Perineal Trauma

Perineal Trauma 

Patient Information

Obstetrics Service

• Author ID: SA 
• Leaflet ref: Obs 038
• Version: 7
• Leaflet title: Perineal Trauma
• Last review: August 2022
• Expiry Date: August 2024

What is perineal trauma?

Perineal trauma is any damage to the area between the vagina and the anus (back passage) during the birth of a baby.  Tears can also occur inside the vagina and in the labia (lips of the vagina). This is not uncommon and as many as 85% of women will have some degree of perineal trauma and 60 to 70% of these women will require suturing (stitches).

How does perineal trauma occur?

Perineal trauma can occur during normal or assisted (ventouse or forceps) vaginal delivery, or is a deliberate incision (episiotomy) made by the midwife or doctor.

Who is at risk?

For many women there is no clear reason why perineal trauma occurs, however, the risk of tearing can be increased when:

• Women are giving birth to their first baby
• The baby is large – over 4kg (above 9lb)
• When instruments are used (forceps/ventouse) to deliver baby
• Labour progresses very rapidly, and the mother finds it difficult to control her pushing
• If you had a tear in a previous birth
• If the midwife or doctor performs an episiotomy (an incision in the perineum)

Can perineal trauma be prevented?

The following have been found to help with reducing the risk of perineal trauma:

• Antenatal perineal stretching and massage performed from 35 weeks of pregnancy has been shown to be beneficial for some women in preventing perineal trauma.  It involves stretching the perineum using fingers with oil lubrication for about 10 minutes every day.  Its main aim is to increase the elasticity of the perineum.
• Practising Yoga/Pilates relaxes and stretches the muscles during pregnancy.
• Episiotomy used to be considered to prevent natural tears but is not routinely practiced today as it has been proven that natural tears heal more quickly than a deliberate cut.  This is only recommended when your baby is showing signs of becoming distressed just before he/she is born, or you need forceps or ventouse delivery.

What are the types of perineal trauma?

There are many types of trauma sustained during delivery of your baby and these include the following:

• First degree tears: These are small, skin deep tears that will heal naturally and may not require suturing (stitching).
• Second degree tears: These are deeper tears affecting the muscle of the perineum and the skin and will require suturing (stitching).

First and second degree tears are more common types of perineal trauma and tend not to cause long term problems.

• Third degree tears: These are tears in the vaginal tissue, perineal skin and perineal muscles that extend into the anal sphincter (the muscles that surround the anus).
• Fourth degree tears: These tears go through the anal sphincter and the tissue underneath it (anus/rectum – the lower most part of the bowel).

Third and fourth degree tears are more serious and require suturing (stitching) of all the damaged tissues in theatre under an effective anaesthetic such as a spinal or epidural.  The doctor will undertake the suturing.  Following these types of tears you will be prescribed antibiotics and lactulose (medications to reduce the incidence of infection and help with ease of going to the toilet).

Following your discharge from the hospital, you will be sent an appointment to be reviewed in The Perineal Trauma Clinic where you will be seen by an obstetrician and a physiotherapist to check the healing process and to address any problem that you may have.

• Episiotomy: This is a deliberate cut made through the vaginal wall and perineum (an area of skin and muscle between the vagina and the anus) to make more space to deliver the baby.  It is usually performed if the baby needs to be delivered quickly, or if an assisted delivery is required.  Local anaesthetic is applied to the area prior to performing an episiotomy. An episiotomy will require suturing (stitching) by the midwife or doctor in the delivery room.

How will I know what perineal damage I have?

Following the delivery the midwife or doctor will inspect your perineum to check to see if you have sustained any damage and if so what type of damage has occurred.  They will then inform you of the type and if it needs suturing (stitching) or not. 

How is the damage repaired?

In most instances the midwife or doctor who helped you to deliver your baby will repair the damage to your perineum in the room where you delivered. You will be helped into a position where it is easy for the doctor or midwife to see what they are doing.  A local anaesthetic by injection will be used to numb the area to be sutured (stitched).  Gas and air can also help when you are having your tear sutured.

If you have sustained a third or fourth degree tear then this will be sutured in theatre under anaesthesia such as a spinal or epidural.  The suturing (stitching) is undertaken by the doctor as these tears are more complicated and require stronger pain relief.

Ideally the perineum should be sutured (stitched) within one hour of the delivery of your baby, maintaining your privacy and dignity at all times.

How do I care for my perineum following trauma/stitches?

The material used for your stitches (polysorb) is dissolvable.  This means that you will not have to have them removed.  Generally perineal trauma heals very rapidly usually within two weeks.  To aid healing consider the following:

• Washing your hands before your visit the toilet as well as after.  This helps prevent introducing infection to the area when you wipe yourself.
• It’s also important to wash hands after handling your baby and before wiping yourself to reduce the risk of catching any possible infection from the baby, in particular Group A streptococcal infection which causes a very mild infection (like a slight cold) in babies and children younger than 3 years but a very serious infection that can be life threatening in older children and adults.   It is very contagious (easy to pass on). Keeping the area clean through bathing and showering.
• Changing your sanitary protection every few hours. 
• Eating a diet containing vitamin C, protein and zinc.
• Starting pelvic floor exercises as soon as possible after birth and this will increase the blood circulation to the area.

Pain relief

The midwife and GP can advise you on appropriate pain relief options which might include:

• Taking pain killers such as paracetamol or ibuprofen to help with your discomfort.
• Applying cool gel pads to the areas from time to time for the first 24 hours.  Take care if you use ice packs as you may get ice burn. Do not put directly on your skin but wrap in a clean cloth.
• Taking plenty of rest and avoiding standing and sitting for long periods.

Going to the toilet?

The thought of passing urine can be frightening at first because of the soreness and because you can’t feel what you are doing.  Sometimes it is easier to pass urine whilst having a bath or shower or by pouring warm water over your perineum whilst going to the toilet. This will dilute your urine so that the urine doesn’t sting.  Drinking plenty of fluids will help too.

You do not need to open your bowels for a few days after the birth however, it is important that you don’t let yourself become constipated.  To avoid this you need to eat a high fibre diet and drink plenty of fluid so that your stools will pass more easily.  Your stitches will not open or break down when you pass a stool motion.

Resuming sexual relations?

This is dependent on how you feel.  There is no normal time to resume sexual intercourse.  You may feel some discomfort for the first few times during and after intercourse, using a water-soluble lubricant can help.  If pain continues you need to consult a doctor.

How do I know if there is a problem with my perineum/stitches?

In the first few days after delivery your midwife will check your perineum at each visit to make sure it is healing properly.

You are likely to experience some discomfort and pain following the birth of your baby, but this will improve.  However, you need to seek medical help if you have any concerns or any of the following symptoms:

• You develop any swelling or throbbing pain in your perineum
• Your stitches start to break down and you observe the wound gaping
• You develop fever symptoms
• You notice a smelly odour or discharge
• You develop incontinence to gas or faeces (can’t control your back passage)

If any of the above are noted, then a swab will be taken and you may be prescribed antibiotics.  You will also be given advice concerning keeping the area clean.  If re-stitching is required, which is very rare, this will be done once the infection has been treated.

What will happen in my next pregnancy?

Most wounds heal well and in your next pregnancy you may not tear or require an episiotomy.  Each birth is assessed on an individual basis by the doctor or midwife.  If you have any concerns or questions regarding perineal trauma speak to your midwife or doctor.

References

Grant A. Repair of perineal trauma.  In Effective Care in Pregnancy and Childbirth. Vol2.

Eds. Chambers I, Enkin M, Keirse M.  Oxford University Press 1989.

NICE Clinical Guideline CG190 () Intrapartum care.  Care of healthy women and their babies during childbirth.