Vaginal and Perineal Lacerations

Midwife visits momMany ask the question can we prevent vaginal and perineal lacerations. Vaginal lacerations and tears are common in child birth, with as many as 80% of first time mothers experiencing some time of vaginal or perineal tear in childbirth.  Most often these tears occur in the perineum. They can occur in other areas such as the labia and clitoris but these are not as common.

Women experience pain differently and any type of injury to the area can cause mild-severe pain. Especially with third and forth degree tears there can be difficulty sitting, and can interfere with normal bowel and bladder functioning.

Lacerations and tears in the perineum vary in length with the smallest tear considered a first-degree laceration that only involves the skin at the perineum. A second-degree laceration involves tissue and muscles extending into the perineum and vagina. A third-degree laceration includes tears that extend into the vaginal tissue, muscle and extends to the rectum/anus. A forth-degree tear includes the vaginal tissue and muscle and extends through into the rectum/anus.

3rd and 4th degree lacerations can cause anal sphincter disruption and this can result in stool incontinence. Women that have had a 3rd and 4th degree laceration can have an impact on a women’s quality of life. It is important for women to recognize this so that they can get the help and treatment required.

Prevention

Preventing tears, there is little that can be done that will help prevent a tear during the delivery. One method that has shown some decrease in tearing is when women use perineal massage in the third trimester. For this to work it must be done several weeks prior to labor and done several times per week.

Previous 3rd and 4th degree lacerations

Unfortunately for the woman that has had a previous 3rd and 4th degree laceration she will be at risk for sustaining another one especially if there was anal sphincter disruption. The chance of getting one is approximately 4% and slightly higher still if the women has another episiotomy.

The American College of Nurse Midwives has an instruction sheet on perineal massage in preventing lacerations: Click Here

Episiotomy

episotomy with medial incision

An episiotomy is a cut that made into the women’s perineum to assist in the delivery of the baby. A healthcare provider will only perform this if there is a medical reason and it is not something that is routinely done. All episiotomy cut are considered a second degree but a concern is that that these cuts can tear into a third or a fourth degree. There are two different types of episiotomy lateral which is a straight line down and a mediolateral which is a cut mad to the side, it is usually up to the provider to determine which type of episiotomy they will be doing.

 Wound healing

Most time wound healing will be spontaneous in first degree tears and will not require suturing. Your healthcare provider will most likely suture 2nd degree, 3rdgree your healthcare provider may suture this by them selves or they may require the assistance of more experienced provider.  In the postpartum period you want to ensure a diet that will help with healing, these includes with Vitamin C, iron and protein.

Anytime there is a tear it is important the injury heals without complications. One major complication is getting infections.

There are some comfort Tips

  • The area should be washed with warm water and patted dry after bathing, voiding and bowel movements. Pads should be changed at least every three hours.
  • Use of ice or cooling pads can help in reducing swelling and pain.
  • Use a perineal bottle when going to the bathroom and gently pour some water over the site so that the urine does not sting the laceration and helps maintain cleanliness.
  • Use a sitz bath. It is only recommended that you use this after 24 hours has passed. Use either cool or warm water, whichever is most comforting and stay in the water for 20 minutes.
  • Use witch hazel, which is an astringent and can help with pain. This is usually.
  • Take pain relievers as recommended by your healthcare provider.
  • Having a bowel movement may also be painful want to avoid constipation and take a stool softener as recommended by your healthcare provider.
  • Taking over the counter mediations such as acetaminophen or ibuprofen.

 

Call your healthcare provder if you experience:

    • Fever greater than 100.4
    • Pain that gets worse or not relieved with pain medications.
    • Drainage from the tear that is yellow or green or foul smelling
    • Swelling in the area

 Available academic articles to read:

de Silva, K. L., Tsai, P. J. S., Kon, L. M., Hiraoka, M., Kessel, B., Seto, T., & Kaneshiro, B. (2014). Third and fourth degree perineal injury after vaginal delivery: does race make a difference?. Hawai’i Journal of Medicine & Public Health73(3), 80. click here

References:

American College of Obstetricians and Gynecologists (2006) ACOG Practice Bulletin No. 71: Episiotomy. Clinical management guidelines for obstetrician/gynecologists. Obstetrics and Gynecology. 107, 4, 957-962.

O’Herlihy, C. (2003, February). Obstetric perineal injury: risk factors and strategies for prevention. In Seminars in perinatology (Vol. 27, No. 1, pp. 13-19). WB Saunders.

 

 

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