A Text-book of Diseases of Women

by Charles B. Penrose

If this tear is detected after labor, it should be closed by the immediate operation. A slight tear involving chiefly the cutaneous aspect of the perineum should be closed by three or four sutures introduced from the outside, as in [Fig. 33]. The needle should be introduced about a quarter of an inch from the edge of the wound. It should not be passed parallel with the plane of the lacerated surface, but should be swept outward and then inward toward the angle at the bottom of the tear ([Fig. 34]). It may either emerge at the angle and be re-introduced, or it may be passed directly through to the skin-margin on the opposite side of the wound. If the suture is passed in this way, there will be perfect apposition throughout the whole surface of laceration. If the sutures are improperly passed, there may result only apposition of the skin-edges.

Fig. 34.—Diagram representing the correct and the incorrect method of passing the suture for closure of slight perineal laceration.

If the laceration extends up the posterior vaginal wall, two sets of sutures must be introduced—one on the vaginal aspect of the tear, and one on the skin aspect ([Fig. 35]).

Fig. 35.—Recent slight median laceration of the perineum extending up the posterior vaginal wall: sutures introduced on the vaginal and cutaneous aspects.

The secondary operation of perineorrhaphy is not indicated in slight median lacerations of the perineum that may have been neglected at the time of labor, as the integrity of the pelvic floor is practically unaffected by them.

Median Tear involving the Sphincter Ani.—In this form of injury the laceration takes place in the median line and extends backward through the sphincter ani muscle, and perhaps upward for one or more inches through the recto-vaginal septum. Permanent incontinence of feces results.

Though this is a most extensive injury attended by most unpleasant results, yet it will be seen that none of the supporting structures (the fascia and the muscles) that support the pelvic floor are injured by it.

The perineum is split in the middle, but the muscles attached to it, being uninjured, are still able to draw the two halves of the perineum forward, thus supporting the posterior vaginal wall and keeping the vagina closed. There is but very little tendency to separation of the two parts of the split perineum by lateral traction, the only muscle that acts at all in this direction being the feeble transverse perineal muscle.