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Perineal tears (where the tissue at the vagina tears during birth) occur in 50-75% of vaginal births. Mild tears (1st or 2nd degree) are more common and easier to heal after. Severe tears (grade 3 or 4) occur in 3-7% of births and are more difficult to heal from and result in more long term issues such as loss of bowel control (fecal incontinence), loss of gas control (flattus incontinence), pain, painful sex and urinary incontinence.
Definition of Tears
1st degree: least severe, involves skin around the vaginal opening
2nd degree: involves the muscles between the vaginal and anus and typically requires stitch(es)
3rd degree: impacts the muscles around the anus and may require repair in the operating room; divided into 3 subgroups based on severity
4th degree: most severe and reaches the tissue lining of the rectum
3rd and 4th degree are sometimes called obstetric anal sphincter injuries (OASI)
Your risk of a perineal tear can be higher or lower depending on factors:
Your provider
midwife-led care results in a reduced likelihood of forceps, vacuum and episiotomy
Your birth setting
home birth leads to 49% intact perineum, 40.9% had 1/2 degree tear and 1.4% episiotomy and 1.2% had a 3rd or 4th degree tear
Overall rates are lower at birth centers (38.7 - 75%) and home births (50.8%)
Hospitals in the US do not publicly report tear rates
How many births you have had
First time birthing people are more likely to experience severe tears
severe (3/4 degree) tears occured in 5.8% of people giving birth for the first time and 0.6% of those who have given birth before
Risk factors for severe tears (grade 3/4)
care provider
first time birthers
higher birth weight of baby
forceps or vacuum use
episiotomy
shoulder dystocia
prolonged OR very short pushing phase
occiput posterior baby position (sunny side up)
family history
So, how can we minimize the chances of a tear (or at least a severe tear)?
Warm compresses
increases the rate of intact perineum (22.4% vs 15.4%)
decreases the rate of severe tears (1.9% vs 5.8%)
decreases the risk of episiotomy (10.4% vs 17.1%)
Birthing positions
birthers who gave birth in upright positions (squatting and sitting on stool) during pushing had decreased forceps, vacuum and episiotomy
upright positions may increase the risk of 2nd degree tears (and therefore should be used when pushing is taking >30 minutes) but these positions decrease the risk of severe tears (which is what we really want to avoid)
lying on your side with delayed pushing significantly increased intact perineum (40% vs 12%)
Avoiding episiotomy
routine episiotomy has been found to increase severe tears
Perineal massage
during labor massage is done by a provider between pushes and sometimes during pushes
participants assigned to massage during labor had a 50% lower rate of severe perineal trauma
First time birthers had a higher rate of intact perineum and fewer episiotomies with massage
BUT has little to no beneift if providers already have a very low severe tear rate (1.5% or less)
hands on vs hands off delivery
hands on is when hands are used to support the perineum or baby's head
hands off or poised is when the attendant does not touch the head or perineum at all during the birth or applies slight pressure on the head to avoid rapid expulsion
there is no benefit to hands-on and potentially increases 3rd degree tears and episiotomy
Expert Midwives say (a group from NZ and Ireland with a "no suture" rate of 40% or greater
calm, controlled birth that is nice and slow
birthing positions (preferred hands and knees)
Spontaneous, birther directed pushing; don't push during crowing
Importance of patients with birth of head and gentlness with the birth of the shoulders
What YOU can do
find out your providers episiotomy rate (it should be <1%), severe tear rate (<2%) and "no suture" rte (ideally 40% or greater)
plan for a slow, gentle crowning of the fetal head and put it in your birth plan
push and deliver in upright positions like hands and knees or sidelying if you have an epidural
push with your own urges, breathe while you push and give birth to the baby's head between contractions
So, what if you did have a perineal tear (whether it is severe or mild) and it is causing you pain, pain with sex or incontinence with gas, stool or urine? That is where physical therapists come in. The scar at the perineum has layers of skin, fascia and muscle. And, if it was a grade 3/4 tear, also involves the anal sphincter muscle and possibly the fascia and tissue of the rectum. Scars can cause the "layers" to be stuck resulting in:
1) Localized pain over the scar
2) Painful sex (especially with initial penetration)
3) Difficulty with the anal sphincter muscle to properly close resulting in fecal incontinence or flattus incontinence
4) Pain with bowel movements
5) Fear and worry about future births
How physical therapy can help:
Manual Therapy:
We assess and treat the perineal scar at the perineum (the space between the vagina and anus), the vagina and even via the external anal sphincter. This work is surprisingly gentle and effective.
Visceral Mobility:
The deeper layers of your scar may involve your urethra or rectum. We use gentle techniques to restore the motion and mobility of your organs through your abdominal wall or intravaginally.
Class IV Laser:
Laser is an FDA-approved treatment that uses light energy to rebuild healthy tissue, decrease pain, increase blood flow and increases the body's natural healing abilities. It only takes 1-2 minutes!
Dry Needling:
We use a gentle technique that is is very comfortable. Case reports suggest that scar needling generates a quick decrease in pain and improvement of mobility in scarred tissues. We rarely use dry needling on perineal scars, yet it IS a tool in our tool box if needed.
Following severe tears, some people have postpartum complaints. However, others might not notice symptoms until the hormonal shifts that occur in the perimenopause or menopause years. ALL of those who have experienced severe tears should see a pelvic floor therapist to assess and treat their scar and pelvic floor to reduce the incidence of incontinence.
If you are pregnant and want to prevent tearing OR postpartum after a perineal tear, reach out for an appointment locally in Richmond, Virginia or via telehealth in the state of Virginia-- specially trained pelvic health physical therapists are trained to help with cesarean scar pain, low back pain, pelvic health issues and adhesions. Call us at 804-372-0291