PERINEAL TEARS

MRS SIAME
 Definition

• These are lacerations occurring on the perineum and surrounding

tissues during the birth of the baby or second stage of labor.
Diagram showing the perineal body
 Perineum shape and size

• Its triangular in shape with the base being the skin and the
apex pointing upwards.
• Each side measures 3.5cm (other books 4cm each).
 Perineum structure

• it consists of 3 layers of tissue:

1. outer layer of the skin
2. superficial muscles of the pelvic floor which are:-
(a) bulbo carvenosus
(b) transverse perinei
3. deep pelvic floor muscles which is:-
(a) pubo coccygeous muscle
 Types of perineal tears

1. 1st-degree tear
2. 2nd-degree tear
3. 3rd-degree tear
1ST-DEGREE TEAR
This involves structures such as the skin of the perineum, can be
repaired by the midwife and bleeding is minimal.
 Types of perineal tears

2ND DEGREE TEAR

• Structures involved are the skin and the superficial pelvic
floor muscles and can be repaired by the midwife.
3RD DEGREE TEAR
• This is an extensive tear involving the skin, superficial pelvic
floor muscles, deep pelvic floor muscles and the anal
sphincter muscle. Should be repaired by the Docter.
 Types of perineal tears
4. 4TH DEGREE TEAR
• Involves the skin, superficial pelvic floor muscles, deep
pelvic floor muscles, anal sphincter and rectal mucosa.
• Should be repaired by the Docter.
 Predisposing factors
Maternal Factors
• Edematous perineum due to pushing or pre-eclampsia.
• In excessive fundal pressure
• In prolonged second stage due to prolonged bearing dawn.
• When there are varicose veins on the vulva.
• Presence of scar tissue, previous tear or episiotomy
 Predisposing factors

Fetal factors
• A large baby
• In malpresentation e.g occipital posterior position, after coming head
of breech or face presentation.
• In case of congenital abnormalities such as hydrocephalus.
 Complications
1.Excessive bleeding especially for 2nd and 3rd degree tears and
those that extent upwards to involve the clitoris.
• If hemorrhage occurs, apply digital pressure with a sterile pad to
control the bleeding and call for help.
• If the bleeding needs clamping, use an artery forceps to clamp
and call for help.
2. Infection may be due to contamination with fecal mater due to
close proximity with the anus also due to use of unsterile swabs
during repair and poor hygiene.
 Complications

3.Dyspareunia,the scar tissue may be tender for some time and

cause painful sexual intercourse.
 Prevention of perineal tears
DURING ANTENATAL PERIOD
• Advise the mother on the importance of good nutrition to keep tissues
healthy.
• Treat vaginal and vulval infections if present during antenatal period.
• Prevent anemia by giving iron/folate during antenatal period.
• Correct pelvic assessment at 36 weeks to confirm pelvic adequacy.
• Give proper IEC to prepare the mother psychologically for labor and
delivery.
 Prevention of perineal tears
DURING FIRST STAGE OF LABOR
• The mother should be given concise instructions in a quite
and gentle but firm manner such as breathing through the
mouth during a contraction to avoid premature pushing.
• Create a therapeutic relationship to prevent unnecessary
anxiety that may lead to premature pushing.
• Ensure adequate pain relief.
 Prevention of perineal tears

DURING SECOND STAGE OF LABOR

• Discourage the woman from bearing dawn prematurely
before second stage is confirmed.
• Protect the head from popping out of the birth canal by
adequate flexion or control of the head.
• Perform episiotomy at the right time.
• Keep hands off the perineum.
• Empty the blader.
 CARE OF THE WOMAN WITH PERINEAL TEARS

PAIN RELIEF
• Explain what has been done and answer questions to alley
anxiety.
• Analgesics such as Paracetamol 1g tds x 5 days.
• Be careful with Brufen may increase bleeding.
CARE OF THE WOMAN WITH PERINEAL TEARS

HYGIENE
• Advise the woman to bath once to two times a day to prevent infection and
bad odor.
• Pads should be changed whenever soiled to prevent growth of micro-
organisms and bad smell.
• Advise the woman to avoid cotton wool to prevent infection.
• Advise the woman to use the front to back cleaning technique after using
the toilet to avoid contamination of the perineum by fecal mater.
• Advise the woman to do sitz baths with cooled boiled water 3 times a day
for 30-40 minutes to promote comfort and prevent infection.
CARE OF THE WOMAN WITH PERINEAL TEARS

EXERCISE
• Encourage the mother to perform Kegels exercises frequently
to strengthen the perineal.
• Advise the mother to ambulate to facilitate increased blood
supply to the area for wound healing.
• Discourage her from lifting heavy things.
• Encourage her to use a cushion when sitting to promote
comfort.
CARE OF THE WOMAN WITH PERINEAL TEARS

BOWEL & BLADER CARE

• Advise the mother to avoid constipation by eating food rich in roughage.
• Advise her to pass urine whenever necessary.
• Discourage straining at stool to prevent a broken dawn episiotomy.
DIET
• Encourage food rich in proteins for repair and tissue build up.
• Encourage adequate vitamins and iron for improved oxygen transportation
to tissues.
• Roughage to prevent constipation.
CARE OF THE WOMAN WITH PERINEAL TEARS

INFORMATION EDUCATION & COMMUNICATION

• Importance of hygiene to prevent infection
• Importance of good nutrition to aid in healing.
• Importance of exercise to facilitate increased blood supply.
• Importance of rest .
DANGER SIGNS
• Gaping of the wound (breaking dawn)
• Foul smelling discharge from the wound
• Fever
• Swelling that gets worse
• Pus discharge
CARE OF THE WOMAN WITH PERINEAL TEARS

RESUMPTION OF SEXUAL INTERCOURSE

• Sex activities should be resumed whenever the wound is
completely healed preferably after 6 weeks and when the
woman is comfortable.