Perineal and

Cervical tears
 Definition

Perineal trauma is any damage

to the genitalia during
childbirth that occurs
spontaneously or intentionally
by episiotomy.
 Perineal trauma affects women's
physical, psychological and social
well-being and can disrupt breast-
feeding, family life and sexual
relations.  It is vital for women's
future well-being that injuries to
the perineum are correctly
identified as quickly as possible
and managed.
• Anterior perineal trauma is injury
to the labia, anterior vagina,
urethra, or clitoris, and is usually
associated with little morbidity.

• Posterior perineal trauma is any

injury to the posterior vaginal
wall, perineal muscles, or anal
sphincter.
 Incidence

• Over 85% of women who have a

vaginal birth will suffer some
degree of perineal trauma and of
these 60-70% will need suturing. 
 Risk factors
• Spontaneous or assisted vaginal delivery.

• First vaginal delivery.

• Increased fetal size, mode of delivery,

and malpresentation and malposition of
the fetus.
• Ethnicity (white women are probably at
greater risk than black women), older
age, and poor nutritional state.

• Intrapartum interventions may influence

the severity and rate of perineal trauma
(e.g. use of ventous or forceps).
 Causes
Perineal tear
Precipitate labour
Inadequate perineal support
Malpresentations
Shoulder dystocia
Multiple vaginal exams
Previous perineal or cervical scars
Narrow pubic arch
Cervical tear

Forceps, ventouse or breech extraction

before full cervical dilatation.
Manual dilatation of the cervix.
Improper use of oxytocins.
Precipitate labour.
Cervical rigidity.
Scarring of the cervix.
Oedema as in prolonged labour.
Placenta praevia due to increased
vascularity.
 Symptoms

There are usually no symptoms of

vaginal tears; however, increased
bleeding from the vagina may occur.
 Diagnosis
• Postpartum haemorrhage, in spite of
well contracted uterus.
• Vaginal examination: The tear can be
felt.
• Speculum examination: using a
posterior wall self retaining speculum
or vaginal retractors and 2 ring
forceps to grasp the anterior and
posterior lips of the cervix so the tear
can be visualised.
 Types of cervical tear
• Unilateral: more common on the left
side due to dextro-rotation of the
uterus. Left occipito-anterior position
is the commonest.
• Bilateral
• Stellate: multiple tears extending
radially from the external os like a
star.
 Types of perineal tear
First degree tear - tear involving the
perineal or vaginal skin only.

Second degree tear - perineal skin and

muscles torn, but intact anal sphincter.
Third degree perineal tear - perineal skin,
muscles and anal sphincter are torn.
– Less than 50% of the external anal sphincter
thickness is torn.
– More than 50% of the external anal sphincter
thickness is torn, but internal anal sphincter
intact.
– Both external and internal anal sphincters are
torn, but anal mucosa intact.
Fourth degree perineal tear - perineal
skin, muscles, anal sphincter and anal
mucosa are torn.

Button-hole tear - anal sphincter is

intact but anal mucosa is torn.
Management of perineal and
cervical tear

• Non-steroidal Aspirin Inhibitors :such as

Ibuprofen for pain and prophylactic
antibiotics.

• Sitz Baths: Sitting in a warm bath that

only covers hips and buttocks can
sometimes help.
• Ice pads: Ice wrapped in a cloth or
chilled applied to the area are
sometimes used to dull the pain.

• Tight pack: may be needed to control

bleeding from a raw surface area.
Foley's catheter should be inserted
before packing and both are removed
after 12-24 hours.
 Repair of cervical tears
• Close the cervical tears with continuous 0
chromic catgut (or polyglycolic) suture
starting at the apex, which is often the
source of bleeding.

• It is important that absorbable sutures be

used for closure. Polyglycolic sutures are
preferred over chromic catgut for their
tensile strength, non-allergenic properties
and lower probability of infectious
complications.
• If a long section of the rim of the
cervix is tattered, under-run it with
continuous 0 chromic catgut suture.
Repair of a cervical tear
 Repair of first and second
degree tears
• Most first degree tears close spontaneously
without sutures.
• Use local infiltration with lignocaine.
• Ask an assistant to massage the uterus and
provide fundal pressure.
• Carefully examine the vagina, perineum and
cervix.
• If the tear is long and deep through the
perineum, inspect to be sure there is no third
or fourth degree tear:
– Place a gloved finger in the anus;
– Gently lift the finger and identify the sphincter;
– Feel for the tone or tightness of the sphincter.
• Change to clean, high-level disinfected gloves.
• If the sphincter is not injured, proceed with
repair.
Exposing a perineal tear
• Repair the vaginal mucosa using a
continuous 2-0 suture
– Start the repair about 1 cm above the
apex (top) of the vaginal tear. Continue
the suture to the level of the vaginal
opening;
– At the opening of the vagina, bring
together the cut edges of the vaginal
opening;
– Bring the needle under the vaginal
opening and out through the perineal
tear and tie.
Repairing the vaginal mucosa
• Repair the perineal muscles using
interrupted 2-0 suture. If the tear
is deep, place a second layer of the
same stitch to close the space.
• Repair the skin using interrupted
(or subcuticular) 2-0 sutures
starting at the vaginal opening (Fig
P-49).
• If the tear was deep, perform a
rectal examination. Make sure no
stitches are in the rectum.
Repairing the perineal
muscles
Repairing the skin
 Repair of third and fourth
degree perineal tears
• Loss of control over bowel movements and
flatus may occur if a torn anal sphincter is
not repaired correctly. If a tear in the
rectum is not repaired, the woman can
suffer from infection and rectovaginal
fistula.
• Repair the rectum using interrupted 3-0
or 4-0 sutures 0.5 cm apart to bring
together the mucosa.

• Place the suture through the muscularis.

• Cover the muscularis layer by bringing

together the fascial layer with
interrupted sutures.
Closing the muscle wall of
the rectum
• If the sphincter is torn:
• Grasp each end of the sphincter
with an Allis clamp (the sphincter
retracts when torn). The sphincter
is strong and will not tear when
pulling with the clamp
•
Repair the sphincter with two or
three interrupted stitches of 2-0
suture.
Repair of anal sphincter
 Post-procedure care
• Prophylactic antibiotics are started:
– Ampicillin 500 mg orally;
– Metronidazole 400 mg orally.
• Follow up closely for signs of wound
infection.
• Avoid giving enemas or rectal
examinations for 2 weeks.
• Give stool softener by mouth for 1
week, if possible.
 Complications

• Hematoma
• Infection
• Faecal incontinence
• Rectovaginal fistula
 Prevention
• Perineal massage
• Kegel Exercises
• Good nutrition (healthy skin stretches
more easily).
• A slow second stage of labor where
pushing is controlled allows the
perineum to stretch slowly.
 Perineal massage
• Massaging the perineum (i.e. the area between the
vagina and anus) during the last few weeks of
pregnancy, from 34 weeks on, helps to stretch
the outlet and prepare the lower birth canal for
delivery.
• It may also reduce the incidence of a
tear or the need for an episiotomy. To
perform this exercise, the mother should
put her thumbs 2-4 cm into the vagina
and press down towards the rectum;
maintain this steady pressure the
thumbs move upwards along the sides of
the vagina in a rhythmic 'U' or 'sling'
type movement, as indicated in the
figure. (should avoid the urinary opening).
• Perineum should be relaxed when
performing the massage. Massage is
continued for up to 5 minutes at a time
and repeated on alternative days.
Perineal massage
Care at Home
Thank U…