Perineal tear - vaginal tear / perineal laceration

- a tear in the tissue (skin and muscles) around the vagina and perineum
- a tear in the perineum after spontaneous vaginal delivery
- can involve the vagina, the labia, the cervix, and the area between the vagina and the rectum.
- Many tears will heal without treatment, but severe tears can cause prolonged pain, problems
with sex, and embarrassment.

Perineal area - perineum

- the space between the vaginal opening and anus

During delivery the perineum can tear causing different degrees of vulvovaginal lacerations:
 superficial (first-degree tear), or
 deeper, affecting the muscle tissue (second-degree tear, equivalent to an episiotomy).

Two adjacent tissues may also be damaged:

1. The anal sphincter muscle
- which is red and fleshy. A tear in this sphincter can be recognized by the loss of the anus'
radial appearance (third-degree tear).

- Repair of the muscle is essential to prevent faecal incontinence.

2. The rectal mucosa

- which is smooth and whitish, extending from the anus.

- A tear in rectal mucosa (fourth-degree tear) must be sutured to prevent anal fistula with
incontinence and infection.

Reasons/causes of perineal laceration:

 a very quick delivery - the skin hasn’t had time to stretch and thin
 If it’s your first delivery.
 The position of the baby (face-up deliveries).
 Use of forceps or a vacuum during delivery.
 A large baby (more than 8 pounds).
 If you’ve had an episiotomy.
1st-degree vaginal tear

First-degree tears -are the least severe, involving only the perineal skin — the skin between the
vaginal opening and the rectum and the tissue directly beneath the skin.
- patient might experience some mild pain or stinging during urination.
- These tears might or might not require stitches and typically heal within a few weeks
- some mild pain or stinging when you pee

- may not require stitches, although some do. They generally heal within a few weeks.

2nd-degree vaginal tear

Second-degree tears - involve the skin and muscle of the perineum and might extend deep into the vagina.
- typically require stitches and heal within a few weeks.
- usually requires stitches and will generally heal within a few weeks.

- most common
3rd-degree vaginal tear
Third-degree tears - extend into the muscle that surrounds the anus (anal sphincter).
- These tears sometimes require repair with anesthesia in an operating room
rather than the delivery room and might take longer than a few weeks to heal.
- Complications such as stool leakage (fecal incontinence) and painful intercourse are
possible. If these problems occur, talk to your health care provider.
- may need anesthesia and have it repaired in the operating room

- may take longer than a few weeks to heal

- may have complications such as leaking stool and painful intercourse.

4th-degree vaginal tear

Fourth-degree vaginal tears - are the most severe.
- They extend through the anal sphincter and into the mucous membrane that
lines the rectum (rectal mucosa).
- Fourth-degree tears usually require repair with anesthesia in an operating
room rather than the delivery room and sometimes require more specialized
repair.
- Healing also might take longer than a few weeks.
- need to be repaired in the operating room with anesthesia
- need a more specialized type of repair
- Healing may take longer than a few weeks
- may have complications such as leaking stool and painful intercourse.
Episiotomy -is a cut (incision) through the area between your vaginal opening and your anus. This area is
called the perineum. This procedure is done to make your vaginal opening larger for childbirth.

- a surgical incision intentionally to increase the diameter of the vulval outlet to facilitate
delivery.

Episiotomy Types

1. Mediolateral episiotomy
- the preferred method in other parts of the world. Both types have various advantages and
disadvantages.

1. Midline Episiotomy
- the incision is made in the middle of the vaginal opening, straight down toward the anus.

- advantages of a midline episiotomy include :

 easy repair and improved healing
 less painful
 is less likely to result in long-term tenderness or problems with pain during sexual
intercourse
 often less blood loss

- main disadvantage of a midline episiotomy is the increased risk for tears that extend into or
through the anal muscles. This type of injury can result in long-term problems, including fecal
incontinence, or the inability to control bowel movements.

1. Mediolateral episiotomy
- the preferred method in other parts of the world. Both types have various advantages and
disadvantages.

- the incision begins in the middle of the vaginal opening and extends down toward the
buttocks at a 45-degree angle.

- primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much
lower

- disadvantages associated with this type of episiotomy, including:

 increased blood loss
 more severe pain
 difficult repair
 higher risk of long-term discomfort, especially during sexual intercourse