Brief overview
- Causes and risk factors: Usually birth injury, rapid delivery, large child, interventions during delivery, e.g. use of forceps or suction cup (vacuum extraction), insufficient perineal protection, very firm tissue
- Symptoms: pain, bleeding, swelling, possibly bruising (hematoma).
- Diagnosis: Visible injury, examination of deeper tissue injuries with the help of a vaginal speculum (speculum)
- Treatment: Depending on the extent (degree) of perineal laceration, in case of superficial skin injury cooling, painkillers if necessary, in case of deeper injuries surgical treatment by suturing.
- Prognosis: Good if appropriate care is given. Increased risk of fecal incontinence if anal sphincter is injured. Rarely complications from infection.
- Prevention: Perineal massages before delivery and moist compresses in the perineal area during delivery reduce the risk of serious perineal tears.
What is a perineal tear?
The perineum is located between the vaginal entrance and the anus. During childbirth, the skin and muscles in this area are put under a lot of stress. Especially when the baby’s head passes through the birth canal during the expulsion phase, the stretching is very strong.
What are the degrees?
A perineal tear is divided into different degrees of severity:
- Perineal tear grade 1: The skin on the perineum is only superficially torn. The musculature is not affected.
- Perineal tear grade 2: The injury affects the skin and muscles, the sphincter is still intact.
- Perineal tear grade 3: The sphincter muscle is partially or completely torn.
- Perineal tear grade 4: The sphincter and intestinal mucosa of the rectum, possibly also the vagina, are injured.
Perineal tear
Sometimes the doctor specifically enlarges the pelvic outlet by making an episiotomy. If this incision is not large enough, perineal tears sometimes also occur during childbirth.
The direction in which the doctor makes the episiotomy also plays a role in the risk of perineal tear. If the incision is made vertically in the middle of the perineum toward the anus (medial), the risk of perineal tear increases.
In contrast, a lateral incision (mediolateral), such as before an obstetric procedure like the use of forceps or a vacuum cup, reduces the risk of perineal tear.
How does an episiotomy occur?
Whether or not an episiotomy will occur during childbirth cannot be generally predicted.
However, the risk is increased if the following factors are present:
- Large child (expected birth weight > 4000 g, head circumference of the child > 35 cm).
- Very rapid birth or too rapid passage of the head.
- Insufficient perineal protection by the midwife or obstetrician
- In the case of operative vaginal birth, i.e. when using mechanical aids (forceps or vacuum deliveries)
- In the case of very firm connective tissue
Symptoms
A perineal tear is noticeable by pain and bleeding, sometimes a bruise develops at the injured site.
Many women often do not notice the symptoms themselves because of the epidural anesthesia (PDA) or a lowered sensitivity to pain after the birth trauma. In this case, close examination by the midwife or gynecologist is necessary.
Examinations and diagnosis
Immediately after the birth, the gynecologist examines the mother’s vagina and perineum very carefully. If there is a perineal tear, he or she will accurately assess the location and extent, that is, the degree of injury. Among other things, the following questions must be answered:
- What is the location of the tear?
- Is only the skin torn?
- Is the perineal musculature also injured?
- Is the sphincter muscle affected?
- To what extent is the bowel involved in the perineal tear?
Treatment
Minor tears of the skin will heal on their own and do not require stitches. Treatment of first and second degree perineal tears is usually uncomplicated.
Women who have received a peridural anesthesia during childbirth do not require additional pain medication. Depending on the extent of the injury, pain, swelling, a feeling of tightness and discomfort when sitting are possible.
Until the perineal tear heals, bowel movements are often uncomfortable. Sometimes the wound burns when urinating. To relieve such discomfort, the doctor often prescribes a drug that softens the stool (called a laxative).
For more serious injuries, such as a third- or fourth-degree perineal tear, it is recommended that laxatives be taken for a period of two weeks.
In addition, it is helpful to rinse the perineal laceration with lukewarm water after each use of the toilet. Sitz baths and wound ointments are not necessary to treat a perineal tear and do not speed healing.
Cooling compresses help relieve swelling and pain. Pain medications are used if needed.
Third and fourth degree perineal tears always require treatment. The most important thing here is to restore the perineal muscles and the sphincter of the intestine by suturing.
In the case of a pronounced and complicated perineal tear, treatment under general anesthesia is sometimes necessary. After surgical treatment of the muscles and intestine, the doctor sutures the perineum in layers.
Prognosis and course
The prognosis for a perineal tear depends on the severity, but is usually good. On average, healing from a perineal tear takes about ten days. Complications such as inflammation or infection of the wound are very rare.
Both perineal incisions and tears leave a scar as a result of the injury. In superficial injuries, the scar is usually small and soft; in a severe perineal tear, the scar sometimes feels hardened, like a lump.
In some cases, the scarring causes pain during sexual intercourse. If the perineal tear injured the sphincter muscle, there is some risk that air or stool will not be reliably stopped.
Physiotherapy with targeted pelvic floor training usually helps to improve the function of the sphincter muscle. If fecal incontinence persists, surgical treatment may be an option.
Simple measures can have a positive effect on the healing process of a perineal tear:
- Avoid heavy pressing during bowel movements.
- Give preference to food that promotes soft stools (soft food, sufficient amounts to drink).
- Refrain from bowel exams, enemas and suppositories if possible.
- If you have a perineal tear, make sure to take proper care of it by rinsing the genital area with water after each visit to the toilet.
- Wear comfortable underwear and clothing.
When is sex possible after childbirth?
The question of when sex is possible again after childbirth and a perineal tear cannot be answered in a generalized way. Basically, birth injuries should have healed and the postpartum flow should have dried up – this is usually the case about four weeks after birth.
In the case of third- or fourth-degree perineal tears, it makes sense to ask the gynecologist for advice on when healing is complete enough for sexual intercourse to be possible without problems.
For many women, psychological feelings about sexuality also play an important role. Thus, it is possible that the desire for sex does not arise, even if the body has already recovered well from the birth.
It varies from person to person and sometimes takes only a few weeks, but sometimes months, until sexual desire returns after childbirth.
Prevent perineal tear
Whether a perineal tear occurs during childbirth depends on many different factors – and these cannot generally be prevented. There is therefore no specific measure that can reliably prevent an episiotomy.
However, studies have shown that the application of warm, moist compresses to the perineum during birth and preparatory perineal massages reduced the risk of third- and fourth-degree perineal tears.