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  • Samara Nanayakkara

Perineal Tears in Childbirth

What is a perineal tear?

According to a 2018 Queensland Health report, 50% of women have some degree of tearing during a vaginal delivery. 30% of have no tears (an intact perineum) with a vaginal birth, 15% have an episiotomy, and approximately 2% have a third or fourth degree tear – these are considered more severe and will require more care and healing time.

Grade of perineal tears

Grade 1:

A grade 1 tear is injury to the perineal skin – no fat, fascia (connective tissue) or muscle is torn. These may require only a few stitches.

Grade 2:

A grade 2 tear is injury to the perineal skin, pelvic floor muscles and the fascia. These require stitches and can take up to 8 weeks to heal.

Grade 3:

Grade 3 tears are injury to the skin, muscles and posterior vaginal wall – and involve partial or complete disruption of the anal sphincter complex (external [EAS] and internal [IAS]). Obstetric anal sphincter injury (OASI): is an acronym used to describe third- and fourth-degree tears. Classification of a third degree tear is dependent upon the severity and the structures damaged:

3a: less than 50% of the external anal sphincter torn

3b: more than 50% of the external anal sphincter torn

3c: injury to the external and internal anal sphincter

Grade 4:

A grade 4 tear is a complete tear of the EAS, IAS and anal mucosa. All third and fourth degree tears are repaired under general or regional analgesia (in an operating theatre).

What is an episiotomy?

An episiotomy is a surgical incision made in the perineum during childbirth. Your doctor may make an incision in this area to enlarge your vaginal opening before you deliver your baby, due to the risk of tearing during delivery or the baby’s position or size.

These have become less common in recent years. Previously, episiotomies were performed to help prevent severe vaginal tears during delivery, and was also thought to heal better than a natural or spontaneous tear. Research suggests that episiotomies shorten the time of labour by 15 minutes, however the evidence is scarce.

Who is at risk of tearing?

According to the Royal Women’s Hospital Third and Fourth Degree Tear Management Guidelines (2017), a number of risk factors have been associated with grade 3 and 4 tears:

· Nulliparity

· Asian or Indian sub-continent ethnicity

· Woman has undergone Female Genital Mutilation / cutting (FGM/C)

· Baby is large in relation to maternal size (> 4kg)

· Previous history of perineal trauma requiring repair

· Previous history of obstetric anal sphincter injury

· Precipitate or faster than expected second stage

· Instrumental birth

· Active second stage longer than 1 hour

· Inappropriate maternal position (e.g. sustained lithotomy position)

· Midline episiotomy or an inadequately angled mediolateral episiotomy which functions like a mid-line

Can you reduce your risk of tearing?

Perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. Women should be made aware of the likely benefit of perineal massage and provided with information on how to massage and stretch the tissue from 34 weeks onwards.

What you can do to help it heal

Healing of the tissue can take up to 6 months. The first 6 weeks are particularly important for muscle and soft tissue recovery. Your team – doctor, midwife, pelvic floor physiotherapist and dietician will recommend medication to help with pain management, constipation reduction strategies, safe ways to move, pelvic floor exercises, and other physiotherapy techniques to aid perineum healing.

REST: lie down regularly (rather than rest in a seated position) for the first 2 weeks after the birth. This will elevate your pelvis and abdominal area. Elevation will reduce swelling and improve healing. Do your best to get as much sleep as possible as this is the best way to promote healing for your whole body. Learn to feed lying on your side to reduce the time you spend sitting. If you feel pain, pressure of discomfort in your perineum lie down and rest! For the first 3 days aim for 30 minutes of rest every 2 hours. From 3 days - 6 weeks gradually reduce to approximately 1-2 hours of rest lying down per day.

ICE: Apply an ice pack to the perineum on the day you give birth. Place the ice pack under the maternity pad. Do not apply ice directly to the skin. Apply the ice for 20mins every 2 hours whilst you are awake for a minimum of the first 3 days. Continue to apply ice if you experience pain, pressure or discomfort for the next 2 weeks. If you continue to experience pain and swelling, consult your healthcare professional and consider whether you are resting enough as outlined above.

COMPRESSION: Wear firm supportive underwear such as compressive or shapewear to provide additional perineal support whilst you are awake. This is only advised if do not have leakage or urine with coughing, sneezing, laughing, or en route to the toilet.

EXERCISE: pelvic floor muscle exercises – see “What are the Pelvic Floor Muscles?” blogpiece.

TOILETING – Have a 20 – 30 cm stool under your feet, rest your forearms on your thighs, relax the belly, and say “moo” – this relaxes the pelvic floor and abdominal muscles to reduce constipation. For the first 6 weeks, you may need to periodically use a laxative to keep the bowel motions soft.

What can I do once I leave the hospital?

Follow up appointments with your pelvic floor physiotherapist for all women who sustain an OASI is strongly recommended:

1. 2 – 3 weeks post birth - an appointment is to be made for 1:1 physiotherapy at approximately 2-3 weeks post birth. Your physiotherapist will check the healing and advise you on how you are doing your pelvic floor exercises.

2. 4 - 6 weeks post birth - If the lochia (vaginal bleed) has stopped, your physiotherapist can perform an internal check of your perineal tissue and pelvic floor muscles.

3. 12 weeks post birth - ongoing appointments and review is then based on the woman’s needs. As tissue healing can take 6 months, your physiotherapist will advise you regarding perineal massage to gently soften the scar tissue, continuing your pelvic floor exercises, and how and when you can return to intercourse and exercise.

What problems may occur after a 3rd or 4th degree tear?

Although long term problems can occur, women should be reassured that 60-80% of women have no symptoms 12 months after a 3rd or 4th degree tear.

Problems include:

● Bowel urgency, flatal (gas) and bowel incontinence

● Pain during sex and perineal pain

● Urinary incontinence

● Pelvic floor muscle weakness

It is important to note that symptoms can arise in the fifth and sixth decade of a woman’s life due to the cumulative effects of menopause and ageing.

To book your postnatal physiotherapy check ups - visit our home page for locations and contact details.

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