About 80% of all women that give birth vaginally will experience a tear to their perineum and/or perineal skin. This can include your vagina, labia and/or anus.
Both midwives and doctors have been trained on how best to prevent a tear during birth, however, they can still occur. There are four grades of tear that can happen, with a fourth-degree tear being the most severe. An episiotomy is a procedure that may be used to widen the vaginal opening in a controlled way. In this article, we will describe the different kinds of tears that can occur. Therefore, you will know what to expect in terms of healing and recovery, and complications.
What is a perineal tear or laceration?
A tear occurs during birth and can emerge in the skin, mucous membranes, or muscle tissue. Most tears usually heal without complications but when a tear does not heal as expected, difficulties can emerge. These can cause long lasting issues for the woman.
All tears, except first degree, occur in the perineum. Our perineum is a lot like a hammock, supported by different muscles. These muscles support our abdomen. When the baby passes through the pelvic canal and is being born, these muscles stretch to more than three times their length. These particular muscles have the ability to stretch in a way that other muscles in our body do not possess. However, this does not mean that the perineum does not suffer trauma during the stretch. Other similar muscle trauma includes sports injuries that need treatment and recovery. The same applies to birth and after the pregnancy. The muscles need time to recover even if they remain intact and do not suffer a tear.
First-degree perineal laceration or tear
A first-degree tear is the least severe of all tears. It is superficial and occurs in the skin or the mucus membrane. This kind of tear is not always visible and usually heals better on its own. If this kind has occurred close to another first-degree tear, a stitch or two may be applied to ensure healing in a correct manner and prevent the tear from merging. Sometimes these kinds of tears can occur close to the urethra. A stitch may be applied to avoid pain when peeing after birth and expedite healing.
Second-degree perineal laceration or tear
A second-degree tear is the most commonly seen tear during childbirth. The tear is slightly bigger here, extending deeper through the skin into the muscular tissue of the vagina and perineum. This includes mucus membrane, skin, and muscle tissue in the perineum. This tear requires stitches to heal properly. Stitches for second-degree tears will usually be performed in the room where you gave birth.
It is worth remembering that a second- degree tear is also a muscle injury. Therefore you may feel more swelling and discomfort in the area. Initially applying ice packs can minimize swelling and pain. After the first day, Warm sitz bath can be very helpful in managing the pain and encouraging the healing process. The stitches usually dissolve on their own within six weeks and do not require to be removed by your healthcare provider.
Third-degree perineal laceration or tear
A third-degree tear is much deeper. This type of tear involves injury to the skin and muscular tissue of the perineal area, as well as damage to the anal sphincter muscles. These muscles control your bowel movements. This type of tear requires repair with stitches in layers under epidural or local anesthesia such as lidocaine.
A fourth-degree perineal laceration or tear
This is the least common type of tear during childbirth. Extending from the vagina, through the perineal area and anal sphincter muscles and into the rectum, this injury is the most severe type of tear. This is usually repaired by a physician.
Severe Perineal laceration or tears
Severe Lacerations or tears such as third or fourth degree affect 4% of all the women giving birth today. Fortunately, they are not common. Most women feel relief from any pain caused by a vaginal tear in about two weeks. If your tear requires stitches, they will dissolve within six weeks as well. You will not need to go back to your healthcare provider’s office to have your stitches removed or receive any additional treatment for the tear/repair unless you experience signs of infection. These can include:
- A foul-smelling discharge.
- A fever.
- Pain that doesn’t go away even with medication.
Some women experience pain with sex, leaking urine, gas or feces after having a tear. If you experience any of these complications after six weeks, talk to your healthcare provider. It is worth noting that about 80% of the affected women will be free from symptoms after 12 months.
Recommendations for a few things you can do to help ease perineal tear/repair discomfort. These tips work with each type of tear:
- Cold - for the first few days a chilled sanitary pad can help with the pain and combat swelling. Use it for about 10-20 minutes at a time to not risk frostbite.
- Pain relief - Tylenol in combination with other NSAID such as Advil can be used to combat pain. Only use prescription narcotics if you truly need them as they can have negative effects on bowel movements and cause constipation. Your midwife and/or obstetrician can discuss pain management with you.
- Use a peri-bottle (a squirt bottle) to wash yourself clean after using the bathroom.
- Gently pat yourself dry with toilet paper instead of wiping.
- Avoiding constipation by drinking lots of water and using stool softeners.
- Lay down and sit in a way that decreases the pressure on the perineum, try to lay on your side when you breastfeed, try not to sit up too much.
- Pelvic floor exercise - you can do pelvic floor exercises if it feels comfortable but you should attend follow-up and rehabilitation sessions at a physiotherapist.
What should I expect if I end up with perineal tears or laceration?
Most perineal laceration or tears during childbirth that get a diagnosis, stitched, and heal correctly will not cause any trouble long term. With consent, your midwife will examine your perineum for any trauma. This will include offering to insert one gloved finger inside your rectum to inspect for any trauma. This can be done with pain relief and must always be with consent.
If you experience severe pain, leakage, or any other kind of discomfort that is not getting better in a few days, you need to contact your healthcare provider. You are the one that determines when and if you need help. Some complications may need further surgical repair and some can be resolved with rehabilitation. The most important thing is that you and your complaints get taken seriously.
Sources: - Goh R., Goh D. & Ellepola H. (2018). Perineal tears – A review. AGP. Jan-Feb (47). DOI:0.31128/AFP-09-17-4333 - Lindberg I., Persson M., Nilsson M., Uustal E. & LIndqvist M. (2018) 'A worse nightmare than expected' - a Swedish qualitative study of women's experiences two months after obstetric anal sphincter muscle injury. Midwifery. Jun (61). DOI: 10.1016/j.midw.2018.02.015 - Lindberg I., Persson M., Nilsson M., Uustal E. & LIndqvist M. (2020) "Taken by surprise" - Women's experiences of the first eight weeks after a second degree perineal tear at childbirth. MIdwifery. Aug (87). DOI: 10.1016/j.midw.2020.102748 - Läkartidningen. (19 november 2019). Abdominell rektusdiastas kan ge funktionella besvär - Indikation för behandling måste förtydligas. https://lakartidningen.se/klinik-och-vetenskap-1/artiklar-1/rapport/2018/11/abdominell-rektusdiastas-kan-ge-funktionella-besvar/ - Socialstyrelsen. (20 maj 2018). Komplikationer efter förlossning- Riskfaktorer för bristningar, samt direkta och långsiktiga komplikationer. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2018-5-20.pdf