Perineal Trauma

During birth, the perineum stretches to make room for the baby and this will make the muscles and skin thinner. As the baby is born the perineum can sometimes tear. Tearing to the perineum or to the labia (the folds of skin around the vagina) is quite common and in most cases this will be straightforward and will heal very well. In a small number of women the tear will be more complicated, and will involve the muscle and the anal sphincter) the muscle that controls the passage of faeces) or the anal canal (the area just inside the anal sphincter)

What are the side-effects of perineal trauma?

Tearing of the perineum at the time of childbirth can reduce the support of your pelvic floor muscles and may result in some urinary incontinence. This trauma could also lead to some discomfort during intercourse.

What are the types of tears during childbirth?

The doctor or midwife will assess the type of tear you have sustained. This will include a detailed examination of the vagina and anus.

There are various degrees of perineal trauma:

• 1st degree tears are small, skin-deep tears on the vaginal wall, which can heal naturally or may require just a few stitches.
• 2nd degree tears are deeper tears affecting the vaginal muscles as well as the perineal skin, requiring stitches.
• 3rd degree tears involve the skin, muscles and anal sphincter.
• 4th degree tears are where the perineum has torn all the way through to the anus.

What is an episiotomy?

An episiotomy is where the midwife or doctor makes a cut into the perineum at the time of the birth of your baby. This helps the vaginal opening to become wider, allowing more space to help deliver your baby.

An episiotomy is usually a simple procedure undertaken just as your baby’s head is being born. Often local anaesthetic is used to numb the area around the vagina so you will not feel the cut being made.

An episiotomy is only made with your consent, and when the midwife or doctor feels that it would be helpful. It is more likely that you will be given an episiotomy if your baby needs to be born using forceps or suction.

What happens if my perineum tears during birth?

Although some small tears can be left to heal naturally, most tears will need to be sutured (stitched) and this will be done by your midwife or doctor soon after your baby has been born.

It is important to make sure that you are not in pain as the stitches are put in. To prevent this, you will be given an injection of local anaesthetic (pain relief) before the perineum is repaired. If you have had an epidural during your labour, this will give you pain relief.

Very occasionally, the suturing of a tear may be complicated, known as a third or fourth degree tear. These tears will need to be sutured by a senior doctor, and are usually repaired in the operating theatre.

Your midwife and doctor will explain this to you should it be necessary, and you will see a member of the hospital team again between six weeks and three months later to check that your perineum is healing well. The skin stitches start to dissolve after about 7-10 days, so they do not have to be removed by your midwife. The deeper sutures can take a few weeks before they dissolve.

The most common complication of a perineal tear or episiotomy is infection in the stitches. In rare cases this can lead to the wound re-opening. When this occurs antibiotics may be required. Sometimes when this happens it is better to let the wound heal without re-suturing.

Looking after your stitches

Your midwife will give you specific advice on hygiene, pain-relieving drugs and self-help measures, all of which will help to reduce your discomfort. However, here are some general tips to help you to feel more comfortable and help your perineum to heal:

• Take pain relief such as paracetamol. Do not wait until you are in pain, but take this on a regular basis for the first few days (no more than one to two tablets four times a day).
• Always wash your hands before and after you go to the toilet and/or change your sanitary towel, especially when you go home. You should change your sanitary towel at least every four hours. Ensure it is secured in place and doesn’t move around and cause further irritation.
• Pour warm water on your perineum when you pass urine. The warm water will dilute the urine so it won’t irritate the wound.
• Drinking plenty of water will also keep your urine diluted; this will also help reduce irritation when you pass urine.
• Pat the area dry front to back to avoid introducing germs from the rectum into the perineal and vaginal area.
• Avoid wearing tight trousers or jeans.
• Avoid standing or sitting for long periods and ensure you are comfortable when sitting to feed your baby. Try lying on your side to feed.
• Avoid perfumed soaps when washing the area. Frequent baths or bidets are soothing but staying in the bath too long may slow down the healing process.
• Begin doing gentle pelvic floor exercises as soon as you can after birth to increase your blood supply to the area and help the healing process. These exercises will also help your pelvic floor regain its tone and control. Please discuss these with your midwife.
• When you get home and have some privacy, you may find relief by lying in bed without a sanitary towel and letting your perineum ‘air dry’.

Having your bowels open

• You can safely open your bowels without any damage occurring to your perineum or stitches after birth. The first few times you have your bowels open, hold a clean pad against your perineum to protect your stitches.
• Drinking plenty of fluids and eating a well-balanced diet that includes fresh fruit and vegetables as well as fibre will help you avoid constipation.
• If you are unable to open your bowels, your midwife can give you the medicine Lactulose (a stool softener) and FybogelTM (a high fibre drink). This will help you you’re your bowels open without straining and avoid constipation.

What about sex?

It is quite safe to have sex when you feel ready but remember the need to use contraception from three weeks following the birth. The first few times you have sex use a lubricating jelly and try out different positions to find one that is comfortable for you. Don’t be surprised if it feels different.  In the first weeks and even months after the birth you may have no desire for sex and this is completely normal.

If you have any problems with your perineum, you can contact your midwife or your doctor or you can self-refer to the FMAU on telephone 028 9442 4345 for Antrim and 028 7024 6128 for Causeway.

There are things you can do to help reduce the incidence of perineal trauma and these are explained in this leaflet. These include perineal massage, optimal positioning in labour and alternative birthing positions.