What’s that?
A perineal tear results in tearing of tissue between the anus (outlet of the bowel) and the back of the vagina. A perineal tear typically occurs as a result of excessive stretching during the birth of a child. At some point, the tissue can no longer withstand this stretching.
In addition, a tear can also occur in the area of the labia, the clitoris and also in the area of the uterus. Usually only weak tissue types are affected by a perineal tear, such as skin and fatty tissue, so that in most cases the muscles are spared. During the birth process, the woman hardly feels the perineal tear.
However, after the birth, when the contractions have stopped, pain and bleeding usually occur. The pain occurs mainly when walking, sitting, defecating and during sports activities. Some women, however, do not feel the pain associated with a perineal tear due to a reduced sensitivity to pain after giving birth, which is why every woman must be examined gynaecologically for a perineal tear after giving birth. Rarely does an perineal tear result in permanent pain during sexual intercourse. In technical terms, this is known as dyspareunia.
Frequency
In almost one third of all women who give birth naturally vaginally, perineal tears occur in the course of delivery. Approximately 13% of all women who give birth suffer a first-degree perineal tear. About 15% of all women who give birth naturally suffer a second-degree perineal tear.
A third- or fourth-degree perineal tear is much rarer, occurring in only about 2% of all vaginal births. Perineal tears occur more frequently in older mothers. The age of the mother has an influence on the metabolism of the unborn child. Children of mothers over 35 years of age are usually taller and heavier, so that perineal tears occur more frequently.
Causes
A perineal tear actually only occurs during birth. Some women also report that perineal tears have occurred during sexual intercourse, but there is no precise evidence of this. A perineal tear during childbirth usually occurs during the expulsion of the baby’s head or shoulders.
There is an increased risk of perineal tears in a particularly large child if the baby is in an unfavourable position during the birth process or if the birth is too fast. If an episiotomy has to be performed during birth, an episiotomy that is too small can also lead to an episiotomy. The use of forceps or other aids, in the so-called operative vaginal birth, often leads to an perineal tear.
Classification
A perineal tear can be divided into four levels of severity. The classification is based on the extent of the tear. A perineal tear of the first degree is when only the skin and subcutaneous tissue is affected, but the stronger muscles are still intact.
With a second degree perineal tear, however, the perineal muscles are now also affected. At most, this extends to the outer sphincter (Musculus Sprinter anti externus), whereby the sphincter is still intact. A perineal tear of the first and second degree occurs relatively frequently and is usually unproblematic.
In the case of a third-degree perineal tear, the external sphincter muscle is now also partially or completely affected, so that faecal incontinence may follow. In the case of a fourth-degree perineal tear, not only the perineal muscles including the external sphincter are affected, but also the mucous membrane of the rectum (last section of the intestine). A third- and fourth-degree perineal tear is much less common than a first- or second-degree perineal tear, since the muscles are a much firmer tissue than the skin, for example.
Perineal tears of the third and fourth degree usually occur during an episiotomy or other obstetric surgery. In principle, the female body is designed for the birth of a child and the tissue can also withstand these forces. This is mainly due to the influence of the pregnancy hormones, which lead to an increased elasticity of the tissue.
Nevertheless, approximately one third of all women giving birth suffer perineal tears. Especially midwives can recommend some methods to prevent perineal tears. Preventive measures can soften the tissue and promote blood circulation.
These measures include perineal massage during pregnancy. This massage loosens the tissue and prepares it better for childbirth. The perineal massage does not have to be performed during the entire pregnancy, but is recommended for about ten minutes daily from the 36th week of pregnancy onwards.
Vegetable oil can be used as a massage oil, for example. Warm compresses are also used, which also aim to increase the elasticity of the tissue. Sometimes a so-called birth gel is also used.
It is applied in the birth canal and ensures reduced friction during birth, so that the birth process can be shortened under certain circumstances, making perineal tears less likely to occur. The choice of birth position also plays an important role in the prevention of perineal tears. The supine position is one of the most common birth positions, but it is the position where most perineal tears occur, because the entire weight is on the perineum.
While in a squatting, kneeling, standing or quadruped position the perineum is rather relieved. A water birth also reduces the risk, as the water makes the tissue soft and therefore more elastic. The water takes over the function of a dam protection.
The upright birthing position in water has proven to be the best. During the birth you should also not press too hard and too long in one piece. If sufficient breaks are taken, the perineum has enough time to recover and stretch in between.
As a prophylactic measure, the midwife can also apply a so-called perineum protection during the birth. For this the midwife presses her hand against the perineum to support it. With her other hand she tries to brake the baby’s head a little (head brake).
Perineal protection is mainly carried out in a supine birth position, because in this position the perineum is put under the greatest strain and the risk of a perineal tear is greater. However, the effectiveness of perineal protection has become controversial. Since a vaginal tear can also occur during childbirth, we recommend our page on: Torn vagina during childbirth – Is prevention possible?
