Among the thousands of fears and concerns of a pregnant woman regarding childbirth , is perineal laceration. As a result, many women opt for cesarean delivery precisely to avoid taking risks. But why do they occur and is there a way to avoid them?
What is Perineal Laceration
Perineal laceration is an unintentional tearing of the skin and other soft tissue structures that, in women, separate the vagina from the anus. Perineal lacerations occur mainly in women as a result of vaginal delivery , which stretches the perineum, causing fissures.
Severity of Injury
These injuries vary greatly in severity, most are superficial and do not require treatment. But severe lacerations can cause significant bleeding, pain or dysfunction in the long run. A perineal laceration is different from an episiotomy , in which the perineum is intentionally cut to facilitate delivery.
It is estimated that 53% to 79% of women experience some type of laceration during vaginal delivery, most commonly on the perineal body (outer side of the vagina). Generally, most of them are simple lacerations .
In a woman, the anatomical area known as the perineum separates the opening of the vagina from the opening of the anus. Each of these openings is surrounded by a wall and there are two types of muscles in the pelvic floor .
One is large, wide and double, called anus elevator, which forms a kind of network on which the pelvic organs rest. The other muscles are smaller, called sphincters, which are nothing more than circular muscles that help close the urethra and rectum.
A perineal laceration can involve some or all of these structures, which normally help support the pelvic organs and maintain fecal continence. This injury can be classified into four categories.
The four categories of laceration
First degree laceration: limited to the labia minora, superficial perineal skin or vaginal mucosa.
Second degree laceration: extends beyond the labia minora, perineal skin and vaginal mucosa to perineal muscles and fascia (fibrous tissue in which some muscles are attached), but not the anal sphincter.
Third degree laceration: small lips, perineal skin, vaginal mucosa, muscles and anal sphincter are torn. Third degree lacerations can be subdivided into three subcategories:
3a. partial shredding of the external anal sphincter involving less than 50% thickness.
3b. greater than 50% tear of the external anal sphincter.
3c. the internal sphincter is torn.
Fourth degree laceration: small lips, perineal skin, vaginal mucosa, muscles, anal sphincter and rectal mucosa are torn.
Why Perineal Laceration Happens
In humans and some other primates, the baby’s head is larger than the birth canal . As the head passes through the pelvis, the soft tissues are stretched and compressed, which can result in injury to the perineum.
So there is no way to predict whether it will happen or not. Everything will depend on the time of delivery, the size of the baby and even the woman’s vaginal passage and dilation.
Who is at risk of third or fourth degree laceration
These severe lacerations can happen to any woman during labor , but they are more likely in the following situations:
- In the first vaginal delivery;
- In a second vaginal delivery where a third or fourth degree laceration has already been obtained;
- In forceps delivery ;
- In a delivery where there has already been a previous episiotomy ;
- If the baby is big;
- If the baby is born in the posterior position (face up);
- For staying for a long time in the expulsion phase;
- If the distance between the vaginal opening and the anus is less than average.
It is also possible to tear in other places. Some women lacerate the top of the vagina, close to the urethra (this is known as a periurethral laceration ). This type of laceration is often small, and will only need a few stitches or even none at all.
These lacerations do not involve muscle, so they tend to heal quickly and are less painful than perineal lacerations. The main complaint is a burning sensation when peeing .
Less commonly, a woman may tear the cervix or the labia majora (the folds of skin that cover the labia minora and the entrance to the vagina) or deeply tear the tissue of the vaginal canal (known as groove laceration ).
Are there any complications after the laceration?
First and second degree perineal lacerations rarely cause long-term problems . Among women who experience a third or fourth degree perineal laceration, 60 to 80% are asymptomatic after 12 months.
The urinary and fecal incontinence, fecal urgency , chronic perineal pain and dyspareunia (pain during intercourse) occurs in a minority of patients, but may be permanent. The symptoms associated with perineal laceration are not always due to the laceration itself, since other injuries, such as the separation of the pelvic floor muscles, which are not evident in the exams, can also cause them.
How is perineal laceration treated?
If you have suffered a laceration (or an episiotomy, or both) that requires stitches, local anesthesia is applied directly to areas that need repair. If the laceration is severe, a larger block is advisable.
In this case, anesthesia on the walls of the vagina, which have greater contact with the pubovaginal nerve, can numb the entire genital area. Soon after, the procedure is performed that consists of suturing all the layers that are lacerated.
After all this process it is possible that there will be great discomfort, therefore, ice packs are indicated for the next 12 hours or more. If the laceration is very large, the discomfort generated will be much greater and pain medications may be administered .
How is recovery after a perineal laceration?
The pain will subside over time, but the discomfort can last for three months or more.
- Peeing or pooping can be extremely painful. In this case, with medical advice, it is possible to use medications that soften the stool. It is also important to maintain a balanced diet, rich in fiber and drink plenty of fluids.
- Do not fight the urge to evacuate. Arresting stools for fear of pain can cause constipation.
- Do not have sex until you can be reexamined by the doctor and you are discharged.
- Avoid using suppositories and enemas.
Women with lacerations in the sphincter or all the way to the rectum are more likely to have gas or stool incontinence later. Keep your doctor informed if you suffer from any of these problems.
Ways to Prevent Perineal Laceration
Several techniques are used to reduce the risk of laceration during labor.
- Exercises with an inflatable balloon inside the vagina during pregnancy increase the resistance of the musculature of the vagina and avoid lacerations;
- Prenatal perineal massage is also highly recommended;
- The technique of guiding the baby’s head through the birth canal is also widely advocated, but its effectiveness is unclear;
- Water birth softens the perineum, which causes a reduction in the rate of laceration;
- Control the urge to push for a time, when the baby’s head is crowning, for example;
- Hot compresses in the last stage of expulsion were also very useful in some women, reducing lacerations through the baby’s head.
For women who suffer from perineal lacerations, there is the option of a surgical procedure to correct or repair the damage caused. This surgery is called perineoplasty and can be indicated by the gynecologist.
What is Perineoplasty
Perineoplasty is the name of the surgery that aims to reconstruct or approximate the muscles of the perineum. In general it is indicated because of:
- Enlargement of the vaginal canal
- Severe perineal laceration Previous surgery (episiotomy)
- Pain and discomfort during intercourse
- Urinary or fecal incontinence
- Scars Tissue adhesions
- Non-healing wounds after delivery.
Most of the women who arrive at the doctor’s offices for Perineoplasty have a history of vaginal deliveries with laceration or episiotomy.
They complain of vaginal enlargement, with consequent loss of sensation (lack of contact and friction on penetration), elimination of vaginal (air) flatus during sex, absence of orgasm, in addition to urinary or fecal incontinence (loss of urine or feces) to a greater or lesser degree.
The specialist will request a urodynamic study, which is an exam capable of assessing the degree of incontinence and if it is a surgical case, the usual preoperative exams are requested next.
How is Perineoplasty performed?
Under epidural or spinal anesthesia with sedation , a V-shaped incision is made in the back wall of the vagina. Any existing scar tissue, abnormal tissue fixations that have resulted from previous lacerations, or any other type of injury are removed.
There is the repositioning of the pelvic organs and the joining of the muscles by a seam . This type of surgery is done in an attempt to make the vagina “tighter”.
Many women are aesthetically apprehensive about the scar, but there is nothing to worry about as the scar from this surgery will remain internally on the back wall of the vagina.
Postoperative care consists of cold compresses, external vaginal absorbent, cleaning the area with intimate soap with balanced Ph, vaginal creams indicated by the surgeon, looser underwear, exercise after 30 and sexual intercourse only after six weeks.
Despite being a very simple surgery, it is also a very uncomfortable surgery in the first days, so very strong painkillers are prescribed , as well as anti-inflammatory drugs .
Complications for Perineoplasty are rare , but heavy bleeding, swelling and infection can occur within the first 72 hours of the procedure. Other rare late complications are excessive stenosis or narrowing of the vagina. After the first month of surgery, physiotherapy exercises are indicated to strengthen the pelvic floor muscles.
Perineoplasty is considered an elective surgery. Its value ranges from R $ 1,300.00 to R $ 2,200.00 and is covered by the hospital health plan.
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My name is Dr. Alexis Hart I am 38 years old, I am the mother of 3 beautiful children! Different ages, different phases 16 years, 12 years and 7 years. In love with motherhood since always, I found it difficult to make my dreams come true, and also some more after I was already a mother.
Since I imagined myself as a mother, in my thoughts everything seemed to be much easier and simpler than it really was, I expected to get pregnant as soon as I wished, but it wasn’t that simple. The first pregnancy was smooth, but my daughter’s birth was very troubled. Joana was born in 2002 with a weight of 2930kg and 45cm, from a very peaceful cesarean delivery but she had already been born with congenital pneumonia due to a broken bag not treated with antibiotics even before delivery.