PERINEAL TEAR

P R ES E N TE D B Y – M AY U R I
Z A N WA R
G U I D ED B Y- D R . S H EE TA L M A’ A M
Content
Definition
Anatomy
Etiology
Causes
Risk factors
Types of perineal tear
Sign and symptoms
Examination
Management
 Definition

Lacerations of perineum are the result of

overstretching or too rapid stretching of the
tissue especially if they are poorly extensile
or rigid. Laceration of the perineum is a
wound or irregular tear of the perineal
tissues during childbirth.
 Anatomy
•Perineum: Perineum is a diamond-shaped space that lies below the pelvic floor. it is bounded by:

•Superiorly: pelvic floor

•Laterally: the pelvic outlet consisting of subpubic angle, ischiopubic rami, ischial tuerosities, sacrotuberous ligaments and

coccyx

•Inferiorly: skin and fascia.

•This area is divided into two triangles by transverse muscles of perineum and base of urogenital diaphragm:

•Anteriorly- Urogenital triangle.

•Posteriorly- Anal triangle

•Most of the support of perineum is provided by pelvic and urogenital diaphragms.

Perineal Body:
• The pyramidal shaped tissue where the pelvic floor and the
perineal muscles and fascia meet in between the vagina and the
anal canal is called the obstetrical perineum.
• It measures about 4 cm × 4 cm with the base covered by the
perineal skin.
• The median raphe of levator ani between the anus and vagina, is
reinforced by the central tendon of the perineum.
• Bulbocavernosus, superficial transverse perineal and external anal
sphincter muscles also converge on the central tendon.
• These muscles contribute to perineal body, which provides much
support to perineum.
Importance
It helps to support the levator ani
which is placed above it.
By supporting the posterior vaginal
wall, it indirectly supports the
anterior vaginal wall, bladder and
the uterus.
Blood supply to perineum:
Major blood supply is by internal pudental
artery and its branches- inferior rectal artery
and posterior labial artery. Posterior labial
Inferior rectal.

It is vulnerable to injury during • Nerve Supply is primarily via pudendal nerve

childbirth. (S2,S3,S4) and its branches Pudendal block.

Deliberate cutting of the

structures during delivery is
called episiotomy
 Vagina
The vagina is a fibromusculomembranous sheath communicating the uterine cavity with the exterior at the vulva.

It constitutes the excretory channel for the uterine secretion and menstrual blood.

It is the organ of copulation and forms the birth canal of parturition.

The canal is directed upwards and backwards forming an angle of 45° with the horizontal in erect posture.

The long axis of the vagina almost lies parallel to the plane of the pelvic inlet and at right angles to that of the uterus.

The diameter of the canal is about 2.5 cm, being widest in the upper part and narrowest at its introitus.

It has got enough power of distensibility as evident during childbirth.

WALLS:
Vagina has got an anterior, a posterior and two lateral walls.
The anterior and posterior walls are opposed together but the lateral walls are comparatively stiffer especially at its
middle, as such, it looks “H” shaped on transverse section.
The length of the anterior wall is about 7 cm and that of the posterior wall is about 9 cm.

FORNICES:
The fornices are the clefts formed at the top of vagina (vault) due to the projection of the uterine cervix through the
anterior vaginal wall where it is blended inseparably with its wall.
There are four fornices—one anterior, one posterior and two lateral; the posterior one being deeper and the
anterior, most shallow one.
RELATIONS:
Anterior—The upper one-third is related with base of the bladder and the lower two-thirds are with the urethra, the
lower half of which is firmly embedded with its wall.
Posterior—The upper one-third is related with the pouch of Douglas, the middle-third with the anterior rectal wall
separated by rectovaginal septum and the lower-third is separated from the anal canal by the perineal body
Lateral walls—The upper one-third is related with the pelvic cellular tissue at the base of broad ligament in which
the ureter and the uterine artery lie approximately 2 cm from the lateral fornices.

VAGINAL SECRETION:
The vaginal pH, from puberty to menopause, is acidic because of the presence of Döderlein’s bacilli which produce
lactic acid from the glycogen present in the exfoliated cells. The pH varies with the estrogenic activity and ranges
between 4 and 5.
BLOOD SUPPLY:
The arteries involved are
(1) Cervicovaginal branch of the uterine artery,
(2) vaginal artery—a branch of anterior division of internal iliac or in common origin with the uterine,
(3) middle rectal
(4) internal pudendal.
These anastomose with one another and form two azygos arteries—anterior and posterior.
Veins drain into internal iliac veins and internal pudendal veins.

NERVE SUPPLY:
The vagina is supplied by sympathetic and parasympathetic from the pelvic plexus.
The lower part is supplied by the pudendal nerve.
 Etiology

Tear in perineum commonly occur at childbirth :

Malpresentations such as breech the head of the fetus is born too soon
Labor is not headed properly

Previously on peineum there is a lot of scar tissue

 Risk Factors
Risk Factor for more complex laceration include:
Midline Episiotomy
Nulliparity (Primigravida ) Longer second-stage labor
Precipitous delivery
Persistent occiput posterior position
Operative vaginal delivery
Asian Race

Increasing Fetal birthweight

 Sign and symptoms
Bleeding in a State where the placenta is born, uterine contractions and well, it is certain that the bleeding
wounds of the street comes from the birth.

Signs that threatens to tear the perineum, among others:

1. The perineum Skin started flaring and tense.

2. The perineum Skin colored pale and shiny

3. There is bleeding out of the holes of the vulva, is an indication of a tear in the vaginal mucosa.

4. When the skin of the perineum at the midline begins to tear, among the fourchette and the sphincter ani.
 Examination
Routine Examination Almost all clinicians examine perineum area after childbirth process to detect tears
can be appear.

Some clinicians also recommend having all labor, followed by routine rectal examination and inspection
of the walls of the vagina and cervix.

Routine examination of the rectal to detect the septal aims on mucosa recta, anal sphincter, and perineum
by using one finger into the rectum.
 Management
Lacerations should be repaired immediately if possible, and certainly within hours of delivery

First step is to define the limits of the lacerations, which includes vagina as well as perineum As accurate an
approximation as possible of all tissues should be secured and no dead spaces are left

There are many ways to repair a perineal lacerations, but the concept is still the same: The suture material
commonly used is 2-0 chromic catgut.

For shallow wound it can be repair with one stitch; for deep wound it can be repair with two or more. Each
stitch should be reach to the base of the wound

Third degree laceration need a special technique.

Thank You!