Perineal tears

Question 1

Why does a perineal tear occur?

Answer 1

-occurs when vaginal opening is too narrow to accommodate baby which leads to skin and tissues tearing as head passes

Question 2

What are perineal tears more common with?

Answer 2

• first births - nulliparity
• large babies > 4kg
• shoulder dystocia
• asian ethnicity
• occipito-posterior position
• instrumental deliveries

Question 3

What are perineal tears classified into?

Answer 3

4 degrees:

first degree
second degree
third degree
fourth degree

Question 4

What is a first-degree perineal tear?

Answer 4

-tear limited to the frenulum of the labia minora and superficial skin

Question 5

What is a second-degree perineal tear?

Answer 5

-tear includes perineal muscles but not affecting the anal sphincter

Question 6

What is a third-degree perineal tear?

Answer 6

-includes perineal muscles and anal sphincter but does not affect rectal mucosa

Question 7

What is a fourth-degree perineal tear?

Answer 7

-includes the rectal mucosa

Question 8

What can third-degree tears be subcategorised as?

Answer 8

• 3a - <50% of external anal sphincter affected
• 3b - > 50% of external anal sphincter affected
• 3c - both external and internal sphincter affected

Question 9

What is the management for first degree tears?

Answer 9

-usually do not require any suturing and just reassuring and pain reflief

Question 10

What is the management for second/third/fourth degree tears?

Answer 10

-requires suturing on ward or theater (3rd/4th)

Question 11

What additional measures can be taken after suturing for perineal tears?

Answer 11

• broad-spectrum antibiotics to reduce risk of infection
• laxatives to reduced constipation
• physiotherapy to reduce risk of incontinence
• followup for monitor

Question 12

What are women that are symptomatic after third or fourth-degree tears offered in subsequent pregnancies?

Answer 12

-elective c section

Question 13

What complications can perineal tears lead to?

Answer 13

• uriniary incontinence
• anal incontinence and altered bowel habit
• fistula between vagina and bowel (rare_
• dyspareunia
• psychological problems

Question 14

What is an episiotomy?

Answer 14

• where obstetrician or midwife cuts perineum before baby is delivered
• done in anticipation of needing additional room for delivery of baby (e.g before forceps delivery)
• performed under local anaesthetic
• cut sutured after delivery

Question 15

What is a perineal massage?

Answer 15

• method for reducing risk of perineal tears
• involves massaging skin and tissues between the vagina and anus
• done from 34 weeks to stretch and prepare tissues for delivery