Overview of Perineal Lacerations
A perineal laceration is a tear that happens in the area between the vagina and the rectum, which can also affect the vaginal and cervix, during childbirth. They are quite common and usually heal without causing any long-lasting problems. However, in severe cases, these tears can lead to ongoing pain, problems with sexual function, and feelings of embarrassment.
It is important that doctors identify these serious tears quickly and correctly during delivery so they can be properly repaired. The lacerations can either occur naturally during childbirth or can be the result of medical procedures such as episiotomies, which is a surgical cut made at the opening of the vagina to assist in delivery. Most of these tears are minor and may require stitches to assist in the healing process.
Nonetheless, severe lacerations, which can involve damage to the anal sphincter (muscles surrounding the anus), aren’t as common, happening in about 4 to 11 percent of vaginal deliveries in the United States. These injuries can lead to significant complications, such as problems with the muscles that support the bladder, uterus and bowels, and difficulty controlling bowel movements.
There are certain factors that can increase the risk of these tears, such as giving birth for the first time, medical interventions during delivery, having a larger baby, the position of the baby, and factors relating to the mother such as her age and ethnicity. Episiotomies, specifically the midline type, a straight cut from the vaginal opening, are associated with a higher likelihood of severe tears, despite this, an angled cut (mediolateral episiotomy) is harder to repair but can decrease the likelihood of serious tears. Doctors now limit the use of episiotomies and only recommend them when it is absolutely necessary.
While minor tears may not need stitches if they don’t involve significant bleeding or changes to the body’s structure, for moderate tears, doctors prefer to use a continuous stitching method to manage post-birth pain. More severe tears that involve the rectal tissues require more complex repair methods.
After the repair, follow-up care is very important. This includes measures to manage pain, prevent constipation, and monitor for difficulties in passing urine. There are potential complications such as infection, wound breaking open, long-term issues with controlling bowel movements and painful intercourse. However, measures like perineal massage in late pregnancy and practicing careful techniques during delivery can help reduce the possibility and severity of these tears.
Anatomy and Physiology of Perineal Lacerations
The external parts of a woman’s reproductive system include the mons pubis (the rounded area of fatty tissue over the pubic bone), labia (inner and outer folds of skin at the opening of the vagina), clitoris (a sensitive part above the opening of the urethra), perineal body (the area between the anus and the vagina), and vaginal vestibule (the area inside the labia minora). The perineum is the region that includes all the structures found within the pelvic outlet, including the muscles. This area is defined by the pelvic bone, pubic bone, sitting bones, ligaments at the back of the pelvis, and tailbone. The perineal membrane, a part of this area, is the part that often tears during childbirth.
Usually, any cuts or tears to the vaginal and vulvar region are not deep and do not need to be stitched up. Sometimes, however, the perineum can have cuts or tears that may involve multiple parts; these cuts are different and are classified according to how severe they are, unlike vaginal and vulvar cuts. Doctors usually group perineal tears into four main types:
1. First Degree: A minor injury to the inside lining of the vagina that may include the skin of the perineum.
2. Second Degree: A first-degree cut that includes the inside lining of the vagina and the perineum.
3. Third Degree: A second-degree cut that also includes the anal sphincter complex, which is the group of muscles that control the anus. These can be divided into three further categories: Category A, where less than half of the external anal sphincter is torn; Category B involves more than half of the external anal sphincter; and Category C, where both external and internal sphincters are torn.
4. Fourth Degree: A tear that includes the anal sphincter complex and the inside lining of the rectum.
The more serious perineal tears, which include third- and fourth-degree tears, are called obstetric anal sphincter injuries (OASIS).
Why do People Need Perineal Lacerations
After giving birth through natural delivery, about 90% of women suffer some kind of injury to the perineum, which is the area between the vaginal opening and the anus. These kinds of injuries can happen either naturally, or as a result of medical procedures called episiotomies. The rates of these injuries can vary quite a bit between different countries due to different definitions and because some cases may not be diagnosed.
The majority of these injuries that occur during natural birth can be classified as first or second degree. Out of all these injuries, around 60% to 70% will require medical stitching. Severe injuries to the anal sphincter (the ring of muscles that controls the anus) occur in around 4% to 11% of deliveries in the United States. With each subsequent birth, the frequency and severity of injuries to the perineum decreases.
In most cases of minor injuries to the external genitals or the vagina, and first-degree perineal injuries, repair is usually not necessary. Studies have shown that letting these kinds of small injuries, which are not bleeding and where the edges meet each other, heal on their own may reduce pain, decrease the need for pain medicine, lessen discomfort during sex post-delivery, and lead to higher rates of breastfeeding. However, because there isn’t a lot of evidence about the long-term effects of this approach, the American College of Obstetricians and Gynecologists suggests that the decision to repair such injuries should be made based on the judgment of the doctor handling the case. Typically, repair might be necessary if the injury continues to bleed or if it distorts the normal anatomy of the region.
The risk of these kinds of injuries increases if it is a woman’s first birth, if instruments like forceps or a vacuum extractor are used during delivery, if an episiotomy is performed along the midline, in women of Asian descent, and if the baby is bigger than average. Injuries are also more likely if the baby’s head is turned to the back (also known as persistent occiput posterior position) and as the pregnancy continues beyond the standard 40 weeks. The use of forceps or a vacuum extractor during delivery, a large baby, and/or an episiotomy along the midline are the most common risk factors for severe injuries to the anal sphincter.
When a Person Should Avoid Perineal Lacerations
Sometimes, using stitches to heal tears around the private parts (perineal lacerations) after childbirth can do more harm than good. Research shows that allowing the body to recover on its own or using skin glue can lead to less pain and speedier recovery. The final result both in functionality and looks is similar to when stitches are used. Therefore, doctors usually prefer to oversee the body healing itself when the tear is not actively bleeding (hemostatic).
However, if the tear continues to bleed or changes the natural shape of the area, treatment should be delayed if there isn’t a skilled doctor available. In such situations, a technique called ‘wound packing’ is used. This is a temporary solution to stop the bleeding where the area is filled with special material, and then a qualified doctor can review and treat it properly within 8 to 12 hours. This approach is backed up by numerous studies showing the importance of expertise in understanding the body’s anatomy and choosing the right repair strategy to help the patient recover best. Moreover, the results from one study showed a decrease in complications after delivery when experienced surgeons were involved and when the right sutures and repair methods were chosen.
An episiotomy is a minor surgery done during childbirth to make the vaginal opening larger. This is done just before the baby is born to lower the amount of blood the mother loses. It may be necessary if the delivery must be sped up, if there’s a difficulty with the soft tissues around the vagina, or to assist with a procedure to help with childbirth. There are two common types of episiotomies – midline and mediolateral. The midline episiotomy, most commonly performed in the United States, has a higher chance of severe tears. The mediolateral episiotomy is tougher to fix afterwards and can lead to more pain and blood loss after birth.
The World Health Organization and American Congress of Obstetricians and Gynecologists advise against routine episiotomy due to these potential issues. Therefore, it should only be used when necessary.
Equipment used for Perineal Lacerations
When a doctor needs to fix a vaginal tear, it’s important that they have good lighting, can clearly see the area involved, and can offer pain relief for both the examination and the repair process. For minor tears, local pain relief (anesthetic) is usually enough. For more serious tears (known as obstetric anal sphincter injuries or OASIS), a regional or general anesthetic, which blocks pain in a larger area or puts you to sleep, might be used. It’s also advised to sanitize the area around the tear with a betadine or chlorhexidine solution.
To carry out the repair, the doctor will need a variety of tools. These include surgical glue, stitches, tools to hold the needle and thread (needle drivers), clamps for holding tissue (Allis clamps), tweezers (forceps), sterile gloves, sponges, and scissors specifically made for cutting sutures. The type of stitch used depends on how severe the tear is. Stitches made from a single strand (monofilament sutures) may have a lower chance of causing an infection.
The American College of Obstetricians and Gynecologists (ACOG) suggests using a certain type and size of sutures for different degrees of tears. For first-degree tears, they recommend 2-0 or 3-0 polyglactin or poliglecaprone sutures. For second-degree tears, 2-0 or 3-0 polyglactin sutures are advised. For third-degree tears, 2-0 polyglactin or 3-0 polyglactin or polydioxanone sutures should be used. For the most severe, fourth-degree tears, 3-0 or 4-0 polyglactin or poliglecaprone sutures are recommended.
Depending on how severe the tear is, the repair might need to be done in an operating room.
Who is needed to perform Perineal Lacerations?
If you have a perineal tear, several healthcare professionals might be involved in your care. These include:
– Obstetric clinicians: These are doctors who specialize in pregnancy, childbirth, and a woman’s reproductive system.
– Family practice clinicians: These are general doctors who take care of people of all ages – from newborns to senior citizens.
– Midwife: Midwives are healthcare providers who specialize in supporting women during pregnancy, childbirth, and postpartum (the period after birth).
– Nurse Practitioner: A Nurse practitioner is a nurse with additional training to provide healthcare services similar to those a doctor provides.
– Anesthetist: This is a healthcare professional who is trained to administer anesthesia, which is the medication used to eliminate pain during medical procedures.
These healthcare professionals work as a team to ensure your best care and recovery.
Preparing for Perineal Lacerations
After giving birth the natural way, doctors always check the mother’s birth canal and the part just outside it. This is to ensure that no harm was caused during the delivery. If any severe tears are noted, doctors would perform an additional examination by hand to check the muscles around the mother’s back passage. This is important to understand the level of injury to the muscle.
Before repairing any severe tears (known as OASIS), doctors often insert a medical device called a Foley catheter. This is for urine to come out without any issues as they heal. Antibiotics are also given to prevent any chances of infection. The type of antibiotics is usually a second-generation cephalosporin, which is a common type of drug used to fight infections.
It’s also important for doctors to keep track of all the tools and materials used before and after the operation. This includes counting any surgical instruments, sponges, and stitches used during the procedure. Doing so ensures that nothing is left inside the mother’s body, which can prevent complications and speed up the healing process.
How is Perineal Lacerations performed
If a person experiences a second-degree perineal tear, which is a cut or break in the area between the vagina and anus, the procedure to fix it may involve stitching up the wound in a specific way to reduce pain and avoid the need to remove the stitches later. The stitches bring the torn skin of the vagina back together. After this part is fixed, the attention then turns to the area between the vagina and anus, making sure this area and the layers of tissue underneath the skin are properly stitched up.
The technique generally goes as follows:
- The surgeon attaches the stitching thread at the far end of the wound in the vaginal area.
- The surgeon then stitches up the layer of the vaginal area, the tissue underneath, and a strong layer of tissue between the vagina and rectum, moving from the far end of the wound to the vaginal entrance. The same stitching thread is used to fix the muscles near the vagina and the tissues just under the skin, moving from the center to the vaginal entrance.
- Finally, the surgeon ties a knot in the stitching thread behind the vaginal entrance, and then checks inside the rectum to make sure the stitching was done properly and there are no misplaced stitches.
However, if a person experiences a third or fourth-degree perineal tear, which involves injury to the muscles that control the anus, the procedure to fix it is more complicated and requires specific expertise and techniques. The focus here is on fixing the muscles that control the anus and the lining of the rectum. Once these areas are fixed, the rest of the wound is stitched up just like in a second-degree tear.
The general step-by-step process for this may include:
- The surgeon attaches the stitching thread at the far end of the wound, inside the anal and rectal area.
- They then stitch up the lining of the anal and rectal area and the tissue between the rectum and vagina. If the internal muscle that controls the anus is torn, it’s stitched back together.
- The external muscle that controls the anus is then identified and stitched back together, using different techniques depending on the severity of the tear.
- Finally, the remaining tissues are stitched back together similar to a second-degree tear, and the rectum is checked to make sure everything was repaired adequately.
After these procedures, it’s essential to monitor the patient for any issues related to anesthesia or after the surgery. On the first day after the operation, the tube used to help the patient urinate should be removed, and the patient’s ability to urinate is assessed. Cold packs, sprays or ointments for numbing, baths with warm water, and painkillers can all be used to manage pain. Any strong painkillers that can cause constipation should be avoided. It is also suggested to give medications to soften stools and get the bowels moving twice daily for six weeks after delivery. These measures help to avoid constipation and decrease the chances of the wound opening up again.
Possible Complications of Perineal Lacerations
One of the common complications after a perineal laceration, which is a tear in the area between the anus and the genitals, is bleeding. Most of the times, any bleeding can be controlled quickly with pressure and surgical repair. However, sometimes a pocket of clotted blood, known as a hematoma, can form and lead to a large amount of blood loss in a short time. Other immediate complications can include pain and the time it takes to stitch the wound, which can delay the bonding time between the mother and child.
For patients who have had surgery (OASIS repair) to treat severe tears, there’s a higher chance of getting a wound infection, or the wound opening up again (dehiscence). This can affect a woman’s physical, emotional, and sexual health. The possibility of wound complications is even higher if the repair was performed by less experienced healthcare professionals. Other things that can increase the risk of complications are smoking, being overweight, having a more severe (fourth-degree) laceration, having an operative vaginal delivery, or using antibiotics after giving birth.
Over the long term, complications like pain, urinary or anal incontinence (having trouble controlling urination or bowel movements), and delay in returning to sexual intercourse due to pain may occur. Some studies have shown that women who had an episiotomy, or a planned cut made by a healthcare professional, have worse complications than those who had natural tears. Also, flatal incontinity (inability to control the passing of gas) can sometimes last for many years after a severe perineal tear.
A significant tear in the perineal area can seriously affect a woman’s quality of life, particularly if it results in long-term problems with controlling urine or bowel movements. About 25% of women who’ve had severe tear repairs could see their wound open up again in the first six weeks after giving birth, and 20% could get a wound infection. Fistulas, or abnormal connections between different body parts, may develop in women who had unidentified or poorly healed perineal tears.
The time it takes for a woman to return to normal sexual function after a perineal injury can vary. It has been observed that the more severe the tear, the longer it takes for her to resume normal sexual activity.
What Else Should I Know About Perineal Lacerations?
Perineal trauma refers to injury in the area between the anus and the genitals, often during childbirth. This can have long-lasting effects on a woman’s life and wellbeing – mentally, emotionally, and socially. Some surveys have shown that serious injuries in this area can lead to long-term psychological stress and even cause women to withdraw from their social circles. These conditions may be difficult for women to talk about and seek help for. So, it is crucial for the healthcare providers to precisely identify and treat such injuries at the time of childbirth and also to address any issues that arise after the childbirth.
Efforts have been made to find ways to prevent perineal injuries during vaginal childbirth. However, medical professionals have not yet agreed on the best preventive measures to reduce or avoid serious perineal injuries. A method called perineal massage has shown to slightly decrease the occurrence of injuries needing stitches. The massage helps relax the perineal area, increases blood flow and stretches the tissue before delivery, reducing the chance of serious injuries. It also might reduce instances where an incision might be made to enlarge the vaginal opening for childbirth (episiotomy). This massage can be started after 34 weeks of pregnancy and performed daily until delivery.
Another preventive measure is the “hands-on” approach or perineal support, which aims to protect the perineal area and reduce the severity of injuries during childbirth. However, different studies give varied results about how much this really helps. Certain delivery positions, such as the lateral position, and timings for pushing during delivery have also been analyzed but showed no difference in the rate of perineal injuries. However, in women giving birth in the lateral position, delaying pushing rather than immediate pushing did result in more instances of delivery with an intact perineum. The use of warm compresses has been shown to decrease the risk of the most severe perineal injuries. The evidence suggests that warm compresses and perineal massage are the best methods currently known to lessen the chance of severe perineal injuries.