Perineal tear

Last updated
Perineal tear
Other namesLatin: Laceratio perinei
The diagnosis and treatment of diseases of women (1907) (14597939340).jpg
Illustration of two perineal tears
Specialty Obstetrics

A perineal tear is a laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tears mainly occur in women as a result of vaginal childbirth, which strains the perineum. It is the most common form of obstetric injury. [1] Tears vary widely in severity. The majority are superficial and may require no treatment, but severe tears can cause significant bleeding, long-term pain or dysfunction. A perineal tear is distinct from an episiotomy, in which the perineum is intentionally incised to facilitate delivery. Episiotomy, a very rapid birth, or large fetal size can lead to more severe tears which may require surgical intervention.

Contents

Anatomy

In women, an anatomical area known as the perineum separates the opening of the vagina from that of the anus. Each opening is surrounded by a wall, and the anal wall is separated from the vaginal wall by a mass of soft tissue including:

A perineal tear may involve some or all of these structures, which normally aid in supporting the pelvic organs and maintaining faecal continence. [3]

Classification

Tears are classified into four categories: [4] [5]

Cause

In humans and some other primates, the head of the term fetus is so large in comparison to the size of the birth canal that delivery may result in some degree of trauma. [7] As the head passes through the pelvis, the soft tissues are stretched and compressed. The risk of severe tear is greatly increased if the fetal head is oriented occiput posterior (face forward), if the mother has not given birth before or if the fetus is large. [8]

A surgical incision on the perineum skin called an episiotomy was historically used routinely in order to reduce perineal tears. [9] However, its routine use has declined as there is some evidence it increases the severity of tears when it is not indicated. [10] A Cochrane review found that routine use of episiotomy increased the incidence of severe perineal tears by 30%. [11]

Several other techniques are used to reduce the risk of tearing, but with little evidence for efficacy. Antenatal digital perineal massage is often advocated, and may reduce the risk of trauma only in nulliparous women. [12] Hands-on techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated, but their efficacy is unclear. [13] Water birth and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing. However, this effect has never been clearly demonstrated. [14]

Prevention and treatment

Perineal protection during the birth of the head Geburtshilfe Dammschutz - Obstetrics perineal protection.png
Perineal protection during the birth of the head

Perineal protection is an obstetric measure to prevent the perineal tissue from tearing (perineal tear) during the birth of the baby's head or to keep the extent of the injury as small as possible. The midwife (or obstetrician) supports the perineal tissue with one hand as soon as the head stretches. The other hand rests on the baby's head and regulates its speed of passage (so-called head brake). At the same time, the woman giving birth is guided to push along slowly and in a well-dosed manner. This allows the head to be born slowly over the perineum, which thus has enough time to stretch. [16]

Treatment is to either let the tear heal naturally or to surgically repair it. Third- and fourth-degree tears generally require surgical repair. A Cochrane review of comparing surgical treatment with natural healing of first- and second-degree tears found no to little difference between the two treatment options. The review concluded that there was insufficient evidence to recommend either treatment option over the other for first- and second-degree tears. [1]

Prevalence

A 2008 study found that over 85% of women having a vaginal birth sustain some form of perineal trauma. [17] A retrospective study of 8,603 vaginal deliveries in 1994 found a third-degree tear had been clinically diagnosed in only 50 women (0.6%). [18] However, when the same authors used anal endosonography in a consecutive group of 202 deliveries, there was evidence of third-degree tears in 35% of first-time mothers and 44% of mothers with previous children. [19] These numbers are confirmed by other researchers in 1999. [20]

A study by the Agency for Healthcare Research and Quality (AHRQ) found that in 2011, first- and second-degree perineal tear was the most common complicating condition for vaginal deliveries in the U.S. among women covered by either private insurance or Medicaid. [21]

Second-degree perineal laceration rates were higher for women covered by private insurance than for women covered by Medicaid. [22]

Complications

First- and second-degree tears rarely cause long-term problems. Among women who experience a third- or fourth-degree tear, 60–80% are asymptomatic after 12 months. [23] Faecal incontinence, faecal urgency, chronic perineal pain, pain with sex, and fistula formation occur in a minority of women, but may be permanent. [24] The symptoms associated with perineal tear are not always due to the tear itself, since there are often other injuries, such as avulsion of pelvic floor muscles, that are not evident on examination. [25]

There are claims that sometimes the perineum is excessively repaired after childbirth using a so-called "husband stitch" and that this can increase vaginal tightness or result in pain during intercourse. [26]

Related Research Articles

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Perineum</span> Region of the body including the perineal body and surrounding structures

The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis and the coccyx, including the perineal body and surrounding structures. The perineal raphe is visible and pronounced to varying degrees. The perineum is an erogenous zone. This area is also known as the taint or chode in American slang.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Episiotomy</span> Surgical incision of the perineum and the posterior vaginal wall

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. This is usually performed during second stage of labor to quickly enlarge the aperture allowing the baby to pass through. The incision, which can be done from the posterior midline of the vulva straight toward the anus or at an angle to the right or left, is performed under local anesthetic, and is sutured after delivery.

<span class="mw-page-title-main">Postpartum period</span> Time period beginning after the birth of a child and extending for about one month

The postpartum period begins after childbirth and is typically considered to last for six weeks. However, there are three distinct but continuous phases of the postnatal period; the acute phase, lasting for six to twelve hours after birth; the subacute phase, lasting six weeks; and the delayed phase, lasting up to six months. During the delayed phase, some changes to the genitourinary system take much longer to resolve and may result in conditions such as urinary incontinence. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.

<span class="mw-page-title-main">Frenulum of labia minora</span> Anatomical feature

The frenulum of labia minora is a frenulum where the labia minora meet posteriorly.

<span class="mw-page-title-main">Perineal massage</span> Massage of a pregnant womans perineum prior to childbirth

Antenatal perineal massage (APM) or Birth Canal Widening (BCW) is the / massage of a pregnant woman's perineum – the skin and deep tissues around the opening to the vagina or, performed in the 4 to 6 weeks before childbirth, i.e., 34 weeks or sooner and continued weekly until birth. The practice aims to gently mimic the 'massaging' action of a baby's head on the opening to the birth canal (vagina) prior to birth, so works with nature, to achieve the 10 cm diameter opening without using the back of baby's head, i.e., doing some of the hard work of labour (birth) before the start of labour, making birth less stressful on the baby and mother. The intention is also to attempt to: eliminate the need for an episiotomy during an instrument delivery; to prevent tearing of the perineum during birth and in this way avoid infection, helping to keep antibiotics working into the future. This technique uses Plastic Surgeons 'skin tissue expansion' principle, to aid a natural birth.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Shoulder dystocia</span> Birthing obstruction complication

Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

<span class="mw-page-title-main">Obstetrical forceps</span> Medical instrument used for the delivery of a baby

Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse method.

<span class="mw-page-title-main">Human anus</span> External opening of the rectum

In humans, the anus is the external opening of the rectum, located inside the intergluteal cleft and separated from the genitals by the perineum. Two sphincters control the exit of feces from the body during an act of defecation, which is the primary function of the anus. These are the internal anal sphincter and the external anal sphincter, which are circular muscles that normally maintain constriction of the orifice and which relaxes as required by normal physiological functioning. The inner sphincter is involuntary and the outer is voluntary. It is located behind the perineum which is located behind the vulva or scrotum.

Sex after pregnancy is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. Injury to the perineum or surgical cuts (episiotomy) to the vagina during childbirth can cause sexual dysfunction. Sexual activity in the postpartum period other than sexual intercourse is possible sooner, but some women experience a prolonged loss of sexual desire after giving birth, which may be associated with postnatal depression. Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's body image.

<span class="mw-page-title-main">Perineoplasty</span>

Perineoplasty denotes the plastic surgery procedures used to correct clinical conditions of the vagina and the anus. Among the vagino-anal conditions resolved by perineoplasty are vaginal looseness, vaginal itching, damaged perineum, fecal incontinence, genital warts, dyspareunia, vaginal stenosis, vaginismus, vulvar vestibulitis, and decreased sexual sensation. Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the perineal muscles and the vagina; the second, to loosen the perineal muscles.

In fecal incontinence (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups.

<span class="mw-page-title-main">Pain management during childbirth</span>

Pain management during childbirth is the treatment or prevention of pain that a woman may experience during labor and delivery. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the contractions, and her outlook. Tension increases pain during labor. Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain.

Warren operation is a surgery performed to correct anal incontinence. It is done by disrupting the anterior segment of the anal sphincter, perineal body and rectovaginal septum.

The husband stitch or husband's stitch, also known as the daddy stitch, husband's knot and vaginal tuck, is a medically unnecessary and potentially harmful surgical procedure in which one or more additional sutures than necessary are used to repair a woman's perineum after it has been torn or cut during childbirth. The purpose is to tighten the opening of the vagina and thereby enhance the pleasure of the patient's male sex partner during penetrative intercourse.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. 1 2 Elharmeel, Suzan MA; Chaudhary, Yasmin; Tan, Stephanie; Scheermeyer, Elly; Hanafy, Ashraf; van Driel, Mieke L (2011-08-10). Cochrane Pregnancy and Childbirth Group (ed.). "Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention" (PDF). Cochrane Database of Systematic Reviews (8): CD008534. doi:10.1002/14651858.CD008534.pub2. hdl: 10072/42893 . PMID   21833968.
  2. ↑ Last, R. J. (1984). Anatomy Regional and Applied. London: Churchill Livingstone. p. 345. ISBN   978-0-443-02989-9.
  3. ↑ Finn, Martha; Bowyer, Lucy; Carr, Sandra; O'Connor, Vivienne; Vollenhoven, Beverley (2005). Women's Health: A Core Curriculum. Australia: Elsevier. ISBN   978-0-7295-3736-0.
  4. ↑ Taber's Cyclopedic Medical Dictionary tabers.com
  5. ↑ "Perineal Trauma: Assessment and Repair CPG". Archived from the original on 2011-10-01. Retrieved 2011-07-12.
  6. ↑ MDConsult mdconsult.com
  7. ↑ Rosenberg, Karen; Trevathan, Wenda (2002). "Birth, obstetrics and human evolution". BJOG: An International Journal of Obstetrics and Gynaecology. 109 (11): 1199–1206. doi:10.1046/j.1471-0528.2002.00010.x. ISSN   1470-0328. PMID   12452455. S2CID   35070435.
  8. ↑ Eskandar, O; Shet, D (February 2009). "Risk factors for 3rd and 4th degree perineal tear". Journal of Obstetrics and Gynaecology. 29 (2): 119–22. doi:10.1080/01443610802665090. PMID   19274544. S2CID   25535374.
  9. ↑ Caroline, Nancy L. (1977-01-03). "Medical Care in the Streets". JAMA: The Journal of the American Medical Association. 237 (1): 43–6. doi:10.1001/jama.1977.03270280045020. ISSN   0098-7484. PMID   576129.
  10. ↑ Frankman, Elizabeth A.; Wang, Li; Bunker, Clareann H.; Lowder, Jerry L. (May 2009). "Episiotomy in the United States: has anything changed?". American Journal of Obstetrics and Gynecology. 200 (5): 573.e1–573.e7. doi:10.1016/j.ajog.2008.11.022. PMID   19243733.
  11. ↑ Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul (2017-02-08). Cochrane Pregnancy and Childbirth Group (ed.). "Selective versus routine use of episiotomy for vaginal birth". Cochrane Database of Systematic Reviews. 2017 (2): CD000081. doi:10.1002/14651858.CD000081.pub3. PMC   5449575 . PMID   28176333.
  12. ↑ Seehusen, DA; Raleigh, M (1 March 2014). "Antenatal perineal massage to prevent birth trauma". American Family Physician. 89 (5): 335–6. PMID   24695503.
  13. ↑ Wang, H; Jayasekara, R; Warland, J (12 March 2015). "The effect of "hands on" techniques on obstetric perineal laceration: A structured review of the literature". Women and Birth. 28 (3): 194–8. doi:10.1016/j.wombi.2015.02.006. PMID   25773668.
  14. ↑ Nutter, E.; Meyer, S.; Shaw-Battista, J.; Marowitz, A. (2014). "Waterbirth: an integrative analysis of peer-reviewed literature". Journal of Midwifery & Women's Health. 59 (3): 286–319. doi:10.1111/jmwh.12194. PMID   24850284. Another popular method of perineal tearing prevention are childbirth exercisers such as Aniball or Epi-No. There are currently ongoing studies supporting their effectiveness.
  15. ↑ Neugeborenenmanagement
  16. ↑ Kleprlikova, Hana; Kalis, Vladimir; Lucovnik, Miha; Rusavy, Zdenek; Blaganje, Mija; Thakar, Ranee; Ismail, Khaled M. (2020). "Manual perineal protection: The know‐how and the know‐why". Acta Obstetricia et Gynecologica Scandinavica. 99 (4): 445–450. doi: 10.1111/aogs.13781 . PMID   31793662. S2CID   208609322.
  17. ↑ Kettle, C., & Tohill, S. (2008). Perineal care. Clinical evidence, 2008.
  18. ↑ Sultan AH, Kamm MA, Hudson CN (1994). "Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair". BMJ. 308 (6933): 887–91. doi:10.1136/bmj.308.6933.887. PMC   2539832 . PMID   8173367.
  19. ↑ Sultan A, Kamm MA, Hudson CN, Thomas JM, Bartram CI (1993). "Anal sphincter disruption during vaginal delivery". N Engl J Med. 329 (26): 1905–1911. doi: 10.1056/NEJM199312233292601 . PMID   8247054.
  20. ↑ Fines M, Donnelly V, Behan M, O'Connell PR, O'Herlihy C (1999). "Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study". Lancet. 354 (9183): 983–986. doi:10.1016/S0140-6736(98)11205-9. PMID   10501360. S2CID   37825406.
  21. ↑ Moore JE, Witt WP, Elixhauser A (April 2014). "Complicating Conditions Associate With Childbirth, by Delivery Method and Payer, 2011". HCUP Statistical Brief #173. Rockville, MD: Agency for Healthcare Research and Quality.
  22. ↑ Moore JE, Witt WP, Elixhauser A (April 2014). "Complicating Conditions Associate With Childbirth, by Delivery Method and Payer, 2011". HCUP Statistical Brief #173. Rockville, MD: Agency for Healthcare Research and Quality.
  23. ↑ Toglia, Marc. "Repair of episiotomy and perineal lacerations associated with childbirth". UpToDate. Retrieved 22 May 2015.
  24. ↑ Fernando, RJ; Sultan, AH; Kettle, C; Radley, S; Jones, P; O'Brien, PM (June 2006). "Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial". Obstetrics and Gynecology. 107 (6): 1261–8. doi:10.1097/01.aog.0000218693.24144.bd. PMID   16738150. S2CID   23901136.
  25. ↑ Lammers, K; Prokop, M; Vierhout, ME; Kluivers, KB; Fütterer, JJ (August 2013). "A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging". Insights into Imaging. 4 (4): 431–41. doi:10.1007/s13244-013-0261-9. PMC   3731469 . PMID   23756995.
  26. ↑ Vinopal, Lauren (17 August 2017). "Are Husbands and Doctors Conspiring to Sew New Moms Up Too Tight?". Fatherly. Retrieved 15 October 2017.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.