Ep 90: Perineal Tears: Risk Factors, Prevention, and Healing

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I get lots of questions about perineal tears - how they happen, how to prevent them, and how to heal them - so I want to answer as many of those as I can for you today.

In this episode you'll learn about risk factors that can increase your chances of having a tear, strategies to prevent them, and how they can affect current and future pregnancies.

We'll walk through the four different types of lacerations and how common each one is. I'll also tell you what healing can look like for third & fourth degree tears since these are a bit more complicated to repair, and touch on incontinence and other issues that may come up after a perineal laceration. 

I'll also share why it's so important to have a provider that is comfortable doing the surgery to repair a third or fourth degree tear and why it may be okay for you to wait a few hours after your birth in order to get the best possible treatment.

In this Episode, You’ll Learn About:

  • What perineal tears (AKA lacerations) are and how common they are
  • Risk factors that can increase your chances of having a perineal laceration
  • How you can help prevent perineal tears by taking action both during pregnancy and during labor
  • Why third and fourth degree lacerations are the most complex to repair, and what that surgery is like
  • Things to think about and prepare for when healing a perineal tear
  • Why tears aren't all that common and how patience during labor can help reduce them

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Ep 90: Perineal Tears: Risk Factors, Prevention, and Healing

Nicole: In this episode, you're going to learn about tears that can happen as a result of vaginal birth. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello. Welcome to another episode of the podcast. This is episode number 90. Thank you for being here with me today. So in this episode of the podcast, I'm talking about vaginal tears, or they are more appropriately referred to as perineal tears. And I'll explain that in a minute. These can happen as a result of vaginal birth. I've actually had a few people request this recently. So here is the episode for you today. Now I'm really going to focus on the more severe tears. Those are third and fourth degree tears, because those are the ones that really increase the risk of long-term problems. So in this episode, you're going to learn just a general overview of what tears are, how common they are, risk factors that can increase your chances of getting a vaginal tear, some strategies to prevent them. And then what happens if you have a vaginal tear, both during the current, as well as future pregnancies.

Nicole: Now, understanding vaginal tears is just one part of labor and birth that you need to know. Inside of the Birth Preparation Course, my signature online childbirth education class, you learn everything you need to know about labor and birth. That is step two of my beautiful birth prep process, which is my unique system to ensure that you are calm, competent, and empowered to have a beautiful birth. So in step two of the process inside the course, you learn things about techniques for pushing, what to expect during every stage of labor and delivery, options for monitoring your baby, what's safe to eat and drink, are IV fluids okay, what should happen in the first hour after your baby's birth, options for pain management and much, much more. So you can check out the course at drnicolerankins.com/enrolled is currently 40% off because of our current crazy times.

Nicole: So do check that out again, drnicolerankins.com/enroll, because I'd love to see you inside the course to learn all the things about labor and birth. All right. So let's get into the episode about perineal tears. So I know we say vaginal tears, commonly, but actually, as I said, the correct medical term is perineal lacerations. And out, let me say real quickly, I'm going to use words that sometimes make people nervous or uncomfortable, like vagina, anus, rectum, those kinds of things. So be warned if you have little ones around, for some reason that you don't want to hear this or listening to it out loud. So the perineum is the area that is between the vulva and the rectum. And your vulva encompasses the mons pubis, that's the area with pubic hair, the labia, the clitoris and the rectum referred to in Urban Dictionary land as taint.

Nicole: Yes, I just use Urban Dictionary language, the taint and the perineal body is the most common site of lacerations. Although you can sometimes get lacerations elsewhere. I would say the second most commonplace would be the labia. Now perineal tears are classified as first, second, third, or fourth degree tears. And that is just based on how much tissue is torn. So first degree tears are the most minor tears. And fourth degree tears are the most severe. First degree tears can often be kind of like scraping your skin. Often describe it as like, if you fell and scraped your knee and kind of scraped your skin like that, except it happens in your vagina. Those often don't need any stitches, or they may only require one or two stitches just to stop any bleeding. Whereas fourth degree tears are the most severe tears and they mean that your vagina's torn, the muscles between your vagina and your anus are torn, and the actual anus or rectal area is torn as well.

Nicole: So those are pretty severe. Now in general, overall vaginal tears are pretty common. Anywhere from 50 to 80% of women will have some type of laceration or tear at vaginal delivery. The vast majority of those are going to be first and second degree tears, and they're going to heal without any problems. Actually, most tears heal without problems. However, a small subset of women will have the more severe tears, which are those third and fourth degree tears. And the reason we get concerned about those third and fourth degree tears is that in the short term, they can cause more pain, but in the long- term, they are a leading risk factor for loss of bowel control in women. These tears result in something called oasis or obstetric anal sphincter injuries. Now I got to do a little bit of an anatomy lesson to explain how these tears can influence the risk of having a loss of bowel control.

Nicole: So basically continence of feces and gas. So being able to hold gas and being able to hold poop and release it. And when you want to, that is maintained by something called the anal rectal complex, and that complex consists of the anal canal and the rectum and the major muscle components of the anal canal are the internal anal sphincter and the external anal sphincter. And the internal anal sphincter is under what's considered autonomic control. And I shouldn't say considered, under what is autonomic control, meaning you don't have a lot of conscious control over it over at your body just does it. Okay. And that means it just normally holds those muscles together. It holds a normal resting pressure in the anal canal in order for you to maintain continence. And when that is damaged, then that is associated with passive kind of releasing gas or stool.

Nicole: And then the external anal sphincter provides most of the squeeze part. Okay. So the internal anal sphincter is just kind of a resting tone. You know, that's always there and kind of keeps things in. Whereas the external anal sphincter is responsible for the squeeze and being able to actually push things out when you want to. Okay. And that is more associated with stool or fecal incontinence. Okay. And third degree tears are when there is injury to the anal sphincter complex. And then depending on how severe it is, whether it's the internal anal sphincter, the external anal sphincter, one of those, or both of those, and then a fourth degree tear is when there's injury to the anal sphincter complex. So both the external and internal anal sphincters, and then also the anal epithelium. Okay. So I know that was a lot, so I'm just kinda summarize it real quick again.

Nicole: So third and fourth degree tears tear through the muscles that are responsible for us being continent of feces and gas and being able to control when we release them. That's what continence means. Okay. Now it doesn't happen all of the time and actually doesn't happen most of the time with third and fourth degree tears. So I don't want you to be worried that if you have one before that, if you have one that it's likely that you're going to have these problems, it just increases the risk. So studies have reported postpartum fecal incontinence anywhere from as little as 0% up to about 28% in women who had an obstetric anal sphincter injury. And that's compared with rates of one to 10% for women who delivered without having an anal sphincter injury. Okay. And most of the time, as you might imagine, uh, one study, I should say, as you might imagine, fourth degree tears are associated with a higher risk compared to third degree tears.

Nicole: And that's because fourth degree tears are more severe. Now, when we look at how common these injuries, these third and fourth degree tears happen, and I'll go back and forth between saying third and fourth degree in oasis or obstetric anal sphincter injuries, that's a lot to get out. Okay. The overall risk is 6.3%, and this is looking at a whole lot of women. So over 90,000 women in this particular study, overall risk is 6.3%. And when you break it down for our first delivery, the risk is 5.7%. And if you've had a baby before and didn't have an oasis injury, then it's 1.5%. So they're not very common knock on wood. I have not seen a fourth degree tear since I was in residency training. It's just not, not very common. And I only occasionally rarely see third degree tears. I think a lot of that has come from a reduced risk of an episiotomy.

Nicole: And I'll talk about that as a risk factor in just a minute and just an overall willingness and ability for us to be patient with a birth instead of like rushing things, because allowing the tissues to stretch naturally on their own is going to decrease the risk of having tears. So let's talk about some of the risk factors, things that can increase your risk of developing a third or fourth degree tear an oasis injury. Well, the biggest risk is actually vaginal delivery. So having a vaginal delivery is going to increase the risk of those things happening. So every single person who has a vaginal birth is at risk of having some sort of tear. Okay. But there are some other things that can increase the risk more. So a longer second stage of labor. And the second stage of labor is from the point of time when you're completely dilated to when the baby's out.

Nicole: So when you, how you're pushing during that time. So if it's longer than three hours, then that increases the risk of oasis injuries. Episiotomy, especially midline episiotomies, can increase the risk of a third or fourth degree tear and midline, especially. And I did a podcast episode on episiotomy. I can't remember what number it is off the top of my head, but episiotomy is when you cut the tissues in the perineum, the perineal body, the taint, so to speak, to make space for the baby to come out. When you cut that tissue straight down, the rectum sits right underneath the vagina. Like those muscles are like right underneath there. If you cut straight down, I wish y'all could see me in my office right now. Um, I'm like demonstrating in the air scissors and cutting episiotomy, but if you cut straight down, then you're gonna, you're more likely to cut through those muscles as opposed to cutting to the side.

Nicole: Cause you can also cut an episiotomy to the side. So if you cut down at like six o'clock versus cutting it, say seven or eight o'clock or five or four o'clock, if you cut straight down at six o'clock, that increases the risk of having those anal sphincter injuries. And it's because if you think about it, if you had a piece of paper, right, and you took a sheet of eight by 11 paper and you kind of pulled it apart, or you had to pull it apart from the sides, it's not likely to pull apart, but take some scissors and cut down the middle of that piece of paper. And then depending on how far you cut and then pull it apart. Well, it very well may tear very easily. So that's how episiotomy can increase the risk of those more severe tears. And then also VBAC is associated with the increased risk of oasis.

Nicole: Not sure why that is exactly. Okay. So longer second stage, episiotomy, VBAC, and then operative vaginal delivery, particularly with forceps increases the risk of tears. And I just did a podcast episode on the operative vaginal delivery as well, but forceps in particular are instruments that go inside the vagina around the baby's head. And they're in contact with maternal tissues. Whereas the vacuum is only in contact with the baby's head. So because the forceps are in contact with your tissue, they are more likely to cause injury to your vagina. So when you look at numbers of how frequently oasis injuries occur with forceps deliveries, it's about 8.6%. And that is versus 3.7% with vacuum assisted deliveries and only 1.3% with spontaneous vaginal deliveries. So those are the top things that will increase your risk of having a more severe tear. And again, episiotomy, VBAC, a longer second stage or pushing phase, and then an operative vaginal delivery.

Nicole: And I forgot to say it makes sense that a longer second stage may cause more injury because the head is sitting down there. The head is sitting in the vagina the longer it's there, the longer that baby, that pressure is there, that can cause the potential for problems, actually in some places in countries that don't have as ready access to medical care. And some places in Africa, for instance, a longer second stage is associated with even more severe injuries, which are like a fistula formation, which is an abnormal connection between the vagina and the rectum or the vagina and the bladder and that results from babies, just sitting down so long in the pelvis from an obstructed labor and not having access to a Cesarean birth. So definitely longer second stages of labor can contribute to that. That doesn't happen very often in the U S okay.

Nicole: Some other things that we know that are not as strong of contributors that can increase risk are fetal occiput posterior presentation. That is a fancy way of saying the baby is Sunnyside up, meaning that they are looking at the ceiling. So if you are laying flat, most babies, when they're coming down the vaginal canal, when they're coming out, they're looking down at the floor because that position is most favorable for a baby to navigate the pelvis. It's the easiest I should say, to come out that way and kind of duck their little heads to get underneath the pubic bone. It's a little bit harder and takes longer for a baby to come out when they're occiput posterior. So when they're looking up, so that contributes to why you may have a higher risk of, of injury in that regard. Also your first baby, you being more than 41 weeks, an epidural, a shoulder dystocia. Shoulder dystocia is when the shoulder gets stuck under the pubic bone. It's not something that happens. It's a rare obstetric emergency, but not something that happens. A birth weight greater than 4,000 grams. That's roughly eight and a half pounds. For whatever reason, Asian race can approximately double the risk of an oasis injury. And then of course having a prior injury will increase your, your risk. Okay? So those are some things that can increase your risk and they kind of all relate to if the baby is bigger or you've been pregnant longer. So the baby has more time to get bigger, or if you have an epidural and you can't necessarily feel things as much, so you don't notice, or it takes you longer to push because you have an epidural, those are all things that are kind of connected and make sense in terms of increasing your risk of having an injury.

Nicole: It's not likely, but they can increase your risk. Okay. So what are some things that can be done to help prevent tears during vaginal delivery and particularly these more severe tears? Well, of course, as I've said, we cannot eliminate the risk, but we can reduce it. Okay. Now, one of the things that we know may reduce the risk of those more severe tears is perineal massage, and that can be done during your pregnancy. And also during that second stage of labor while you're pushing. And the reason that we believe perineal massage works is that it may reduce the resistance in the muscle surrounding the vagina. And if those muscles are looser, as your baby is passing through your vagina, if those muscles are nice and loose and relaxed, then you may be less likely to have tears. Okay. And perineal massage is exactly what it sounds like.

Nicole: It's massaging the tissues of your perineum. And that specifically the area between the opening of your vagina and your rectum. I have a more detailed explanation of perineum massage, as well as a tip sheet of exactly how to do it within the Birth Preparation Course. Now, another thing that can help reduce the risk of vaginal tears is warm compresses. Okay. So warm compresses applied to the perineum can certainly help reduce those more severe tears, especially the way you are positioned can influence the rate of tears. The rates are higher if you deliver in a standing position, a squatting position or in lithotomy, which is like the traditional position where you're laying on your back and your legs are kind of up in the stirrups. There's a higher risk of tears in those circumstances compared to being semi recumbent, where you're not laying completely flat, or if you are on your side, there's a reduced risk of tears in those positions.

Nicole: Also how well trained your provider is on understanding anatomy, being able to recognize when tears happen and repair them accordingly. Also being patient, also not doing episiotomy, fetal occiput posterior presentation. So your provider, their training will have some influence as well. And then finally, Cesarean delivery can reduce the risk of oasis. It actually surprisingly does not completely eliminated. Like you can have only Cesarean births and in rare circumstances still have injury to those muscles. There may be something about the way that your baby was sitting during your pregnancy that caused those injuries to happen, but it does definitely, definitely, definitely reduce the risk of those things happening. So to help prevent it, perineal massage and warm compresses are going to be the two big things. And then the position you're in during birth, I say that that's less likely because honestly, you're going to give birth and what position works best to get the baby out.

Nicole: So you may not be able to necessarily control that. Having a good provider will reduce your risk. And then in the extreme cases, the Cesarean birth. So let's talk about what happens if you have a tear. So if you have a, an oasis injury, a third or fourth degree tear, they're almost always diagnosed at the time of delivery and we have to fix it. So immediate surgical repair is how things are done. And this is something that can take some time. These tears are extensive and we need to really take our time to make sure that we put them back together. So to repair a fourth degree tear can take an hour or more to put everything back together correctly. A third degree tear, probably, you know, 30 to 45 minutes. It takes some time to get these things together and get them together right. Now, we almost always do it like right away and some things that are a mainstay of treatment of course, you're going to have adequate pain control, but you really want to be sure you have someone who is comfortable with the anatomy and who is comfortable with fixing those more severe tears. So for someone like me, who hasn't seen a fourth degree tear since residency, if I saw one, then I would want to call a colleague, usually a urogynecologist to come in and potentially help fix it because you want to get it right the first time. And it's really important. So in some cases, I say all that to say that in some cases we may actually delay repair. If we feel like circumstances aren't great to repair it right after delivery. If it's not bleeding, then we can wait to repair. There is a study that showed that waiting eight to 12 hours even after delivery did not make a difference in terms of having symptoms afterwards or incontinence issues.

Nicole: So it can be worthwhile if the person who's there at the delivery, either isn't trained to repair it, or you don't have good anesthesia available because you're going to need good anesthesia available, to wait and repair it when you have those things there. Now, one thing people always ask, which is a very natural and common question, is how many stitches did I get? So with a second, third or fourth degree, it's usually not just like a discrete number of stitches. So like a little first degree, that may be a couple stitches, but a second degree repair is usually like one long stitch and third or fourth degree tears are going to be multiple stitches that have to be done in different places. I'm kind of hesitating because I'm trying to think of a good way to explain, like how it's so many different stitches without it sounding like it's crazy, but it's really hard to say, like, it's not like if you had a cut on your scalp and you just put a line of like five stitches in it or something like that, it's really a more complicated repair.

Nicole: And it's just, I say that to say, it's a lot of stitches and it's really difficult to say like, oh, it's five stitches or it's 10 stitches because it's a, a complex sort of thing that's being done. These are all absorbable stitches. So you don't have to come back and get them taken out or anything. They usually absorb on their own within four to six weeks. Sometimes they hang around a bit longer than that. But most of the time they absorb on their own within four to six weeks. Now, after you have a more severe tear, especially like a third or fourth degree, a few things are going to be important afterwards to make sure things heal up. Well, number one is pain control because it's going to be uncomfortable. So pain control is going to be important. Some things that work great are ice packs. Ice packs can work very, very well.

Nicole: You can put a bag of ice in a baggie and put a towel around it, leave it on your bottom for 15 to 20 minutes at a time. They work great. Witch Hazel is great. Sometimes we've prescribed topical numbing spray just to numb things a bit, a peri bottle, which is a squirt bottle that helps squirt water in the perineal area, uh, can help with that discomfort as well, as far as medications NSAIDs, which are non-steroidal anti-inflammatory drugs, that would be the generics are ibuprofen or Naproxen. The brand names for ibuprofen or Motrin and Advil are the most common ones. The brand name for Naproxen is Aleve, but those NSAID medications work very well to reduce inflammation and help with pain. And you can alternate that with acetaminophen, which is Tylenol. Alternating those two things actually work synergistically together to help reduce pain.

Nicole: And when those two things aren't quite enough, or you need something to say to help you sleep, or a little bit more, then we add opioid medications as well. Something that is also really, really important is to avoid constipation. As you can imagine, or as I've described, I've talked about how these third and fourth degree lacerations we've just put back the muscles that you need in order to control your poop and your gas. So the last thing you need is to be straining to use the bathroom and putting pressure on that repair that's there. So we have to avoid constipation. Usually we do that with stool softeners, rarely with laxatives, but usually stool softeners are enough to keep stool on the softer side. So it's easy for it to come out. You should definitely be seen within one or two weeks after a third or fourth degree tear, just to make sure it is on the right path to healing.

Nicole: It will not be completely healed by then. It's going to take four to six weeks to heal, or sometimes even longer for it to heal. But we definitely want to see you back in those first one to two weeks to make sure things are healing well. And we're also on the lookout for other things like infection, making sure it's not falling apart in those first one to two weeks. Now, some other things that may happen in a long-term in terms of after having a tear, a rare small subset of people, and these numbers are kind of hard to quantify, will have persistent pain in the area or persistent, painful intercourse in the area. Sometimes that requires surgery. Sometimes it may be as simple as going to a pelvic physical therapist to help get used to this rebuilt anatomy. I think we under utilize pelvic physical therapist in general, a lot.

Nicole: I see a lot more pelvic physical therapists coming about. So that's definitely something that you should, I think really actually probably routinely be referred to if you have a third or fourth degree laceration, a pelvic physical therapist, and then sometimes the cosmetic appearance isn't necessarily satisfactory. So everything feels fine. Like you're not having pain, it's not infected, but maybe there's a skin tag that's there and it doesn't look normal to you. Or maybe it feels like it rubs funny in your underwear. Or maybe sometimes some folks report feeling too open or too tight. Those are, again, things that may be addressed with a pelvic physical therapist or rarely with surgery. All right. So just to wrap up what happens in future pregnancies, if you had an oasis injury. So if you had an oasis injury in one pregnancy, the risk in a future vaginal delivery is not very high.

Nicole: It's actually just three to 5%. So I think you can be reassured that if you've had it one time, the risk of recurrence is low. Now, if you do happen to sustain a second oasis injury, then that does increase your risk a lot for long-term incontinence problems. There have been studies that show that if you have two third or fourth degree injuries, that you can have a 10 fold increased risk of injuries in a next pregnancy and also injuries or problems with that anal incontinent. So if you have one, it's not likely that you're going to have a second, but if you do have a second, then it does increase your risk of things happening or having problems in the long-term from it. So if you've had one prior Oasis injury, and honestly there's not a lot of studies or data or research to make like scientific recommendations.

Nicole: So a lot of this is just based on what we think is best practice. So if you have had one prior oasis injury, so a third or fourth degree tear, then really vaginal delivery can certainly be a reasonable option after you're counseled about the risk. Again, the risk of repeat injury is three to 5%. So if you want to try for a vaginal delivery, you certainly can. And that's assuming that things healed up well, you're not having any symptoms. You're not having any problems. Everything is good in that regard. Okay. Now, if you have had two or more prior injuries, then certainly we offer a planned Cesarean birth with two or more prior third or fourth degree injuries. We would reasonable to offer that, to avoid it in the future, or if you have symptoms. So if you had a third or fourth degree tear and you had a lot of symptoms from it, it took you a long time to heal, you don't want to go through that again or risk that again, then certainly reasonable for you to have a planned Cesarean birth. Okay. So that is it for the episode on perineal tears. Just to recap, they are not very common, some risk factors that can increase your risk of having a vaginal tear, especially those third and fourth degree ones are a longer pushing phase, episiotomy, VBAC and operative delivery. The two best strategies to prevent them are perineal massage and warm compresses. And if you have a vaginal tear, most often you will heal well with a good surgical repair repaired at the time of the event happening, or sometimes delayed. If we need to get things in better shape with better anesthesia, someone who's more skilled in it surgically to repair it. But most of the time things are going to heal well and it's not likely to recur.

Nicole: Okay. So that's it for this episode, be sure to subscribe to the podcast in wherever you're listening to me right now, Spotify, Google Play, Apple Podcast, and I would love it if in Apple Podcast, you leave me an honest review. Uh, it helps other folks to find the show. It helps the show to grow. And of course I love reading those reviews. I do shout outs on the podcast from time to time from those reviews in Apple Podcasts in particular. And don't forget about checking out the Birth Preparation Course. Remember perineal tears are just a tiny, tiny part of what you need to know about labor and birth. You can learn everything that you need to know to be calm, confident, and empowered, to have a beautiful birth by going through the Birth Preparation Course, it is currently 40% off because of these crazy times we're in. You can check that out at drnicolerankins.com/enroll. Next week on the podcast, it is another birth story episode, and this will be another one from a dad's perspective. So please come on back next week because I'd love to see you. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.