Perineal tear

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A perineal rupture is a skin laceration and other soft tissue structure which, in women, separates the vagina from the anus. Perineal tears primarily occur in women as a result of vaginal delivery, which disrupts the perineum. Tears vary widely. The majority are superficial and require no treatment, but severe tears can cause significant bleeding, pain or long-term dysfunction. The perineal rupture differs from the episiotomy, in which the perineum is deliberately incised to facilitate labor.

Video Perineal tear

Anatomy

In a woman, the anatomical area known as the perineum separates the opening of the vagina from the anus. Each opening is surrounded by a wall, and the rectal wall is separated from the vaginal wall by soft tissue mass including:

• Anal's muscles (corrugator cutis ani, internal anal sphincter and external anal sphincter)
• Medial muscle of the urogenital region (superficial transverse perineal muscle, transverse internal perineal muscle and bulbocavernosus)
• levator ani medial muscle (puborectalis and pubococcygeus)
• Fascia perineum, which covers these muscles
• The skin on it and the subcutaneous tissue

A perineal rupture may involve some or all of these structures, which usually help support pelvic organs and maintain stool containment.

Maps Perineal tear

Classification

Tears are grouped into four categories:

• First degree: laceration limited to fourchette skin and superficial perineal skin or vaginal mucosa
• second degree tear: laceration extends beyond the fourchette, perineal skin and vaginal mucosa into the perineal and fascial muscles, but not the sphincter ani
• Third degree degrees: fourchette, perineal skin, vaginal mucosa, muscle, and anal sphincter tear; third-degree tears can be subdivided into three sub-categories:
  • 3a: partial tear from external anal sphincter involving less than 50% thickness
  • 3b: more than 50% ripped from external anal sphincter
  • 3c: ripped internal sphincter
• As high as four degrees: fourchette, perineal skin, vaginal mucosa, muscle, anal sphincter, and rectal mucosa tear

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Cause

In humans and some other primates, the fetal head is very large when compared to the size of the birth canal so that labor can cause trauma to some degree. As the head passes through the pelvis, the soft tissue is stretched and compressed. The risk of severe tearing is greatly increased if the fetal head is posteriorly oriented (front-facing), if the mother has not given birth before or if the fetus is large.

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Prevention

Some techniques are used to reduce the risk of tearing, but with little evidence for success. Antenatal perineal digital massage is often recommended, and can reduce the risk of trauma only in nulliparous women. The 'hands on' technique used by the midwife, where the fetal head is guided through the vagina at a controlled level has been widely advocated, but their efficacy is unclear. Waterbirth and water work are very popular for several reasons, and it has been suggested that by softening the perineum they can reduce the rate of rips. However, this effect has never been clearly demonstrated.

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Prevalence

A 2008 study found that over 85% of women who had vaginal births sustained some form of perineal trauma, and 60-70% received stitches. A retrospective study of 8,603 vaginal delivery in 1994 found a third degree tear had been clinically diagnosed only in 50 women (0.6%). However, when the same authors used anal endosonography in a consecutive group of 202 deliveries, there was evidence of a third grade reduction in 35% of first-time mothers and 44% of mothers with previous children. These figures were confirmed by other researchers in 1999.

A study by the Healthcare Research and Quality Agency (AHRQ) found that in 2011, the first and second perineal tears were the most common complication conditions for vaginal delivery in the United States among women covered by private insurance or Medicaid.

Second-degree perineal laceration rates are higher for women covered by private insurance than for women covered by Medicaid.

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Complications

The first and second degrees of tears rarely cause long-term problems. Among women who had a third or fourth tear, 60-80% had no symptoms after 12 months. Fecal incontinence, fecal urgency, chronic perineal pain and dyspareunia occur in a small percentage of patients, but may be permanent. The symptoms associated with perineal rupture are not always caused by the tear itself, as there are often other injuries, such as pelvic floor muscle avulsion, which is unclear on examination.

Excessive reproduction after childbirth, using so-called "husband stitches" to increase vaginal tightness, can aggravate pain during intercourse.

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References

Source of the article : Wikipedia