Taylor Rackey, CPM Candidate 

Midwifery Practice Documents 

Revised April 23rd, 2020 

Examining the Perineum After Birth 

 
Postpartum Adjustment and Timeframe Considerations 
 
After the birth and before checking for lacerations: 
● Are the birthing parent and baby stable? 
● Has the placenta been delivered? 
● Is bleeding stable? 
● Is the uterus firm, low, and midline? 
● Is the birthing parent comfortable, hydrated, and cleaned up? 
● Has the baby nursed? 
● Is the birthing parent ready to be checked? 
● Is your equipment ready to suture if needed? 
 
Timing of inspection and repair: 
● Allow the birthing parent time to bond and establish nursing 
● While waiting to examine --- have the birthing parent self-administer 1 
pellet of 30C Arnica q10-15min after the birth 
○ This will help to minimize swelling and treat s/sx of trauma 
● After the first postpartum hour, remind the birthing parent that there are 
less endorphins running through the body for natural pain relief that may 
contribute to less numbness, and therefore hurt more. 
○ Moving into the second hour, prepare the area and arrange the 
birthing parent so that a perineal exam can occur while they 
nurse/bond with their baby 
○ In ideal circumstances --- do not wait longer 6-8hrs from the time of 
injury to make arrangements to have the repair completed 
 
Postpartum Perineal Examination 
Positioning: 
● Make sure the bed is firm enough, place a bedpan upside down 
underneath a chux pad, or utilize a cookie sheet for a flat surface 
● Have the birthing parent position themselves so that their bottom is at the 
edge of the bed with their legs butterflied out to the sides 
● Sit in an adequately placed chair that is positioned squarely between the 
birthing parent’s legs 
 
Setting up for an exam: 
● Position the brightest light available so that it shines directly on the 
perineum 
● Make sure that you have all necessary equipment 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

○ Sterile gloves 
○ Sterile field 
○ Sterile lube 
○ Sterile 4x4 gauze 
○ Sterile water or hydrogen peroxide 
○ Sterile speculum (if necessary) 
○ 3 mL syringes 
○ Topical Lidocaine 
○ Injectable Lidocaine HCl 1% 
○ Suture kit (needle driver, tissue forceps, scissors, long ring forceps) 
○ 3-0, 4-0 Vicryl 
○ Dermabond 
● Explain the exam to the birthing parent, warn them that it may be painful 
and to continue breathing through it 
○ You may spray a topical lidocaine anesthetic on the perineum 
before the exam begins 
 
Bleeding: 
● Using gauze and sterile water/hydrogen peroxide, gently blot the blood 
away as you are trying to examine; do not rub the tissue, as this is painful 
and disrupts clotting 
● Locate the source of any significant bleeding and address as necessary 
 
The order of examination: 
● Beginning from the top down and from the outside in 
 
Periurethral/superficial clitoral/labial area 
● Normally not obvious until the labia are parted 
○ Labia majora lacerations are rare and are usually indicative of a 
varicose vein that ruptured; hematoma will result 
● Using your fingers to open the labia and examine the labia minora 
○ Check for tears at the top, at the clitoral hood 
■ Skid marks and skin splits may be found in the periurethral 
area or more commonly in the labia minora, the clitoral hood 
or clitoral frenulum  
● Skid marks - refers to the most superficial skin 
separation or abrasion 
● Skin splits - similar term for a slightly deeper tear 
■ These types of lacerations are too shallow to stitch and 
usually heal well; typically only painful for the first 24hrs 
○ Longitudinal labial tears may be left to heal on their own 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

■ Those that heal better if repaired include lacerations where 

the tissue peels back to form a flap of skin; tears that run 
across the width of the labia that leaves a chunk of tissue 
sagging away from the rest; tears that have a chunk of tissue 
that is nearly torn away and hanging down 
Perineum area 
● Perineal skin tears are usually obvious 
● Examine to determine how deep a tear is from the skin’s surface towards 
the central point of the perineum 
● Check the mouth of the vagina to see if the edges of any tears lie together 
or are mismatched 
● Check the introitus for any iatrogenic skin tags 
○ Usually occurs when a previous repair has been sewn too tightly 
● Be sure positively identify the most posterior end of the external apex  
○ Separate the tissues and follow any tear to its visible end; it is 
possible to have a tear go over, around, and beneath an intact or 
partially torn external mucosa and beneath an intact or partially 
torn external sphincter 
 
Vaginal floor 
● Open the vagina with one or two hands and begin by placing the length of 
an index finger against the upper side-wall of the vagina and gently press 
against the tissue 
● Slowly sweep your finger down to the posterior midline of the vaginal wall 
of both sides, noting if the color or texture of the tissue changes 
○ Feel for any cleft in the posterior vaginal wall where the appearance 
changes --- this is a laceration 
○ After identifying one side of the tear, begin to examine the tear at 
the introitus and work your way back toward the cervix to assess 
how deeply into the tissue, as well as how far back into the vagina 
any tearing extends 
○ Shallow skid marks may occur inside the vagina and can often by left 
unrepaired 
● May perform an anterior vaginal wall exam while here as well; rarely 
damaged but must be ruled out 
○ Usually can be accomplished by a visual inspection alone if you can 
see the anterior wall; if you cannot, place two fingers deep in the 
vagina, press the floor of the vagina down, out of the way and hold it 
there while inspecting the anterior wall for damage with the other 
hand 
 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

Hymenal ring 
● With rare exceptions, the hymenal ring will be torn during birth 
○ You will often note a trickle of blood during crowning 
● The hymenal ring is an important landmark when performing a repair, but 
the hymen itself does not need to be reconstructed 
 
Cervix 
● A large, purple-red, smooth mass that protrudes from the middle of the 
vaginal canal is likely the cervix (rule out hematoma, cervical polyp or 
fibroid) 
● Gently push the cervix towards the uterus, if it is extremely swollen, it may 
not retract much 
○ Gently move it to the side to perform vaginal wall inspection 
○ Have the birthing parent self-administer 30C Arnica to reduce 
swelling 
 
Cervical damage 
● Gently insert 3 or 4 fingers of the non-dominant hand, palm down, along 
the posterior wall of the vagina  
● Applying downward pressure on the posterior wall, using a long ring 
forceps, gently clamp the edge of the cervix to the first ratchet teeth 
● Slide your nondominant fingers into the posterior fornix and apply strong 
downward pressure again 
● Insert another ring forceps to grasp the posterior lip of the cervix at 6 
o’clock 
● Leave each forceps in place, apply slight traction to them and use the 
handles to move the cervix to one side of the introitus, this will pull the 
cervix over to one side so that you can inspect it. 
 
Anal sphincter 
● Visually inspect the anal sphincter 
○ Carefully assess the distance between the introitus and the anterior 
anal margin 
■ There should be a normal amount of skin between them 
○ Study the corrugator cutis ani; it should be evenly puckered all 
around the anal circumference  
● Perform a digital exam  
○ Place your finger at the introitus of the vaginal, press the pad of 
your finger down firmly and ask the birthing parent to tighten their 
sphincter to check for integrity 
 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

Assigning a degree of damage 

First degree:  
● Involves the vaginal epithelium or perineal skin only  
● The tear is shallow at each apex and does not involve perineal muscles 
● This type of laceration occurs most frequently 
● Include very minor damage (such as abrasions, skid marks, and skin splits), 
many of which do not require repair 
 
Second degree:  
● Involves the muscle of the perineum 
○ Extends through the muscle fibers of the perineal body but does not 
involve the anal sphincter 
 
Third degree: 
● Involves injury to one or both of the anal sphincters 
○ 3A - ​a tear that involves less than 50% of the thickness of the 
external sphincter 
○ 3B - ​a tear that involves more than 50% of the thickness of the 
external sphincter 
○ 3C - ​a tear that involves both the external and internal anal 
sphincters 
 
Fourth degree: 
● Includes third degree damage as well as disruption of the anal mucosa  
○ Tears that involve only the anal mucosa with an intact anal 
sphincter complex (buttonhole tear) should be classified as a fourth 
degree tear with the actual injured parts described in detail 
 
Labial: 
● Skid marks and skin splits may be found in the periurethral area or more 
commonly in the labia minora, the clitoral hood or clitoral frenulum  
○ Skid marks - refers to the most superficial skin separation or 
abrasion 
○ Skin splits - similar term for a slightly deeper tear 
 
Cervical:  
● Tears can occur at any point around the os, often on the sides 
● Typical cervical lacerations present as longitudinal (vertical) splits at 3 or 9 
o’clock, which extend from the edge of the cervical lip towards the uterus 
○ Cervical tears less than 1cm in length can be left to heal on their own 
 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

Standard of Care - Suturing Recommendations: 

● Ultimately, the decision is the birthing parents and requires 
thorough shared decision making and informed consent around the 
lacerations found 
● Labial tears can usually be left to heal on their own unless they are 
deep or form a flap, or a dangling chunk of skin 
● Shallow skid marks cannot be sutured due to not being deep 
enough 
● Many midwives do not suture first degree lacerations if the birthing 
parent has good postpartum support and can stay in bed with their 
legs together for 2-3 weeks 
● Second degree lacerations involving muscle should be carefully 
considered if choosing to not suture, as this is a popular practice 
but does not carry much evidence-based research. 
○ Most second degree lacerations have significant muscle 
involvement and are unlikely to heal well unless approximated 
with sutures 
● Third and Fourth degree lacerations are out of an LDM’s scope of 
practice in the state of Oregon and require transfer to a higher level 
of care 
 
Considerations for suturing 
● The birthing parent wants sutures 
● Concern for good cosmetic repair 
● Little postpartum help and the birthing parent will be on their feet a lot 
● Poor nourishment or poor health 
● The wound is ragged or oddly shaped 
● The edges of the wound do not approximate when the birthing parent’s 
legs are together 
● The wound is bleeding excessively 
 
Considerations for not suturing 
● The birthing parent refuses/declines sutures  
● Ongoing support at home, managing to stay in bed for 2-3 weeks and 
avoiding stairs for up to 4 weeks 
● The tear is very short and shallow throughout 
● The edges are short and lie together without assistance 
● The tear is along an old scar that was painful 
● Rectal and anal sphincters are intact 
 
Taylor Rackey, CPM Candidate 
Midwifery Practice Documents 
Revised April 23rd, 2020 

References: Frye, A. (2010). Healing passage: a midwife's guide to the care and 
repair of the tissues involved in birth (6th ed.). Portland, Oregon: Labrys Press.