Almost all women will have bruising or grazes after a vaginal birth, creating a sore, stinging sensation, but these don’t require any medical treatment. Tearing, however, might need to be repaired. This all depends on the degree of the tear, and how it affects the surrounding tissue and muscles.
How does it happen?
Although the vagina stretches during labour, the pressure of the baby moving through the pelvis can strain the skin and underlying muscle until it tears.
In other cases, a midwife or obstetrician may perform an episiotomy to cut the perineum if the baby is unable to pass through, or if forceps or a ventouse need to be used. This will be done while a woman is under a local anaesthetic or has had an epidural.
When the skin in the genital area tears during a vaginal birth, it can be in a number of different areas:
• between the vagina and anus (the perineum)
• on the inner vaginal walls
• on the outer vagina (on the labia, clitoris or at the top of the vagina)
• in the cervix (although this isn’t common).
There are several different degrees of tearing:
• 1st degree: A small tear between in the perenium, involving the skin only, requiring no stitches or only one or two.
• 2nd degree: Tearing further into the perineum, through the skin and into the pelvic floor muscles (similar in depth to the cut that is made for an episiotomy). Some stitches are usually needed to help mend the pelvic floor muscles, which can be done by a midwife or an obstetrician.
• 3rd degree: This is a tear that affects even more of the pelvic floor muscles that extend into the anal sphincter. It will require more extensive stitching by an obstetrician while under a local anaesthetic or an epidural.
• 4th degree: This is when a tear extends completely from the vagina to the rectum, so that the whole perineum is torn. It requires suturing in a theatre by an obstetrician or bowel surgeon, under anaesthetic or an epidural.
Internal or external vaginal tears can occur with perineal tears, or on their own, and might also require stitches depending on how deep they are. Cervical tears will need to be fixed in surgery as well.
What are the risk factors?
There are a few factors that can increase your chances of tearing during labour, including the following:
• being a first time mum, because the pelvic floor muscles are tighter than in later pregnancies
• having a large baby
• when a baby is in an unusual position, face up instead of face down, or breech with their buttocks closest to the vagina
• having a very long labour, or when complications arise (such as shoulder dystocia) which require forceps or ventouse, and an episiotomy
• having a third or fourth degree tear in a previous birth.
What's the treatment?
The main reason for repairing tears is to bring the different layers of tissue together to optimise healing and prevent excessive blood loss. Women who have third or fourth degree tearing are also at a small risk of developing fistulas, which are small holes between the inner vagina and rectum, which can require additional surgery,
Dissolving stitches are almost always used. Once the tears have been stitched up, pain medication and antibiotics might be prescribed. The area will need to be kept clean to avoid infection, including changing pads in the first few weeks when bleeding is still occurring.
Stitches usually heal within a week, and dissolve within a month or so. While they do, try the following things to ease the discomfort:
• use a urinary alkaliniser to make urine less acidic and laxatives to soften stools, so it hurts less to go to the toilet
• urinate standing up in the shower so less urine touches the vagina. Women who have third or fourth degree tears may have a catheter inserted for a few days until they recover.
• use ice to soothe swelling
• sit on a doughnut pillow (the same ones used for people with haemorrhoids)
• drink plenty of water to prevent constipation.
You should speak to your doctor if the area becomes inflamed, starts smelling funny or has a strange discharge, or if you have no control over your bowels.
How can it be prevented?
Some people believe doing perineal massage or holding warm compresses against the perineum throughout the third trimester help to stretch the skin. Doing pelvic floor exercises during the whole nine months of pregnancy could also help with muscle tone so tearing is less likely to happen. Some women might also choose to use a special device which assists in stretching the perineum during the last few weeks of pegnancy, called an Epi-No.
Women who have had third or fourth degree tearing in a previous pregnancy will have a detailed and personalised discussion with their doctor about how subsequent births will be managed.
Facts verified by Dr Andrew Zuschmann. Dr Andrew Zuschmann is a Miranda-based fertility specialist, obstetrician and gynaecologist.