In every third to fourth spontaneous birth, as well as in forceps or suction-cup births, the woman giving birth suffers a so-called perineal tear: The tissue between the anus and the vagina is stretched so much by the pressure of the baby during the expulsion phase that it can tear. This birth injury occurs in varying degrees of severity and severity.
What is a perineal tear?
Perineal tear is a birth injury feared by pregnant women that may or may not occur during child birth. Tearing of this delicate perineal area is also divided into different degrees of severity, based on which the injury is graded by the attending physician after delivery:
In the case of the first-degree perineal tear, only the upper layer of skin tears to a maximum of the middle of the perineum, thus not extending to the anus and sparing the deeper muscle layers. The stronger vaginal tear of the muscle tissue up to just before the anus is called a second-degree perineal tear. In the third degree, the entire perineum tears and also includes the sphincter muscle. In the last and most obvious degree, the complete perineum, the sphincter and the anterior portions of the wall of the rectum tear.
Causes
During the expulsion phase, also known as “pushing contractions,” there is very strong downward pressure from the contractions of the uterus and the mother’s pushing. All of the baby’s weight presses down on the woman’s delicate pelvic floor during this phase, exerting pressure that is unusual for the sensitive perineal region. In the final stage of normal spontaneous birth, the baby’s head is born first, followed by its shoulder, and then the rest of its body. The size of the head and body put a lot of pressure on the vaginal and perineal muscles and the vaginal outlet is stretched to its maximum. However, if it is overstretched, the described tearing of the tissue occurs at this point with or without muscle involvement. Multiple perineal tears may also occur simultaneously.
Symptoms, complaints and signs
Complaints such as pain, burning or bleeding are still possible weeks after birth. If the perineal tear is not noticed and treated right at birth, it often becomes noticeable through pain when walking, sitting or exercising. Mild bleeding may occur, which is often not self-recognized due to natural postpartum bleeding. Bowel movements and urination in particular can be very painful in the first days after birth and are often associated with a strong burning sensation. Even though the wound usually heals quickly, the skin may harden. This hardening may be palpable frequently, depending on the severity of the injury, and may continue to cause pain during sexual activity or exercise even after healing. If the perineum itself produces severe pain and may be accompanied by foul-smelling urine, this may indicate an infection of the suture or even a urinary tract infection. Hemorrhoids and abscesses can also form around the perineal suture, and these are manifested by itching, pain and possibly slight bleeding. However, most signs and symptoms of perineal tears disappear within the first few weeks after birth.
Diagnosis and course
By classifying the severity of this birth injury, the doctor can determine how many stitches will be needed to suture it. Immediately following delivery, after the newborn is removed, the woman’s injury is sutured under local anesthesia. If the birth took place under peridural anesthesia, the area to be sutured is not anesthetized separately. At this point it should be mentioned that the tearing of the perineum at the time of expulsion is perceived by the woman giving birth herself as pleasant and relieving rather than painful, since all the pressure is taken off her pelvis. Also, the supply of the injury occurs under the influence of the body’s own hormones and is rarely perceived as seriously painful.
Complications
A perineal tear can lead to a variety of complications. Depending on the degree of injury, there may be harmless skin lesions or severe tears to the sphincter muscle that are associated with pain, dysfunction, and further discomfort. Surgical intervention may be associated with further injuries and infections in the anus area. Patients at risk also run the risk of circulatory shock and similar complications.Swelling and pain may occur in the course of wound healing. A sutured perineum causes tension pain and other discomfort for several days afterward. When going to the toilet, there may be burning pain and rarely tearing of the scar. After the wound heals, excessive scarring may occur, causing discomfort especially during bowel movements and sexual intercourse. In the case of more severe perineal tears, abscesses may form, necessitating another operation. Severe perineal tears can also cause fistulas to form between the vagina and the bowel. An injured sphincter can lead to temporary incontinence, mainly affecting the discharge of diapers. The impaired muscle functions can cause functional discomfort after a perineal tear, which must be treated specifically with the help of pelvic floor training.
When should you see a doctor?
A perineal tear occurs in a direct relation to childbirth. This should always be accompanied and supported by a doctor and/or midwife. If the perineum tears outside of a birth process, this is considered unusual. If pain and discomfort occur at the anus during defecation or sexual activity, they should be examined and clarified by a doctor. If the discomfort increases or becomes more widespread, a doctor should be consulted to find out the cause. If bleeding occurs or open sores are present in the region around the anus or the vaginal outlet, germs can enter the organism and trigger further illnesses. For this reason, a doctor should be consulted so that the wounds can be treated and closed in a sterile manner. In case of fever, itching, changes in the skin or a burning sensation on the skin, a doctor should be consulted. A visit to the doctor is also necessary if there is any discomfort with locomotion, sitting or during a bending posture. If there is no bowel movement for more than two days, a medical examination must be initiated. A doctor should be consulted even for small tears in the skin near the perineum, as complications may arise if the wound is self-care.
Treatment and therapy
Treatment of perineal laceration is as described by direct suturing of the wound. Some physicians also opt for a prophylactic perineal incision while the baby is still at birth, but this is being performed less and less because the torn sutures grow together and heal better than those caused by the scalpel. Because the perineal and vaginal regions are very busy and mucous membranes are involved, there may be delays or difficulties in the healing process. Sitting, walking or going to the toilet constantly stretches and stresses the suture, which can cause re-tearing of the suture or wound healing problems. Hygiene has top priority at this point, but also caution and patience. In most cases, absorbable, i.e. self-dissolving, sutures are used for suturing, which do not need to be extracted. Nevertheless, the suture should be checked regularly by the gynecologist or follow-up midwife for inflammation or wound healing problems of other kinds.
Outlook and prognosis
Perineal laceration is readily curable with today’s medical options. The procedure takes a few minutes and is considered routine treatment. The patient is usually discharged from treatment a few days or weeks after the corrective procedure. However, there may be lifelong complications or impairments. Since the perineal tear is sutured, there is a risk of unwanted scarring in the process. In some cases, this leads to problems with bowel movements or sexual intercourse. To improve well-being, the patient can take various measures that are helpful and relieving in everyday life. When going to the toilet, strong pressing should be avoided. Nutrition and hygiene can be optimized. Short, lukewarm sitz baths are found to be pleasant and beneficial. If the measures taken are not sufficient, the patient can have the scarring treated in a further therapy. The prognosis in these cases is individual and depends on the intensity of the existing scars. However, deterioration is considered rather unlikely. As late sequelae, perineal lacerations can lead to increased inflammation. These are considered unpleasant, but are also easily treatable.In unfavorable cases, the late effects of perineal rupture make colonoscopy, enemas or other bowel examinations difficult. This is considered particularly unfortunate for cancer screening.
Prevention
To prevent perineal tear, perineal massage with a suitable oil can be performed during the last weeks of pregnancy. There are several techniques, usually involving inserting the thumb about pad-deep into the vagina and massaging with the index finger with careful pressure from the anus toward the vagina. Regular massage can soften the tissues, better preparing them for the pressures of childbirth.
Aftercare
Due to the perineal tear and the subsequent suturing of the same, the tissue becomes irritated and swells a lot. To prevent this, patients are immediately given decongestant medications. Cooling the area by means of special cooling gels or cool packs also causes swelling and relieves pain. Midwives also recommend freezing pads soaked in cooking oil and using them instead of gel or cool packs. The cold effect achieved in this way is perceived as more pleasant and at the same time has a caring effect on the skin. Some sufferers prefer healing sitz baths made of warm water with special bath additive or healing plant extracts instead. However, the baths should only be used once a day for about ten to fifteen minutes to avoid softening the wound and increasing swelling. It is extremely important to observe a rest period of at least five days, during which the affected person should not sit or walk if possible. When going to the toilet, it is recommended to take small steps that do not stretch or strain the wound. When going to the toilet itself, there are also a few things to keep in mind. Increasing the amount of fluid dilutes the urine and thus reduces burning when urinating. Similarly, sufferers can pour lukewarm water from a glass between their legs in the meantime to achieve further dilution and minimize pain.
Here’s what you can do yourself
In order for a perineal tear to heal well, the suture should not be subjected to much stress. There should be plenty of air to the fresh wound and the suture area should be kept as dry as possible. Avoiding sitting positions such as cross-legged is advisable. Abdominal and pelvic muscles should also not be put under too much strain, which is why sports such as cycling are not recommended until healing is complete. To make sitting easier, a soft cushion can be placed underneath, but a ring-shaped seat cushion should not be used, as this creates a lot of downward pressure. To get up from a lying position, rolling to the side is recommended. In addition, care should be taken to ensure a soft bowel movement. This can be promoted by drinking water, eating yogurt and dried fruit, or by the additional administration of magnesium. Painful burning during urination can be prevented by rinsing the wound with warm water during urination. Gentle rinses and sitz baths can also be performed with herbal extracts of chamomile or oak bark, which are available in pharmacies. For the first few days, the wound can also be cooled with a Coolpad wrapped in a towel to promote swelling and relieve pain.
