Around 90% of women having a vaginal birth will suffer some degree of a tear, episiotomy or graze.
It is not always possible to prevent a tear occurring, however, for most women a tear, while painful, is relatively minor and quick to heal and in most cases will not amount to medical negligence.
However, it is vital that all tears are identified and repaired as quickly as following possible birth to avoid long term complications.
What is a perineal tear?
Your perineum is the area of muscle and tissue between your vagina and anus (back passage). It connects to the muscles of your pelvic floor. Your pelvic floor muscles support your pelvic organs and maintain continence of your bladder and bowels.
During labour, your pelvic floor stretches, and this can result in some perineal tearing (a tear to your skin and muscles of your perineum) as your baby is delivered. A tear can also occur inside your vagina and labia (lips of the vagina).
In some births, an episiotomy can help to prevent a severe tear and can speed up delivery if your baby needs to be born more quickly if they are in distress. It also allows instruments such as forceps or ventouse suction to help with the birth. An episiotomy is a cut made by a medical professional through your vagina wall and perineum to make your vagina opening a bit wider, allowing your baby to come through more easily.
Can a perineal tear be avoided?
Massaging your perineum in the last few weeks of pregnancy and having a slow and controlled birth of your baby’s head can reduce the chances of having an episiotomy and/or tear during birth. Still, it is not always possible to avoid severe tears.
Certain risk factors make you more prone to suffering a tear which include;
- Your first vaginal delivery
- If you have suffered a third-degree or fourth-degree tear in a previous birth
- Your baby weighs more than 4kg.
- Having an induction
- Having an epidural
- There is a very long or very short second stage of labour.
- Your baby suffers shoulder dystocia (where your baby’s shoulder gets stuck behind your pubic bone)
- The delivery is an assisted delivery, i.e. undertaken using forceps or ventouse.
Types of perineal tears
There are four different types of tear which are based on severity.
- First-degree tear – a superficial tear to your vaginal tissue or perineal skin layer only. These usually heal naturally.
- Second-degree tear – Injury to your vaginal tissue, perineal skin and perineal muscle. These usually need to be repaired soon after birth using stitches.
- Third-degree tear – A tear in your vaginal tissue, perineal skin and perineal muscles which involves your anal sphincter (the muscle that controls your anus).
- Fourth-degree tear – More extensive than a third-degree tear and extends further through your anal sphincter and into the tissue underneath, i.e. in your anus or rectum.
For third and fourth-degree tears, these need repair in an operating theatre with stitches.
When should a tear be identified?
Perineal tears are common and are usually easily treated. Medical professionals are trained to carefully examine your vagina, perineum and rectum for any tears after delivery of your baby. Any tears should be carefully assessed to determine the severity of your tear and whether it involves your anal sphincter. A tear should be documented in your medical records. If a tear is not appropriately identified and repaired swiftly following birth, it can cause unnecessary pain and complications for you, so this part of your post-partum care is extremely important.
A first-degree tear may require stitching, but it can be left to heal naturally. A second-degree tear will require stitching of your muscles and skin under local anaesthetic. According to the Royal College of Obstetricians and Gynaecologists, third or fourth-degree tears occur in 3% of women having a vaginal birth. If you have suffered a third or fourth-degree tear, then you are likely to be transferred to an operating theatre where your muscles will be repaired under a more effective anaesthetic such as a spinal, epidural or general anaesthetic to prevent bleeding.
The stitches used for perineal tears are dissolvable and do not need to be removed.
Complications from perineal tears
Complications can occur, and usually, this is in the form of infection, so you must seek advice from your midwife or GP straight away if you experience any red or swollen skin, persistent pain or any liquid coming from the cut.
Generally, more severe complications occur following a third or fourth-degree tear, particularly if these are not identified immediately following the birth, or they are not repaired correctly, as these tears get close to the anal sphincter. If left untreated, this can have serious consequences; some women can experience faecal incontinence (stool leakage); flatus (wind) and other pelvic floor problems ranging from several months to long term. Women who suffer with perineal tears, particularly more serious ones, are often reluctant to talk openly about their symptoms. They feel embarrassed, and many suffer without the support and can develop anxiety, depression and find bonding with their baby very difficult.
How we can help
It is uncommon for a tear to be negligent traumatic birth injury in itself and based on our experience, claims for perineal tear generally fall into two categories;
- Failure to identify your perineal tear following the birth or the failure to categorise your tear appropriately); and
- Failure to adequately treat your tear or manage the symptoms.
If you have suffered a third or fourth-degree tear which was not identified (or incorrectly identified); or your tear was not repaired at the time of the delivery and is causing you ongoing problems, please contact us.