Insert service
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Maternity record identification label
Perineal Assessment Tool
Pregnancy and birth history
Antenatal care
Antenatal Risk Factors
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Gravidity: ____ Parity: ____ Gestation: ______
Second stage commenced: __:__ on __/__/____
Baby birthed: __:__ on __/__/____ Birth weight: _____g
First vaginal birth (including previous c-section)
Southeast Asian ethnicity
Previous 3rd or 4thdegree perineal tear
Birth mode
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Antenatal Perineal Protective Practices
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Woman informed of risk factors
Perineal massage from 34 weeks gestation
Pelvic floor training
Induction of labour
Spontaneous vaginal birth
Water birth
Forceps assisted vaginal birth
Vacuum assisted vaginal birth
Intrapartum care
Intrapartum Risk Factors
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Episiotomy
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□ Episiotomy indication
□ Instrumental assisted birth
□ Fetal concern/distress
□ Prolonged second stage
□ FGM
□ Episiotomy declined
□ Verbal consent obtained
□ Episiotomy performed
□ Mediolateral
□ Midline
□ Anterior
□ Lateral
□ Instrument:
□ Episcissors
□ Mayo Scissors
Persistent posterior presentation
Shoulder dystocia
Prolonged second stage:
□ Primip – active 2nd stage >2 hours
□ Multip – active 2nd labour >1 hour
Instrumental assisted vaginal birth
□ Forceps assisted
□ Vacuum assisted
Epidural pain relief
Fetal birth weight >4kg
Intrapartum Perineal Protective Practices
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Warm compress applied during second stage
Hands-on support of the perineum
Verbal guidance provided during birth of the
fetal head and shoulders
Consent obtained to perform interventions
Performed by: _____________ Designation: _________
Date: __/__/___ Time: ___:___ Accoucheur: _______________________ Designation: _________________
Date: __/__/___ Time: ___:___ 2nd Clinician: _______________________ Designation: _________________
Perineal Assessment Tool
OFFICIAL
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Insert service
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Maternity identification label
Postpartum assessment
Perineal assessment
Perineal status
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Verbal consent to genito-anal examination
Genito-anal examination declined
Genito-anal examination performed
Analgesia provided prior to assessment
RCOG classification system used
Perineal tear reviewed by second
experienced clinician to confirm diagnosis
and grade of tear
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Intact
1st degree (perineal skin tear)
Episiotomy
Episiotomy with extension
2nd degree (perineal muscle tear)
3a tear (less than 50% external anal sphincter)
3b tear (more than 50% external anal sphincter)
3c tear (internal anal sphincter)
4th degree tear (anorectal mucosa)
Rectal button-hole
Other type of tear _____________________________
Examiner 1: _________________ Designation: _________ Examiner 2: _________________ Designation: _________
Perineal repair
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n/a (continue to post-partum care)
required
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Perineal status communicated to woman
Consent to repair obtained
Tear grade
Repaired by
Repair location
Anaesthetic
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Episiotomy repair
2nd degree
3rd degree
4th degree
Midwife
Obstetrician
Gynaecologist
Surgical specialist
Other: _____________
Area of repair
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Perineal skin
Perineal muscle
External Anal Sphincter (EAS)
Internal Anal Sphincter (IAS)
Anal/rectal mucosa
Other ___________________
Birthing suite
Operating theatre
Care escalated to
alternative health service
Repair technique
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Continuous
Continuous
End-to-end
End-to-end
Continuous
Continuous
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Interrupted
Interrupted
Overlapping
Interrupted
Interrupted
Interrupted
Local anaesthetic
Nitrous Oxide
Epidural
Spinal
General anaesthetic
Suture type
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Vicryl Rapide
Vicryl Rapide
PDS 3.0
PDS 3.0
PDS 3.0
Vicryl Rapide
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Vicryl 2.0
Vicryl 2.0
Vicryl 2.0
Vicryl 2.0
Vicryl 2.0
PDS - polydioxanone sutures
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Repeat rectal examination performed post EAS, IAS or anal mucosal repair
Repair performed by: __________________________ Designation: ________________ Date: __/__/____ Time: ___:___
Perineal Assessment Tool
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Maternity identification label
Post-partum and post-operative care
Vaginal packs
Indwelling catheter (IDC)
Medications prescribed
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n/a
number of packs: ______
packs removed: _______
packs insitu: ___________
to be removed __/__/____
removed: __:__ __/__/____
(time)
n/a
inserted __/__/____
removed intraoperatively
to be removed __/__/____
removed: __/__/____
urine passed: __:__ __/__/____
(date)
(time)
(date)
Analgesia
Antibiotics
Stool softeners
Aperients
Blood loss
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Measured: ________mls
Estimated: ________mls
Total volume: ______mls
Debrief
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Debrief offered
Debrief declined
Debrief provided
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Interpreter required
Interpreter provided
Interpreter not available
Information discussed in debrief:
□ Review of perineal tear risk factors
□ Events during labour and birth
□ Perineal protection practices
□ Perineal tear grading
□ Details of repair
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Recovery expectations
Available supports to aid recovery
Referrals to support recovery
Take home information provided
Debrief provided by: __________________________ Designation: ________________ Date: __/__/____ Time: ___:___
Discharge and Follow-up care
Information provided:
Referrals made:
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Midwife
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Psychologist
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Obstetrician
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Social Worker
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Gynaecologist
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Perineal Clinic
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Specialist Surgeon
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Endo-anal ultrasounds
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Physiotherapist
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Anorectal manometry
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Continence Nurse
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Other: ______________
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Dietitian
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Wound care
Diet
Toileting
Medications
Pelvic floor recovery
Reliable information/support resources
Concerning signs and symptoms
□ who to contact if concerned
Details of first follow-up appointments
When to see GP
Information provided by: ______________________ Designation: ________________ Date: __/__/____ Time: ___:___
Perineal Assessment Tool
OFFICIAL
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