What are perineal tears?
The perineum is the skin between the vagina and the anus. The skin often tears during vaginal deliveries. Perineal tears are graded 1-4 where 1 is the smallest and 4 is the largest.
Grade 1 Tears include only the skin of the perineum.
Grade 2 Tears include the skin of the pelvic floor muscles and the perineal skin.
Grade 3 Tears include the anal sphincter complex. A sphincter is a circular-shaped muscle, when these muscles are active, they close together. The anal sphincter complex comprises two (2) muscles that when active, keep your stool inside your body. Grade 2 tears can be longer than Grade 3 Tears. The grading is only indicative of the structures they affect.
Grade 3a affects less than half of the external anal sphincter.
Grade 3b affects more than half the anal sphincter.
Grade 3c also includes the internal anal sphincter.
Grade 4 Tears affect all the above structures as well as the anal mucosa.
What happens if I get a Grade 3 or 4 Tear?
Ouch! Don’t worry. It is rarely as bad as you probably imagine. Your anal sphincter can recover from tears. It normally means that you might have to wipe a bit more carefully and make sure to have formed but soft stools while you are retraining your anal muscles with a pelvic health physiotherapist.
If you get a Grade 3 or 4 Tear, your doctor will stitch up the tear. The best practice is for this to occur in the operating theatre as the doctor will have more light than at your bedside. The sooner this is done, the better, as there will be less time for your body to grow scar tissue. The less scar tissue, the better your body will be able to close those sphincters. If you do have to go to the theatre, you might need to be away from your little one for a few hours, so make sure you organise for them to be with someone you trust during this time.
What is an episiotomy?
An episiotomy is a small cut made in the perineum from the back of the vagina on an angle to one side. Episiotomies are usually only performed in specific circumstances such as when instruments such as kiwi cup forceps are required or if the baby needs to be birthed quickly. Episiotomies are also sometimes performed if it looks like the tear is towards the anus. The theory being that if the tissue is cut at an angle, there is less likely to be a tear through the anal sphincter.
Am I at risk?
85% of births result in some kind of vaginal or perineal tear, with tears becoming less likely the more children you have. About 6% of first-time deliveries result in Grade 3 or 4 Tears, decreasing to 2% on all subsequent births.
Quick Tips
If you are worried about birth-related perineal tears, you can try perineal massage in the lead up to your labour. It is safe to begin perineal massage 35 weeks into your pregnancy. To start perineal massage, find a comfortable position lying on your back with your knees bent up (you might want to prop up your left hip with a towel). Some ladies like to do it in the bath. If you have a partner, you can also ask them to help you. Make sure that your nails are short, your hands clean, and that you have some kind of body-safe lubricant before you begin.
The best technique is to start by putting your thumbs next to each other and nails together. Use gentle pressure to place the tip of your thumbs into the vaginal opening, pressing downwards until you find the bottom and back of the vagina. Press downward gently so your hands move closer to the bottom, use your thumbs to draw 2 outward circles maintaining this direct of pressure. You may feel strong stretching or an itching sensation while you are doing this. Do not press hard enough to cause pain. Doing this once or twice a week in the later part of your pregnancy can help improve the elasticity of the perineum and reduce the risk of tearing.
If you choose to wax or shave, ensure that you protect the skin by doing so carefully, and by cleaning and moisturising the skin well. Avoid using scented soaps, moisturisers, or scented sanitary products as these can irritate the weakened skin.
Already managing a tear?
If you have already sustained a tear, try to keep the wound clean and dry. Sitting on a doughnut pillow can make sitting more comfortable in the weeks following the injury. Alternatively, you could sit on a folded towel 4 times lengthways, then rolled into a U shape to take the pressure off the area. As the scar becomes stronger, you will need to start doing some scar tissue massage to ensure that normal sensation and elasticity return to the tissues. This is something a pelvic health physiotherapist can guide you through.
Reference List
Goh, R., Goh, D. and Ellepola, H. (2018) ‘Perineal tears – A Review’, Australian Journal of General Practice, 47(1–2), pp. 35–38. doi:10.31128/afp-09-17-4333.
