Perineal trauma/pelvic floor tearing is an ongoing fear amongst women (especially first time mothers) and rightly so. I believe knowledge is power and educating women on the potential trauma and recovery can help eliminate the anxiety that's associated. So lets dive in....
What is your perineum?
This is probably part of your body you've never given much thought to or even realised where it is. Your perineum is the area between your vagina and anus, this part of your body will need to stretch and adapt during childbirth to allow delivery of your baby. This is also the area where they will cut for an episiotomy or where you may experience tearing or trauma.
What is a perineal tear?
A perineal tear is tear that affects the perineum (above) and the muscles of your perineum (pelvic floor). Women can experience varying degrees of tearing which can leave short term or long term side effects on your pelvic floor function. Tearing is graded based off the length and extent of the injury.
1st Degree: Injury to the perineal skin only.
2nd Degree: Injury to the perineum involving perineal muscles but not involving the anal sphincter.
3rd Degree: Injury to the perineum and anal sphincter
4th Degree: Injury to the perineum with complete tear of internal and external anal sphincter and lining.
Risk factors that can make you more likely to sustain a 3rd or 4th degree tear:
if this is your first baby
if you have had a perineal tear in your previous deliveries
you require forceps or vacuum to assist the delivery
if your baby weighs more than 4kgs
if your baby is posterior (their back against your back)
your babies shoulders become stuck during delivery
Reducing the risk of perineal tearing:
Whilst Pregnant:
Perineal Massage: This is done from approximately 35 weeks and can be performed by you or your partner. Always ask your healthcare provider when is the best time for you to start. It involves strong massage over the perineum to assist in softening and stretching the muscles and soft tissue. Please note this can be contraindicated in some pregnancies.
Pelvic Floor Muscle Training: Pelvic floor muscle training in pregnancy has been shown to improve muscle control, and strong flexible muscles may contribute to the optimal descent of your baby’s head during delivery. Carrying out pelvic floor exercises during pregnancy has been reported to protect new mums against a prolonged second stage of labour.
Education: Speak to your healthcare provided if you are concerned at all and ask lots of questions.
During Childbirth:
Warm Compress: Application of a warm compress to your perineum when your baby’s head is crowning to soften the soft tissue can improve its stretching ability.
Slow controlled delivery of babies shoulders and head: Consider labour and birthing positions during your second stage that will help your baby to be born slowly, and not pop out in a rush. (check out our blog on birthing positions). Utilise breathing techniques to assist a slow controlled birth of baby, without direct pushing. Use hands on technique to gently support your perineum during the birth of babies head and shoulders
Episiotomy: If you need some extra assistance (with vacuum or forceps) to deliver baby safely, utilise an episiotomy (an incision made with scissors, at an angle, at the entrance of the vagina). This can reduce the likely of a 3rd or 4th degree perineal tear during use of this equipment.
Treatment of Perineal Tearing:
Once an injury has occurred to the pelvic floor, the muscles and connective tissue no longer provide the support they previously did. Injury to the pelvic floor is often deep and cannot be seen which makes it difficult to identify at the time of birth. It is often picked up much later when women have bladder, bowel problems or prolapse that it is recognised.
At the hospital:
After labour has finished and your placenta is birthed, you're midwife or obstetrician will assess the extent of your perineal damage.
Depending on the extent of the damage will depend on what course of action will be taken.
If you experienced a 1st or 2nd degree tear, your midwife may stitch you in the comfort of your own room if needed.
If you experienced a 3rd or 4th degree tear, due to the severity you may be take to the operating room to have it surgically repaired by an obstetrician.
Following you tear you should be provided with cold compresses to help manage pain.
Once You're Home:
Seeing your Women's Health Physiotherapist is crucial between 4-6weeks to assess your scar and your pelvic floor muscle strength and control. They will then be able to provide you with a pelvic floor program to help strengthen and maintain your pelvic health.
Keeping your stitches dry and clean to prevent infection.
Managing your pain effectively with cold compresses and compression (doubling maternity pads).
Taking the pressure of your tear is important to help manage pain and swelling.
References:
Harvey, Pierce, Walter, Chou, Diamond, & Epp. (2015). Obstetrical Anal Sphincter Injuries (OASIS): Prevention, recognition and Repair. Journal of Obstetrics and Gynaecology Canada, 1131-1148.