Perineal tears

Question 1

Prevalence of perineal tears:

Answer 1

Up to 9 in every 10 first-time mothers who have a vaginal birth will experience some sort of tear, graze or episiotomy.

Question 2

Why does a perineal tear occur?

Answer 2

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

Question 3

What are perineal tears more common with?

Answer 3

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

Question 4

What are perineal tears classified into?

Answer 4

4 degrees:

first degree
second degree
third degree
fourth degree

Question 5

What is a first-degree perineal tear?

Answer 5

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

Question 6

What is a second-degree perineal tear?

Answer 6

-tear includes perineal muscles but not affecting the anal sphincter

Question 7

What is a third-degree perineal tear?

Answer 7

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

Question 8

What is a fourth-degree perineal tear?

Answer 8

-includes the rectal mucosa

Question 9

What can third-degree tears be subcategorised as?

Answer 9

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

Question 10

What is the management for first degree tears?

Answer 10

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

Question 11

What is the management for second degree tears?

Answer 11

-requires suturing on ward by a suitably experienced midwife or clinician

Question 12

what is the management for third degree tears?

Answer 12

require repair in theatre by a suitably trained clinician

Question 13

what is the management of forth degree tears?

Answer 13

require repair in theatre by a suitably trained clinician

Question 14

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

Answer 14

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

Question 15

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

Answer 15

-elective c section

Question 16

What complications can perineal tears lead to?

Answer 16

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

Question 17

What is an episiotomy?

Answer 17

• 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 18

What is a perineal massage?

Answer 18

• 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

Question 19

A 35 year old primiparous woman is seen by the obstetrician following an uncomplicated vaginal delivery at 39 weeks gestation. On examination, she has a perineal tear which extends through the perineal skin, muscles, fascia and a quarter of the thickness of the external anal sphincter.

What degree is this perineal tear classified as?
A. 3a
B. 3b
C. 3c
4. 4
5. 2

Answer 19

A: 3a
-perineal tear extended onto perineal anal sphincter, <50% thickness torn

Question 20

what is the management of forth degree tears?

Answer 20

require repair in theatre by a suitably trained clinician