Perineal Tears and Consequences

by Dr Shareefa Rahim
Published: Updated:
Perineal Tears & Consequences
Reading Time: 4 minutes

“Perineal” relates to anything affecting the perineum, the region between the vaginal opening and the anus for women. For a successful vaginal birth, vaginal and cervical expansion should occur slowly and the tissue should be allowed to stretch in a proper manner.

At this time, spontaneous tears may occur in rapid foetal head descent and formation of vaginal dilatation. These tears are divided into 4 degrees; most frequent one involves just the lining of the vagina and perineum (1st degree), they may extend to the vaginal muscles (2nd degree), anal sphincter complex (3rd degree) and rectum (4th degree). According to the Royal College of Obstetrician & Gynaecologists, third- or fourth- degree tears, also known as an obstetric anal sphincter injury (OASI), can occur in 6 out of 100 births for the first-time mothers and less than 2 in 100 for women who have had a vaginal birth before.

Another reason for perineal tears at birth is a controlled and properly executed episiotomy. An episiotomy is a surgical procedure where a small incision is made in the area between the vagina and anus (perineum), thereby facilitating the birth of the baby. These two main types of episiotomies are commonly practiced; Midline (from the posterior fourchette to the anus) and Mediolateral (from the hymenal ring downwards with at least a 45-degree angle). An episiotomy is performed for various reasons. A few of these may include:

  • The infant needs to be delivered without delay, as in these instances:
    • Foetal Distress during 2nd stage of labour
    • Maternal Exhaustion
    • Maternal cardiac disease
  • The delivery of a preterm infant (to reduce pressure on the foetal head)
  • There is high risk of a 3rd degree tear, or when such a tear has previously occurred.

Perineal tears during childbirth, especially third- and fourth- degree tears can cause annoying complications such as urinary or faecal/flatus incontinence and sexual discomfort.  Let us further discuss the consequences.

The effects on intimacy

According to multiple studies, a significant impact has been observed in all aspects of intimate life, such as dyspareunia (painful intercourse), lack of vaginal lubrication, difficulty reaching orgasm, vaginal bleeding or irritation after sex and loss of sexual desire.

During sexual intercourse, women rarely felt incapable of having orgasm, but they were dissatisfied with the reduced variety of sexual activities and usually felt some pain. Furthermore, their orgasms after childbirth were mostly less intense, compared to those they had before pregnancy.

Also, the amount of time prior to the initiation of an active sex life, and the regaining of reproductive health must be considered with respect to perineal tears. In general, dyspareunia is more common in patients with perineal lacerations, especially because of an episiotomy. This results in a delay coital resumption after delivery.

Due to intact perineum, patients who have had a caesarean section have an early active sex life and higher amount of intercourse than patients who have had a vaginal delivery with vaginal tear.

Faecal/Flatus Incontinence

Faecal and flatus incontinence can be either Frequency (feeling the need to use the bathroom too often) or Urgency (difficulty in holding the stool or wind when the need arises).

Faecal Incontinence tends to be commoner among women with median episiotomy than among those who gave birth vaginally with a first- or- second degree tear. The latter has a risk of faecal incontinence like women with an intact perineum. Women with incontinence of stool are more likely to also have involuntary escape of wind.

At three months post-partum, many women have better control of stool but have difficulty to hold their wind. Anal sphincter competence remains the biggest concern as Flatus incontinence can be present even 10 years after OASI. Although, faecal incontinence has a more devastating effect on quality of life than does incontinence of flatus, women with daily escape of wind have an awkward and embarrassing condition. Multiple studies have found that the lack of control over stool and wind lead to long term psychological trauma and social isolation in some women. 

Care must be taken to address post-partum problems such as painful intercourse, faecal/urinary/flatus incontinence in all women regardless, of the degree of perineal tear. Perineal trauma can have long term effects on a woman’s life and wellbeing. Some women who experience severe perineal tears suffer long term psychological trauma and social isolation. They may be embarrassed by their symptoms and therefore find it hard to discuss with their health care providers.

Ladies, do not be embarrassed about talking to a healthcare professional if you have these symptoms as support and treatment is available for you.

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