PERINEAL TEAR

In obstetrics, a perineal tear is a spontaneous (unintended) laceration of the skin

and other soft tissue structures which, in women, separate the vagina from the
anus. Perineal tears mainly occur in women as a result of vaginal childbirth, which
strains the perineum. Tears vary widely in severity. The majority are superficial
and require no treatment, but severe tears can cause significant bleeding, long-term
pain or dysfunction. A perineal tear is distinct from an episiotomy, in which the
perineum is intentionally incised to facilitate delivery.

Anatomy
In a woman, an anatomical area known as the perineum separates the opening of
the vagina from that of the anus. Each opening is surrounded by a wall, and the
anal wall is separated from the vaginal wall by a mass of soft tissue including:
 The muscles of the anus (corrugator cutis ani, the internal anal sphincter and
the external anal sphincter)
  The medial muscles of the urogenital region (the superficial transverse
perineal muscle, the deep transverse perineal muscle and bulbocavernosus)
 The medial levator ani muscles (puborectalis and pubococcygeus)
 The fascia of perineum, which covers these muscles
 The overlying skin and subcutaneous tissue[1]
A perineal tear may involve some or all of these structures, which normally aid in
supporting the pelvic organs and maintaining faecal continence.[2]

Classification
Tears are classified into four categories:
 First-degree tear: laceration is limited to the fourchette and superficial
perineal skin or vaginal mucosa
 Second-degree tear: laceration extends beyond fourchette, perineal skin and
vaginal mucosa to perineal muscles and fascia, but not the anal sphincter
 Third-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, and
anal sphincter are torn; third-degree tears may be further subdivided into
three subcategories
o 3a: partial tear of the external anal sphincter involving less than 50%
thickness
o 3b: greater than 50% tear of the external anal sphincter
o 3c: internal sphincter is torn
 Fourth-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, anal
sphincter, and rectal mucosa are torn
Cause
In humans and some other primates, the head of the term fetus is so large in
comparison to the size of the birth canal that term delivery is rarely possible
without some degree of trauma. As the head passes through the pelvis, the soft
tissues are stretched and compressed. The risk of severe tear is greatly increased if
the fetal head is oriented occiput posterior (face forward), if the mother has not
given birth before or if the fetus is large

Complications
First and second degree tears rarely cause long-term problems. Among women
who experience a third or fourth degree tear, 60-80% are asymptomatic after 12
months. Faecal incontinence, faecal urgency, chronic perineal pain and
dyspareunia occur in a minority of patients, but may be permanent. The symptoms
associated with perineal tear are not always due to the tear itself, since there are
often other injuries, such as avulsion of pelvic floor muscles, that are not evident
on examination.

Homoeopathic Remedies

Aconite. Contractions feel violent and intense, producing a state of fear, panic and
anxiety. This is a major remedy for a precipitous labor where contractions come on
very suddenly. Woman fears she will not make it through childbirth and/or is
convinced that she will die. Emotional shock and trauma of the infant after a
difficult birth when baby appears shocked and frightened. A dose of Arnica is
usually followed 30 minutes later if there has been physical trauma. Useful for
newborns with ophthalmia, jaundice, retention of urine, neonatal asphyxia and
post-circumcision.

2) Arnica. Common anti-inflammatory remedy given at the beginning of and

hourly throughout the labor. A dose of 200C can be given to mother immediately
after birth to prevent postpartum hemorrhage, after surgical births (C-sections,
forceps or vaccuum extractions) to promote healing and reduce swelling, bruising,
risk of infection, soft tissue damage (perineum or abdomen) and to baby with
swelling or bruising.

3) Arsenicum. Indicated for anxious restlessness leading to physical exhaustion

and insonia. Women who are compulsive and can’t let go. Perineal infections
following childbirth. Newborn resuscitation in severely depressed baby with little
or no color or respiratory effort.

4) Bellis Perennis. After a miscarriage, a dose of Arnica is given followed by a

few doses of Bellis Perennis, spaced 30 minutes apart. Soreness of abdominal wall
and sciatica caused by position of baby during pregnancy. Wonderful remedy for
tears in the perineum or periurethral area after birth (including episiotomy), helps
control the bleeding as well. Also indicated for bruised, sore pelvic or abdominal
tissues following birth or Caesarean section.