with 2 or 3 sutures. Close the muscle and vaginal mucosaand the perineal skin 6 days later.COMPLICATIONS• If a haematoma is observed, open and drain it. If there are no signsof infection and the bleeding has stopped, the wound can bereclosed.• If there are signs of infection, open and drain the wound. Removeinfected sutures and debride the wound:- If the infection is mild, antibiotics are not required;- If the infection is severe but does not involve deep tissues, givea combination of antibiotics (page C-35):- ampicillin 500 mg by mouth four times per day for 5 days;- PLUS metronidazole 400 mg by mouth three times per dayfor 5 days.- If the infection is deep, involves muscles and is causingnecrosis (necrotizing fasciitis), give a combination ofantibiotics until necrotic tissue has been removed and thewoman is fever-free for 48 hours (page C-35):- penicillin G 2 million units IV every 6 hours;- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;- PLUS metronidazole 500 mg IV every 8 hours;- Once the woman is fever-free for 48 hours, give:- ampicillin 500 mg by mouth four times per day for 5days;