Perineal tear

What's this?

A perineal tear causes tissue between the anus to tear (Anus) and back of the vagina. A perineal tear typically occurs as part of excessive stretching during the birth of a child. At some point the tissue can no longer withstand this stretching.
In addition, there can also be tears in the area of ​​the labia, the clitoris and also in the area of ​​the uterus.

Please also read: Vaginal tear - what is it and is it possible to prevent it?

Usually only weak tissue types are affected by a perineal tear, such as skin and fatty tissue, so that the muscles of most of those affected are spared.
During the birth process, the woman hardly feels the tear in the perineum. However, after the birth, when the labor has subsided, pain and bleeding usually occur. The pain occurs primarily when walking, sitting, defecating and exercising.
However, some women do not feel the pain associated with a perineal tear due to a reduced sensitivity to pain after childbirth, which is why every woman has to undergo a gynecological examination for a perineal tear after giving birth.
Permanent pain during sexual intercourse rarely occurs as a result of a perineal tear. In technical terms, one speaks of a dyspareunia.

Read more on the topic Pain in childbirth

frequency

At just under a third of all womenwho give birth naturally vaginally, a perineal tear occurs in the course of labor. Circa 13% of all women giving birth suffer a first-degree perineal tear. About 15% of women giving birth naturally have a second-degree perineal tear.
A third or fourth degree perineal tear is much rarer, they only occur in about 2% of all vaginal births.

A perineal tear is more common older mothers on. The age of the mother has an impact on the metabolism of the unborn child. Children of mothers over 35 years of age are usually larger and heavier, so that perineal ruptures are more common.

causes

A perineal tear actually only occurs in one birth. Some women also report that the intercourse caused a perineal tear, but there is no specific evidence.
If the perineum ruptures during childbirth, the baby's head or shoulders are usually torn during the expulsion. There is an increased risk of a perineal tear in a particularly large child if the child lies unfavorably during the birth process or if the birth is too fast.

If a perineal incision has to be performed during childbirth, a perineal incision that is too small can also lead to a perineal tear. The use of forceps or other aids in so-called surgical vaginal birth often causes a perineal tear.

Read more on this topic: Childbirth complications

Classification

A perineal tear can be divided into four degrees of severity. The classification is based on the extent of the tear. From the perineal tear first degree you speak when only the skin and subcutaneous tissue are affected, but the stronger muscles are still intact.
At the perineal tear second grade however, the perineum muscles are now also affected. This is a maximum of external sphincter (Sprinter anti externus muscle), with the sphincter still intact.
First and second degree perineal tears are relatively common and usually are unproblematic.

At the perineal tear third degree the external sphincter is now partially or completely affected, so that a Fecal incontinence can follow.
Is it a perineal tear? fourth degree is in addition to the perineal muscles including the external sphincter muscle Mucous membrane of the rectum (last section of intestine) affected.
A third and fourth degree perineal tear occurs much less often than a first or second degree perineal tear, as the muscles are a much firmer tissue than the skin, for example. Third and fourth degree perineal tears usually occur as part of a perineal incision or another obstetric intervention in front.

How can you prevent a perineal tear?

In principle, the female body is designed for the birth of a child and the tissue can also withstand these forces. This is mainly due to the influence of pregnancy hormones, which lead to increased elasticity of the tissue. Nevertheless, about a third of all women giving birth have a perineal tear.
Some methods of preventing perineal rupture can be recommended, especially by midwives. Preventive measures can soften the tissues and promote blood circulation.

These measures include, for example, a perineal massage during pregnancy. It ensures that the tissue is loosened and thus better prepared for a birth. The perineal massage does not have to be performed during the entire pregnancy, but is recommended for around ten minutes a day from the 36th week of pregnancy. Vegetable oil, for example, can be used as a massage oil.
In addition, warm compresses are used, which also aim to increase the elasticity of the tissue.
Sometimes a so-called birth gel is also used. It is applied in the birth canal and ensures reduced friction during the birth, so that the birth process can be shortened under certain circumstances and there is less chance of a perineal tear.

The choice of the birthing position also plays an important role in preventing a perineal tear.The supine birthing position is one of the most common childbearing positions, but it causes most perineal ruptures because the entire weight rests on the perineum. While in a birthing position in crouching, kneeling, standing or in a quadruped position, the perineum is relieved.
A water birth also lowers the risk, as the water softens the tissue and thus makes it more elastic. The water takes on the function of a dam protection. The upright birthing position in the water has proven to be best.
Furthermore, during childbirth you should not press too hard or too long in one piece. If enough breaks are taken, the dam has enough time in between to relax and stretch.

As a prophylaxis, the midwife can also use what is known as perineal protection during the birth. To do this, the midwife presses her hand against the dam to support it. With her other hand she tries to brake the child's head a little (Head brake).
Perineal protection is mainly carried out in the supine position in childbirth, as the perineum is most stressed in this position and the risk of a perineal tear is greater. However, the effectiveness of the dam protection is now controversial.

also read Perineal cut

Since a vaginal tear can also occur during childbirth, we recommend our page on: Vaginal tear during childbirth - can it be prevented?

treatment

The treatment of a perineal tear depends on the severity levels already described. First-degree perineal tears that do not affect the muscles can do without treatment. Because the skin tears heal on their own without a seam.
If there are deeper cracks, these must be sewn in layers. Care takes place in the delivery room, i.e. immediately after the birth, usually under local anesthesia. Found the birth under epidural anesthesia (PDA) instead, no local anesthesia is necessary, but the anesthesia of birth can still be used.
In the case of a second-degree perineal tear, self-dissolving sutures are used so that no sutures have to be pulled after healing.

Especially in the case of a third or fourth degree perineal tear, particular care must be taken to ensure correct treatment, as the external sphincter muscle is also affected in both degrees and therefore there is a risk of fecal incontinence if the treatment is poor.
In both cases, the sphincter muscle and the intestine are supplied first before the perineum can be sutured. If there is a complicated perineal tear, this is sometimes treated under general anesthesia.

Before treating a perineal tear, the treating gynecologist must examine various factors: Where is the tear located? Is it only the skin or the muscles too? If the muscles are affected, is the external sphincter also affected? Is the intestine also affected by the perineal tear?

Also read the article: How does the vagina change after giving birth?

maintenance

A torn perineum that has been treated must be well cared for to prevent inflammation or bleeding. Some patients are recommended one Anti-inflammatories to take to prevent inflammation of the wound or to counteract any swelling that has developed. The anti-inflammatory drug will reduce the swelling and improve blood flow so the wound can heal better. Short, lukewarm ones are good for care Hip baths. After cleaning, the wound should always be good dried off become.

bowel movement

In the first days to weeks after a perineal tear has been treated, it often occurs during bowel movements Pain and a burning sensation in the area of ​​the injury. If the injury has not completely healed, a strong pressing should be avoided during defecation so that the seams do not tear again.
Furthermore, it should be best soft food be consumed so that the stool is also soft. If the external sphincter is also affected by the perineal tear, it can up to few months take until it works properly again.
Permanent incontinence can also occur as a complication. This occurs however very rare on. To counteract functional disorders, a targeted one is suitable Training the pelvic floor muscles.

Please also read our page bowel movement

Perineal cut

In order to avoid a perineal tear during the birth or to speed up the birth process, a Perineal cut carried out. Most of the time, a perineal incision is performed based on the child's state of health in order to reduce the stress on the child during the birth. Sometimes a perineal incision is also carried out to get a Avoid perineal tear.
The pelvic outlet is enlarged by the perineal incision. However, if the perineum incision is made too small, this can also lead to a perineal tear. A perineal incision is made not infrequently carried out, but is controversial.
A perineal incision can injure Blood vessels and Nerve tracts cause bleeding and loss of sensation. If the perineum ruptures, however, blood vessels and nerves are usually spared. Later incontinence, which can occur in a perineal tear, albeit rarely, cannot be prevented by a perineal incision.
In the area of ​​later Scar of the perineal incision pain and complications can occur.

scar

As a result of the surgical treatment of a perineal tear, a scar is created after it has healed. This scar can sometimes cause discomfort. In some cases, a bulging scar forms in the vaginal area, which can cause pain. The pain can occur while sitting or walking. In very few patients, the scar can also lead to permanent pain during sexual intercourse (Dyspareunia) to lead.
Some women can develop what is known as keloid formation. This creates excess tissue around the scar tissue. Keloid formation is more common in dark-skinned people.

If the scar is thickened or hardened, a perineal massage with oils can soften the tissue. If the symptoms are pronounced, it may be necessary to remove excess tissue and sew the wound a second time.