A Text-book of Diseases of Women

by Charles B. Penrose

The edges of the septal tear should be denuded, the strip of tissue being cut away to the line of normal rectal mucous membrane. Annoying bleeding may occur if the mucous membrane of the rectum is injured. The denudation may be extended on the vaginal aspect as far as is necessary to obtain a sufficiently broad surface for approximation.

The tear in the septum should be closed by interrupted sutures introduced from the vaginal aspect. The suture is passed through the vaginal mucous membrane at about an eighth of an inch from the edge of the wound, and emerges in the edge of the rectal mucous membrane. It should not pass through the rectal mucous membrane.

Fig. 41.—Denudation. Sutures introduced to close the laceration of the recto-vaginal septum.	Fig. 42.—Laceration of the recto-vaginal septum closed. The operation is completed by the introduction of sutures as in [Fig. 38].

After the sutures in the recto-vaginal septum have been shotted, the operator may proceed to repair the perineum and the sphincter ani muscle ([Figs. 41], [42]).

There is a variety of perineal laceration (between the first slight median laceration and the second complete laceration through the sphincter ani) in which only the outer fibers of the sphincter muscle are injured. In this injury partial incontinence results. The woman may be able to control feces when the movements are hard, but loses control over liquid feces and flatus.

There is no loss of support of the pelvic floor, and the indication for operation is the partial incontinence. The operation is performed in a way similar to that already described for complete laceration. The ends of the ruptured fibers of the sphincter muscles are usually indicated by a slight depression on the overlying skin or mucous membrane.

Laceration in One or Both Vaginal Sulci.—In this form of injury the tear takes place not in the median line, but in the direction of the vaginal sulci or furrows. The left sulcus is usually the more deeply torn.

In this form of laceration the sphincter ani muscle usually escapes injury; the tear is directed toward the ischio-rectal fossa, and the rectum and anus are pushed to one side. The structures of importance that are injured are the fascia, the levator ani muscle, the sphincter muscle of the vagina, and perhaps the transverse perineal muscle. All the supporting structures of the perineum and of the posterior vaginal wall are injured. If the laceration be bilateral, complete loss of support of the perineum and the posterior vaginal wall results, and if the condition be untreated, all the disastrous consequences of loss of support of the perineum occur—prolapse of the vagina, of the uterus, and of the other pelvic organs.

It is unusual that this form of laceration is entirely limited to one sulcus, though one is usually more involved than the other. When the injury is limited to one side, the perineum is still supported by the muscles and fascia upon the other side, and the tendency to prolapse is not so marked.

The nature of this injury may always be detected by examination after labor. The anterior vaginal wall should be elevated by a retractor, and the posterior wall should be carefully examined. An external tear of the skin, generally in the median line, usually accompanies laceration in the sulci; that is, the lacerations in the sulci converge toward the fourchette.