Perineal tear is a pathological condition characterized by damage to the posterior adhesions, pelvic floor muscles, vaginal walls and rectum, as well as the anal sphincter during childbirth. Clinically, the threat of rupture of the perineum is manifested by protrusion between the anus and the vagina, swelling, cyanosis, which turns into pallor, pathological sheen of the skin, skin cracks. When a rupture of the perineum occurs, a violation of the integrity of the tissues is revealed. Diagnosis is based on a direct examination of the perineum during childbirth and revision of the birth canal after the birth of the afterbirth. The treatment is surgical, includes wound treatment and restoration of the anatomical integrity of the damaged structures.
Perineal tear is a traumatic injury in obstetrics and gynecology that occurs when excessive pressure of the adjacent part of the fetus on the vagina and adjacent anatomical structures. Pathology is observed in 12-16% of all women in labor, which makes it the most common complication during childbirth. In primiparous women, the risk of perineal tear is 1.5-3 times higher than in those who give birth repeatedly. In addition, the risk group includes women with traumatic injuries of the perineum, recurrent diseases of the uterus and vagina in the anamnesis. The relevance of this pathology is also due to a large number of potential complications, which include septic diseases, bleeding, loss of anal sphincter tone, prolapse and prolapse of the vagina and uterus, formation of a fistula between the vagina and rectum, suppuration and failure of sutures.
Causes and classification
The ability of the perineum to stretch even with a favorable course of labor has its limit. When the adjacent part of the fetus passes through the birth canal, additional pressure is created, which, under certain circumstances, can cause a rupture of the perineum. The main contributing factors are rapid childbirth, a large fetus, the use of obstetric aids, an anatomically narrow pelvis of a woman in labor (most often infantile and flat–bronchitic). Risk factors include a decrease in the tone of the perineal tissues (typical for first-time mothers over 35 years old), pronounced development of the musculature of this area, frequent vaginitis and colpitis in the anamnesis, the presence of postpartum scars. Also, the rupture of the perineum can be provoked by irrational, overly aggressive tactics of a gynecologist.
Depending on the etiology and mechanism of development , perineal tear are divided into:
- Spontaneous. Such ruptures of the perineum occur independently against the background of a discrepancy between the anatomical and physiological characteristics of the fetus and the genital tract of the woman in labor.
- Violent ruptures of the perineum. Injuries develop as a result of delivery operations or inadequately chosen tactics of labor management.
There are 4 degrees of severity of perineal tears:
- I degree – rupture of the skin, posterior adhesions. At the same time, the pelvic floor muscles remain intact.
- II degree – damage to the skin, muscles, and walls of the vagina while maintaining the integrity of the anal sphincter.
- III degree – a combination of all the above signs of II degree with rupture of the anus sphincter.
- IV degree – rupture of the perineum of the III degree in combination with damage to the anterior wall of the rectum.
Separately, the central rupture of the perineum is isolated. With it, the birth of a child passes through a defect formed between the intact posterior junction and the anus. It is also possible to rupture regional muscles while maintaining the integrity of the skin. These variants are rare.
The rupture of the perineum is almost always preceded by a pathological condition called the threat of rupture of the perineum, which is an indication for perineotomy or episiotomy. Pathogenetically, it is caused by compression of regional blood and lymphatic vessels, leading to venous and lymphatic stagnation, ischemia. Clinically, the threat of rupture of the perineum is manifested by pronounced pathological protrusion, increasing edema, cyanosis, which turns into pallor. Further, shine appears on the skin, cracks form, after which the perineum ruptures. The rupture of the perineum itself is characterized by a violation of the integrity of the soft tissues of the adjacent part of the fetus. Depending on the severity, the skin, muscles, walls of the vagina and rectum, anal sphincter may be damaged.
The main complication of perineal tear is bleeding from regional blood vessels. As a rule, with grade I and II pathology, blood loss is minimal. At III and IV degrees, as well as against the background of concomitant varicose veins, massive bleeding may occur. If the integrity of the birth canal is violated, there is always a risk of bacterial complications.
Diagnosis and treatment of perineal tear
The diagnosis of perineal tear is not difficult. It consists in the visual determination of a soft tissue defect during delivery. If there is a possible minor damage, the examination of the birth canal is performed immediately after the toilet of the uterine cavity. On the eve of childbirth, as a preparation for possible complications, an obstetrician-gynecologist assesses the risk of perineal tear. To do this, an anamnesis is collected, a visual examination is carried out, data from preliminary studies of the pregnant woman and fetus are studied – ultrasound, etc.
Treatment of perineal tear is carried out according to the general principles of surgical treatment of wounds and restoration of the integrity of soft tissues. The type of anesthesia differs depending on the severity of the damage. At I and II degrees, infiltration or ischiorectal anesthesia is used, less often intravenous injection of an anesthetic. At III and IV degrees, surgical intervention is performed under general anesthesia. The essence of the operation for the rupture of the perineum is the layer-by-layer stitching of all damaged structures with the help of chrome-plated catgut, silk, vicryl. Regardless of the nature of the damage, the intervention is performed after the revision of the uterine cavity and vagina and (if necessary) restoration of their integrity.
After surgery, daily monitoring of the stitches is carried out. Antiseptic dry treatment of the perineum after defecation and urination is indicated. In the absence of purulent complications, the sutures are removed for 4-6 days. For 15-20 days after the operation, it is not recommended to occupy a sitting position. Surgical treatment for perineal tear of the III and IV degree should be carried out only by experienced obstetricians and gynecologists with the participation of several assistants. These conditions are dictated by the technical complexity of the operation and the high risk of complications. The most significant of them are the omission of the vagina and uterus or their prolapse, hematomas, loss of tone of the anal sphincter with involuntary defecation, suppuration and failure of sutures.
Prognosis and prevention
The prognosis for perineal tear against the background of properly performed surgical treatment is favorable. After removal of sutures and healing of damaged tissues, all pelvic functions are fully restored. The question of subsequent pregnancies is decided individually, but, as a rule, there are no contraindications to carrying a child.
Direct prevention of perineal tear during childbirth in the event of threatening symptoms involves performing surgical incisions: median – perioneotomy or lateral – episiotomy. This step is due to the fact that the healing of smooth cut edges is better than torn ones. Treatment of episiotomy and perineotomy is similar to the treatment of perineal tear. During pregnancy and before the threat of perineal tear, prevention includes Kegel exercises, perineal massage, starting from the second trimester, early treatment of infectious and bacterial pathologies of the birth canal, proper breathing, alternating periods of relaxation and tension during childbirth, regular visits to a women’s consultation.