Birth Injuries – Perineal (Vaginal) Tears

Injuries related to childbirth are common and can have a significant impact on a new mother. Tearing, for example, can occur in several areas, including on the perineum (the area between the vaginal opening and the anus), within the vagina, near the urethra (where urine comes out), or on the labia.

Perineal tears are also called vaginal tears or perineal lacerations.

There are four types of perineal tears. 

• First- and second-degree tears are tears of the vaginal tissues. These types of tears are very common and are often repaired with dissolvable sutures at the time of delivery. 
• Third- and fourth-degree tears are more severe injuries involving tearing of the vaginal tissue, vaginal muscles, and the muscles that control the anus (anal sphincter muscles). These tears are also repaired with dissolvable sutures at the time of delivery, but there is a higher risk of complications afterward, such as painful intercourse and loss of bowel control. 

Risk factors for severe third- and fourth-degree perineal tears include:

• Prolonged pushing during delivery
• Episiotomy or cut made on the perineum during delivery
• Large baby 
• Delivery position of the baby is occiput posterior, also known as sunny-side up (the baby’s head is down but is facing the mother’s front)
• Use of forceps during delivery

After a third- or fourth-degree perineal tear or another complex birth injury, our urogynecologists can help treat your symptoms and evaluate your healing. We recommend early follow-up for these injuries, within two to four weeks after delivery.

Diagnosis starts with a detailed medical history, with a focus on your recent pregnancy issues and delivery. Your urogynecologist will:

• Evaluate your pelvic floor symptoms, including your bladder and bowel function, pelvic pressure, pain, and wound healing.
• Examine your pelvic floor by visual inspection, usually performed without a speculum. Your exam may also include a rectal exam.
• Educate you about your pelvic floor anatomy.
• Discuss your plans for future pregnancies and birth.

Specialized diagnostic testing, including a 3D ultrasound, may be recommended to evaluate the pelvic floor and anal sphincter further.

Your perineum, the tissue between the vagina and anus, may be sore following delivery, particularly if you had a tear or your doctor performed an episiotomy.

We recommend keeping the area clean and dry. Additional suggestions to reduce swelling and inflammation include:

• Wrap ice packs in a soft cloth and apply to the perineum. Ice should be applied for no more than 20 minutes at a time and is most beneficial and soothing during the initial days after your delivery.
• Pour warm water over the area while urinating or to clean the area after using the bathroom. This can help minimize irritation and keep the area clean.
• Take 10-minute sitz baths (warm, shallow baths) 2 to 4 times a day until you are fully healed. A sitz bath cleanses the perineum, increases blood flow to promote faster healing, and provides relief from itching, irritation or minor pain. Dry off gently – avoid rubbing the area and irritating the perineum. While bath additives do not provide additional benefits, if you prefer to use Epson salt, add ½ a teaspoon for every 1 gallon of water. If you have pain, itching, or swelling, immediately stop taking sitz baths and contact your doctor.
• Use acetaminophen, ibuprofen or other over-the-counter pain relief medications approved by your doctor. Avoid using narcotic pain medications, when possible, which can lead to constipation.
• Many women use witch hazel pads to cool the perineum and perianal area. To make your own, soak cotton pads in witch hazel and put them in the refrigerator. Use them several times a day, disposing of each pad after one use. 
• Avoid straining during bowel movements. Ask your doctor about taking a stool softener or laxative if needed.
   

Treatment for perineal tears following childbirth is tailored to each woman’s needs and preferences. We start with the most conservative approach available, working with you to provide effective, lasting treatments that achieve your goals.

Postpartum treatments can include:

• Physical therapy to strengthen and increase control of your pelvic floor muscles and reduce pain
• Vaginal creams or ointments to reduce pain and promote healing
• Antibiotics to treat an infection
• Trigger point injections for vaginal pain
• Medications to address bladder and bowel control issues
• Pessary for pelvic organ prolapse or activity-related urinary leakage

Surgical treatment options include:

• Surgical procedures to treat urinary and fecal incontinence
• Surgical reconstruction using minimally invasive vaginal, laparoscopic and robot-assisted procedures to repair more severe injuries and pelvic organ prolapse
• Repair of obstetric fistulas

To make an appointment with a Baylor College Medicine urogynecologist, call 832-826-7500.