Definition

The perineum is a group of organs that include the genitals, surrounding skin, anus, supporting muscles, vaginal membrane, and more. Both women and men have perineums.

As part of childbirth preparation, the skin around the vagina will thin out. This area will lengthen and widen so the baby's head and body can pass through without causing injury. However, due to the baby's head being much larger than the vagina, the perineum can still tear when the baby passes through. This tear is called a perineal rupture.

Based on the location of the tear, perineal tears can be divided into two types: anterior perineal tears and posterior perineal tears. Generally, during childbirth, the more common type is the posterior perineal tear, which is a tear in the back wall of the vagina extending towards the anus. Based on the severity, perineal tears is classified into 4 degrees.

Causes

Perineal tears often occur during normal delivery. This is because the normal birthing process involves many muscles working together, such as those in the vagina, vaginal lips, cervix, and the area between the vagina and anus. Most of these tears can heal without special treatment, but in some cases, severe tears can cause prolonged pain. Some causes of vaginal tears include:

• Large body and/or head size of the baby
• Very rapid labor, giving the vaginal skin insufficient time to stretch and thin out
• Use of forceps during delivery
• Typically occurring during the first normal delivery

Risk Factor

Several factors can increase the risk of a mother experiencing perineal rupture, including:

• First natural delivery
• Use of instruments like forceps or vacuums during delivery
• Large head and/or body size of the baby (baby weight over 4 kg)
• Breech position of the baby
• Previous episiotomy. This procedure cuts the middle part of the vaginal opening to the area of the anus.
• Asian women
• Age. Older women have a higher risk of perineal tears.

Symptoms

The main symptom of perineal tears is a tear in the vagina. Based on the severity, perineal tears are classified into 4 degrees:

• Degree 1: The mildest tear, involving only the vaginal membrane.
• Degree 2: This tear is the most common during childbirth. It is slightly larger and deeper, extending through the vaginal membrane to the underlying perineal muscle tissue. Degree 2 tears usually require stitches and generally heal within a few weeks postpartum.
• Degree 3: This tear extends from the vagina, through the perineal muscle, to the anal sphincter muscle. The anal sphincter muscle is a group of muscles around the anus that control the release of gas or stool. Mothers may have difficulty controlling gas, stool, and urine.
• Degree 4: This tear is rare during childbirth. It extends from the vagina, through the perineal muscle, anal sphincter muscle, to the anus itself. This is the most severe tear, requiring surgery with anesthesia to repair and taking longer to heal compared to degree 1-3 tears. Like in degree 3, mothers may have difficulty controlling gas, stool, and urine.

Diagnosis

Perineal tears typically occur during normal delivery. The doctor will immediately recognize the tear during delivery and will provide stitches if necessary.

Management

Most mothers do not feel pain from perineal rupture within 2 weeks postpartum. Treatment depends on the severity of the tear. For degree 1 tears, stitches may not be required.

Stitching the Tear

For degree 2–3 tears, stitches will be given to address the bleeding. Stitches generally dissolve on their own within 6 weeks. For degree 4 tears, surgery with anesthesia is required to stitch the torn tissue.

In some cases with severe tears, the doctor will recommend repairing the tear, including the anal sphincter muscle. The stitching material used is typically absorbable by the body, so there is no need to remove the stitches during healing.

Also, watch for signs of infection during the healing process, such as:

• Foul odor
• Fever
• Persistent pain despite medication

Tips to Relieve Discomfort from the Tear

It is possible to experience discomfort in the weeks after delivery. Several measures to reduce discomfort include:

• Using a special tool (peri bottle) to help clean yourself after urination
• Gently patting the genital area dry with tissue (do not wipe)
• Avoiding constipation by drinking plenty of water and using laxatives
• Pain relief medication, if necessary, discussed with the doctor to ensure it is safe for breastfeeding

Complications

Currently, there is no prevention for perineal rupture. An episiotomy procedure can enlarge the birth canal opening, but it cannot fully prevent vaginal tears. Episiotomy can sometimes lead to a higher risk of 3rd-4th degree tears, so it is best to discuss the pros and cons of the procedure with the doctor.

Prevention

Currently, there is no prevention for perineal tears. An episiotomy procedure can enlarge the birth canal opening, but it cannot fully prevent vaginal tears. Episiotomy can sometimes lead to a higher risk of 3rd-4th degree tears, so it is best to discuss the pros and cons of the procedure with the doctor.

When to See a Doctor?

If you experience a tear postpartum and feel pain during sexual intercourse, consult your doctor if you experience such symptoms.

Additionally, contact your doctor immediately if you suspect infection symptoms from the tear, including fever, foul odor from the vagina, and persistent pain despite pain medication.

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