A second degree tear is one that extends down into the perineal body and may involve the levator ani, or even extend down to, but not through the rectal sphincter. Such a tear usually extends upward on one or both sides of the vagina making a triangular injury.
A third degree tear extends entirely across the perineal body and through the rectal sphincter and sometimes up the anterior wall of the rectum. This variety is often called a complete tear, in contradistinction to those of first and second degree, which are incomplete.
It is a fairly general custom to repair these lacerations at the time of labor, no matter what their extent, the sutures being introduced but not tied, during the third stage. The patient is usually sufficiently anesthetized to permit of this, without further anesthesia, in all but complete tears, and as there is usually but very slight bleeding before the expulsion of the placenta, the field is comparatively clear and the stitches are easily put into place. They are not tied, as a rule, until after delivery of the placenta because of the strain which its expulsion would put upon the fresh stitches. In all but very slight tears, the doctor will usually want the patient turned across the bed, with her hips brought to the edge, and her legs supported in the lithotomy position. As the few instruments necessary for perineal repairs should be boiled and placed in readiness before labor, there is usually no further preparation for the nurse to make, and the perineal dressing, after the stitches have been taken, is ordinarily the same as that following a normal delivery. (See Fig. [80] for necessary instruments.)
Some physicians prefer not to repair perineal tears until some days after labor, contending that the congestion of the soft parts immediately after delivery is not favorable to a satisfactory union. When the repair is made subsequently, therefore, the nurse prepares as she would for any perineal operation, performed independently of labor. Repairs are not often postponed for more than a few days, since long delayed or neglected attention frequently gives rise to gynecological disorders, such as descensus or prolapse of the uterus.
Episiotomy. Some obstetricians prefer to anticipate a perineal tear by making an oblique incision, usually on one or both sides, extending downward and outward from the margin of the vaginal outlet down into the perineum. This operation is termed episiotomy, and the incision is sutured after labor just as a tear would be. It is the belief of those who perform this operation that the clean-cut incision heals more satisfactorily than an irregular tear, and that by directing the incision to the side, away from the median line, the integrity of the rectal sphincter is preserved, even though the perineum tears beyond the end of the incision, when distended during the birth of the head.
Breech Extraction. In some cases of breech presentation, particularly among primiparæ, it is necessary to assist nature in the delivery of the child in order to save its life. Complete anesthesia is usually necessary at such times and the patient is preferably on a table or at the edge of the bed in a lithotomy position.
In the majority of cases, no effort is made toward assistance until the body is born as far as the umbilicus, partly because of the difficulty of taking hold of the child securely before that time, and partly because the perineum is not likely to be fully distended, in which case a serious tear would probably result. But after the body has been extruded as far as the umbilicus, it is usually considered imperative to complete the delivery within eight minutes to save the child from asphyxiation, due either to pressure on the cord between the head and pelvic brim, or to premature separation of the placenta. The baby’s feet or legs are grasped by a towel to prevent slipping, and downward traction is made on the body until the tips of the scapulæ appear at the outlet. During this procedure the nurse may be called upon to make pressure on the uterus with the idea of keeping the baby’s head flexed forward; preventing the arms from becoming extended upward above the head and also to help in expelling the child.
After the scapulæ appear, the arm lying posteriorly is brought down over the chest and delivered. The body is then rotated until the other arm lies posteriorly and that is delivered. After delivery of the arms and shoulders the head is usually delivered by what is known as Mauriceau’s maneuver as follows: The accoucheur slips the index finger of one hand into the vaginal outlet and into the child’s mouth, and supports the body of the child upon his hand and forearm; two fingers of the other hand are slipped around the back of the neck and curved forward like hooks over the shoulders and strong downward traction is made by these fingers; not by the one in the baby’s mouth. The occiput emerges from beneath the symphysis, after which the body is lifted upward and the chin, nose, forehead and entire head are born.
Version. By version is meant the turning of the child within the uterus so that the part which was presenting at the superior strait is replaced by another part, in order to hasten or facilitate delivery. It is usually performed as the patient lies flat on her back, completely anesthetized, and with great gentleness, for fear of rupturing the uterus.
Common indications for a version are a transverse presentation; a prolapsed cord, when the head has just begun to enter the superior strait; and in some cases of placenta prævia. When the fetus is so turned that the head becomes the presenting part, the procedure is termed a cephalic version; if so turned that the breech presents, it is termed a podalic version. The methods of accomplishing these ends are described as external version, if the turning is done entirely with the hands working through the abdominal wall; internal version if one entire hand is introduced into the uterine cavity, and combined version when one hand is outside on the abdomen and two fingers of the other are introduced through the cervix into the uterus.