Among the thousands of fears and concerns an expectant mother has about childbirth, perineal laceration is one of them. Because of this, many women opt for a cesarean delivery precisely to avoid the risk. But why do they happen and is there a way to prevent them?
What Is a Perineal Laceration
A perineal laceration is the unintentional tearing of the skin and other soft tissue structures that, in women, separate the vagina from the anus. Perineal lacerations happen mainly in women as a result of vaginal delivery, which stretches the perineum causing fissures.
Severity of the Injury
These injuries vary greatly in severity; most are superficial and don’t require treatment. But severe lacerations can cause significant bleeding, pain, or long-term dysfunction. A perineal laceration is different from an episiotomy1, where the perineum is intentionally cut to facilitate delivery. It is estimated that 53% to 79% of women experience some type of laceration during vaginal childbirth, most commonly on the perineal body (the outer area of the vagina). Generally, most of these are simple lacerations.
Female Anatomy
In women, the anatomical area known as the perineum separates the vaginal opening from the anal opening. Each of these openings is surrounded by a wall and there are two types of muscles in the pelvic floor. One is large, wide, and double, called the levator ani, which forms a kind of net supporting the pelvic organs. The other muscles are smaller, called sphincters, which are circular muscles that help close the urethra and rectum. A perineal laceration may involve some or all these structures, which normally help support the pelvic organs and maintain fecal continence. This injury can be classified into four categories.
The Four Categories of Laceration
First-degree laceration: limited to the labia minora, the superficial perineal skin, or vaginal mucosa. Second-degree laceration: extends beyond the labia minora, the perineal skin, and vaginal mucosa to the perineal muscles and fascia (fibrous tissue where some muscles attach), but not the anal sphincter. Third-degree laceration: labia minora, perineal skin, vaginal mucosa, muscles, and anal sphincter are torn. Third-degree lacerations can be subdivided into three subcategories: 3a. Partial tearing of the external anal sphincter involving less than 50% thickness. 3b. More than 50% tearing of the external anal sphincter. 3c. The internal sphincter is torn. Fourth-degree laceration: labia minora, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are torn.
Why Does Perineal Laceration Happen?
In humans and some other primates, the baby’s head is larger than the birth canal. As the head passes through the pelvis, the soft tissues are stretched and compressed, which can lead to a perineal injury. For this reason, it is not possible to predict whether it will happen or not. Everything will depend on the moment of delivery, the size of the baby, and even the mother’s dilation and vaginal passage.
Who Is at Risk for Third- or Fourth-Degree Laceration
These severe lacerations2 can happen to any woman during labor, but are more likely in the following situations:
- During the first vaginal birth;
- In a second vaginal birth where there was already a third- or fourth-degree laceration;
- During a forceps delivery;
- In a delivery with a previous episiotomy;
- If the baby is large;
- If the baby is born in the posterior position (face up);
- Prolonged time in the pushing (expulsion) phase;
- If the distance between the vaginal opening and the anus is shorter than average.
It is also possible to lacerate in other places. Some women have tears at the top of the vagina, near the urethra (this is known as a periurethral laceration). This type of laceration is often small and may require only a few stitches or even none. These lacerations do not involve muscle, so they usually heal quickly and are less painful than perineal tears. The main complaint is a burning sensation when urinating. Less commonly, a woman may have a tear of the cervix or the labia majora (the folds of skin that cover the labia minora and the entrance to the vagina) or a deep tear of the tissue in the vaginal canal (known as a sulcus laceration).
Are There Complications After a Laceration?
First- and second-degree perineal lacerations rarely cause long-term problems. Among women who experience a third- or fourth-degree perineal laceration, 60 to 80% are asymptomatic after 12 months. Urinary and fecal incontinence, fecal urgency, chronic perineal pain, and dyspareunia (pain during sexual intercourse) occur in a minority of patients, but can be permanent. Symptoms associated with perineal laceration are not always due to the laceration itself, as other injuries, such as separation of the pelvic floor muscles (not always obvious on examination), may also cause them.
How Is Perineal Laceration Treated?
If you have suffered a laceration (or an episiotomy, or both) that requires stitches, local anesthesia is applied directly to the areas needing repair. If the laceration is severe, a stronger block is recommended. In this case, anesthesia in the vaginal walls—which have greater contact with the pubovaginal nerve—can numb the entire genital area. Afterward, the procedure consists of suturing all the layers that have been torn. After the entire process, considerable discomfort is possible; therefore, ice packs are recommended for the next 12 hours or more. If the laceration is very large, discomfort will be more intense and pain medication may be administered.
What Is Recovery Like After a Perineal Laceration?
The pain will decrease over time, but discomfort may last for three months or more.
- Urinating or having a bowel movement can be extremely painful. In this case, with medical advice you may use medications that soften the stool. It is also important to maintain a balanced, fiber-rich diet and drink plenty of fluids.
- Do not fight the urge to have a bowel movement. Holding stool out of fear of pain can cause constipation.
- Do not resume sexual activity until you have been examined by your doctor and are officially cleared.
- Avoid using suppositories and enemas.
Women with lacerations to the sphincter or all the way to the rectum are more prone to gas or fecal incontinence later. Keep your doctor informed if you experience any of these problems.
Ways to Prevent Perineal Laceration
Several techniques are used to reduce the risk of laceration during labor.
- Exercises with an inflatable balloon inside the vagina during pregnancy increase the resistance of the vaginal muscles and help prevent lacerations;
- Prenatal perineal massage is also highly recommended;
- The technique of guiding the baby’s head through the birth canal is also widely recommended, though its effectiveness is unclear;
- Water birth softens the perineum, which leads to a reduction in the rate of lacerations;
- Controlling the urge to push for a time, for example when the baby’s head is crowning;
- Warm compresses in the final stage of pushing have also been very useful for some women, reducing lacerations as the baby’s head passes through.
For women who suffer from perineal laceration, there is the option of surgical repair or correction of the resulting damage. This surgery is called perineoplasty and can be recommended by your gynecologist.
What Is Perineoplasty
Perineoplasty3 is the name of the surgery aimed at reconstructing or approximating the perineal muscles. It is generally recommended for:
- Vaginal canal widening
- Severe perineal laceration Previous surgery (episiotomy)
- Pain and discomfort during sexual intercourse
- Stenosis
- Urinary or fecal incontinence
- Scars Tissue adhesions
- Non-healing wounds after childbirth.
The majority of women seeking perineoplasty in medical offices have a history of vaginal births with laceration or episiotomy. They complain of vaginal widening, with consequent loss of sensation (lack of contact and friction during penetration), passage of vaginal flatus (air) during intercourse, absence of orgasm, in addition to urinary or fecal incontinence (loss of urine or feces) to a greater or lesser degree. The specialist will request a urodynamic study, which is an exam that evaluates the degree of incontinence, and if surgery is needed, standard preoperative tests are requested next.
How Is Perineoplasty Performed?
Under epidural or spinal anesthesia with sedation, a V-shaped incision is made on the rear vaginal wall. Any existing scar tissue or abnormal tissue connections resulting from previous lacerations, or any other injury, are removed. The pelvic organs are repositioned and the muscles are joined together by stitching. This type of surgery is done in an attempt to make the vagina “tighter.” Many women are concerned about the appearance of a scar, but there is no need to worry since the scar from this surgery will be internal, on the back wall of the vagina. Postoperative care consists of cold compresses, external vaginal pads, cleaning the area with a pH-balanced intimate soap, vaginal creams recommended by the surgeon, looser underwear, physical activity after 30 days, and sex only after six weeks. Although this is a very simple surgery, it is also quite uncomfortable in the first few days, so strong painkillers are prescribed as well as anti-inflammatories. Complications from perineoplasty are rare, but heavy bleeding, swelling, and infection may occur in the first 72 hours after the procedure. Other rare late complications include excessive stenosis or narrowing of the vagina. After the first month post-surgery, pelvic floor physiotherapy exercises are recommended to strengthen the pelvic floor muscles. Perineoplasty is considered an elective surgery. The cost ranges from R$ 1,300.00 to R$ 2,200.00 and it is covered by hospital health insurance. See also: Normal Birth Positions You Can Try