What measures can be taken to reduce pain, infection and promote healing of the sutured perineum during the postnatal period
Post-natal perineal trauma has been shown to be a source of significant morbidity for many women (Hall and Baston, 2009). Perineal trauma is any damage to the perineal area during child birth via surgical incision (Episiotomy) or spontaneously. Majority of women (over 85%) experience perineal trauma after birth of which 60-70% required stiches (Brandie and MacKenzie, 2009). This essay will significantly focus on what measures that can be taken to reduce pain, infection and promote healing of the sutured perineum during the post-natal period. Reflective account of some observations in practice in relation to the chosen topic will be discussed.
The perineum is the most posterior part of the external female reproductive organs and its made up of skin, muscle and fasia (Ricci and Kyle, 2009). The perineum is the area of tissue between the vagina and anus and it connect the muscles of the pelvic floor (Vercellini, 2011). In support to this, Alcamo (2003) explained that the floor of pelvis and its associated structures are collectively known as perineum and in the perineum, the pelvic floor extends from the sacrum and coccyx to the pubis and ischium. Moreover, the muscles support the organs of the pelvic cavity and bring about flexion of the sacrum and coccyx (Alcamo, 2003). They also control the movement of materials through the urethra and anus (Terfera and Jegtvia, 2012 & Alcamo 2003, Stanton and Zimmern, 2003).
The perineum is an important part of the women’s body and it plays a very special role to women during child birth (ref). During childbirth, the vagina further stretches to allow the baby to come through to the point at which the skin of the perineum strains and tear (ref). Likewise, a review by Carroli & Mignini (2009) identified that injuries to the vagina during labour occur at the vaginal opening, and may tear as the baby’s head passes through. Moreover, the author stated that for a successful vaginal delivery, the vaginal opening must dilate slowly to allow the appropriate stretching of the tissues. Various research has proved that tearing during childbirth is a most common occurrence among women (ref). This statement concurs with Dahlen et al, (2013) and Soong and Barnes (2005), the rate of spontaneous perineal tearing was recorded to be from 44-79%. Similarly, A quantitative study by Costa and Riesco and Luiza (2006) shown the prevalence of perineal laceration during child-birth. They found in their study of 63 women who delivered spontaneously, among these, 46.7% had an intact perineum after delivery and 53.3% had perineal lacerations. This can significantly damage the skin, anal sphincter and the muscle that control the anus and subsequently impacting quality of life.
Nonetheless, Aasheim et al (2011) elucidates that women are more likely to experience tearing during a first virginal birth. This was further supported by Smith et al (2013) an increased risk of severe perineal laceration was found more in primiparous women, supporting findings of other research Landy et al, 2011 and Keriakos & Gopinath, 2015 . A study by Lyer (2017) recorded 639,402 first time mothers who had a virginal delivery. The data came from the hospital episodes’ statistics which consisted all maternity admissions in NHS hospitals. From this research, an increased rate of women with vaginal delivery for the first-time experience severe tearing. According to Hanratty (2003), perineal laceration is common in primigravidae because the perineum is more likely to be rigid, as supported by Gould (2007).
The classification of the degree of perineal tearing was based on first, second, third or fourth degree, in reference to the classification of Royal College of Obstetricians and Gynaecologists (2015). The classification degrees of tears experienced by women during vaginal birth has been further explained in a study by Daniilidis et al (2012) the authors identified first-degree tear as perineal laceration extending through the vaginal mucosa and perineal skin only. Second degree tear has been described as extending into the perineal muscles, third degree tear involving the external anal sphincter and the fourth-degree tear involving both the anal sphincter and the anorectal mucosa; this is supported by (Essa and Ismail 2015).
A prospective study by Leeman et al (2009) showed that major trauma was defined as a second degree, in agreement to this, a cross-sectional study which was carried by Francisco et al (2012) found second degree as a major trauma after child birth, requiring suturing. Though keteen (2007) argued that first and second degree of tear are classified as spontaneous and mild tear and require no suture and is associated with reduced wound healing up to 3months after birth and reduces dyspareunia and pain at up to 3 months (Kettle and Tohill, 2008). When in fact, many studies have found third-fourth degree tears as a major/severe trauma after child birth as they can become contaminated with bacteria from the rectum, which can significantly increases the chance of perineal wound infection, pain and more maternal morbidity (Dahlen et al, 2007; Rodriguez et al, 2008; Kominiarek, 2010; Minaglia, 2009; Persico et al , 2013; Leal et al, 2014). A qualitative study by Urganci et al (2013) establish an Increase in the rate of third-fourth degree perineal tears in England, with the rate rising from 1.8% in 2000 to 5.9% in 2011; and this increased risk of severe tear was associated with a maternal age above of 25years, forceps and ventouse delivery. Royal College of Midwives (RCM) proposed that, midwives have an essential role in the management of the sutured prenieum in the post-natal stage, this includes; the assessment of wound healing and prevention of infection.
Several other risk factors have been reported for third-fourth severe perineal lacerations developing during child birth (Urganci et al, 2013). These includes; asian race, nulliparity, higher birth weight, occiput posterior fetal position, vaginal delivery and midline episiotomy (Landy et al, 2011), this statement was supported by Schmitz et al (2014). Conversely, in another study by Groutz et al (2011) showed, mild perineal tears are also reported to occur in up to 73% of nulliparious patrutirients. In consequence, mild tears also deserve special consideration as it can affect the muscular structure (Hervas et al, 2015). A considerable number of studies have been published to avoid an episiotomy (ref). In support to this, other studies by Shiki, Yamasaki & Shimoya (2009); Revicky ey al (2010) & Carroli and Mignini (2009) showed that episiotomy does not serve its putative benefits of preventing pelvic floor damage and incontinence, rather the procedure increases the risk of severe perineal tear, need for suturing, wound complications and impaired sexual functions. This means when episiotomy is avoided, the risk of third-fourth tear is reduced (ref).
In addition to this, it was reported by Graham et al (2005) that the rate of episiotomy for both multiparous and primiparous women differ widely worldwide from 9% to over 90%, as supported by Raisenen, Julkunen and Heinonen (2010), even with increasingly compelling evidence and national practice guideline recommendations to minimise use of the procedure (National institute of health and clinical excellence (NICE), 2007; Carrolli and Mignini (2009); World health organization (1985). In a study, the strongest risk factors for episiotomy were vacuum assistance and the maternity hospitals (ref). Therefore, according to NICE (2007), the reduce in use of episiotomy among women is associated with benefits of improved healing, faster recovery post-partum, less pain, improved maternal infant bonding and restoration of normal sexual function, as supported by Hartmann et al (2005) and Carroli and Mignini (2009).
In contrast, a study by Urganci et al (2013) argued that women who had an episiotomy do not experience a severe perineal tear regardless of the mode of delivery, which was in agreement with Grigoriadis et al (2009) & Vakilian et al (2011) who suggests that the use of episiotomy in normal delivery results in fewer perineal laceration and trauma. Yet, there is more evidence in the UK to support the need for routine episiotomy to be avoided in women. Indeed, research suggests that an episiotomy can be recommended when the baby develop a condition known as foetal distress, where the baby heart rate and regularity significantly reduces or increases before birth to avoid the risk of birth defects or stillbirth. In addition, an episiotomy can also be carried out to widen the vagina opening so the forceps or ventouse suction can be used to assist with the birth. (Ref) explained that episiotomy requires stitches and any other degree of tear may require stitches and usually heals in two to three weeks, as agreed by (Chou & Abalos, 2013). They went further explaining that any trauma and stiches can cause discomfort, pain and infection. A retrospective audit by Johnson, Thakar and Sultan (2012) proposed vaginal delivery that required suturing can develop perineal wound infection. The authors described wound infection as the presence of any of the following markers; such as; perineal pain, wound dehiscence or purulent vaginal discharge. Hankins, Hauth & Gilstrap (2000) suggests that these wounds will normally dehisce in the first 7-14 days following childbirth. A study by Elharmeel, et al(2011) explained that suturing gives better wound approximation and reduces the risk of bleeding and haematoma formation. However, (ref) argued that suturing interferes with breast feeding and increases burning sensation and longer healing process.
Both perineal laceration and episiotomy are strongly linked with the presence of perineal pain during immediate postpartum period (Leeman,2009). In a likely manner, Francisco et al (2014) carried a survey conducted with 2,400 women in the US on perineal pain. They found that among 1,656 women who had a vaginal delivery, 40% reported pain in the first two months following the delivery. At or after six months, some women still reported pain in the perineum as a persistent problem. Furthermore, East et al (2012) did a survey with 215 Australian women 72 hours post vaginal delivery and it was showed that the intensity of perineal pain was significantly affected by the degree of the trauma. They found that severity of the pain was related to the existence of an episiotomy. 7% of women with vaginal delivery reports a painful perineum six months after birth whereas for who had an episiotomy, the rate was 9%. Though Beckmann & Stock (2013) suggests despite if the perineum is intact after vaginal delivery, some women may still report pain, as supported with Francisco et al (2014). From several literatures suggests, many women who have had birth experience pain as a result of perineal trauma defined the pain as occurring in their perineal body, the area of muscular and fibrous tissue which extends from the symphysis pubis to the coccyx (Bick et al, 2012). This may be from an episiotomy or bruising or oedema of perineal tissues which may occur even if the perineum is intact.
Additionally, Leeman et al (2009) reports that, perineal pain result in discomfort when passing urine, decreased mobility and can negatively impact on the women ability to breast feed or care for their new infant which contributes to depression or mental exhaustion; this statement was supported by Sultan & Thakar 2002; Kapoor et al, 2005 & Hedayati et al, 2005). Postpartum depression has shown to have negative impact on the infant -mother relationship/interaction and may interfere with the overall experience of motherhood. Ultimately, a study by Rogers et al (2009) also found that perineal pain that continues beyond the immediate postpartum period also have long term effects such as painful sexual intercourse for up to 18months after birth. Perineal tear has been highlighted in many studies to have psychosocial impact on women’s life at a post-natal stage such as; altered body image, isolation and fear. This can therefore pose a serious threat to the general wellbeing and quality of life of the mother (Marx, Williams & Hicks, 2007).
When perineal trauma occurs regardless of the underlying contributing factors or interventions, when pain is present it requires attention. Evidence supports the use to oral analgesia such as paracetamol and ibuprophen to reduce pain of sutured perineum during post-partum (ref). Francisco et al (2011) qualitative study found Paracetamol (Acetaminophen) as the most preferred oral analgesic for mild sutured perineal pain due to its useful analgesic properties and no side effects. In addition, they identify in their study that when paracetamol is not effective, non-anti-inflammatory agents can be most suitable as they rarely have any collateral effects and its exertion in breast milk is limited. Equally, East et al (2012) and Wienecke and Gotzsche (2004) stated that of all oral medication, paracetamol is the most popular, first choice of oral analgesia and most effective at reducing perineal pain (in a single dose of 500-1000mg) with few side effects. Many studies recommended the use of a non-steriodial inflammatory drug as an additional analgesia if required in the absence of contraindications (Chou et al, 2010; East et al, 2012; Wuytack & Smith, 2014). On reflection, during the student clinical placement at the community, at post-natal visit, majority of women had second degree tear and they reported the use of paracetamol and ibuprofen to be effective for their pain. A systematic review by Nauta, Landmaster & Koren (2009) carried out a study, examining post-surgical perineal pain. From their findings, they found the combination of paracetamol and NSAID combination with less side effects.
However, Akil et al (2009) advocates that when NSAID is contradicated, the combination of codeine and other oral opioids to single dose oral paracetamol were effective in reducing severe pain of the sutured perineum. Yet, East et al (2012) in an Australian study states only 3.7% of women reports using oral opioids for perineal pain possibly due to concern about its side effects of constipation and drowsiness According to Koren et al (2006) a death of a two-week-old breastfeed baby whose mother was using oral codeine was later found to be in the 10% of the population who are ultra-rapid metabolisers of oral codeine, converting it to abnormally elevated levels of morphine in her breast. Indeed, many study has caution the use of codeine for perineal pain due to its adverse effect. Rectal analgestic medication has been identified to be the faster acting and more effective in perineal analgesia. For example, a study by east et al (2012) found that many women who administered non-sterodial anti-inflammatory rectal analgesia rated it as effective. This supports the work of Yildizhan et al (2009) that indomethacin and diclofenac suppositories provides efficient relief from perineal pain. A Cochrane review of post-partum rectal pain relief by Achariyapota & Titapant (2008) highlight that NSAID rectal suppositories administered following perineal suturing/ or episiotomy reduced pain for up to 24 hours and the subsequently use of less additional an analgesia. Though, Srimaekarat (2011) contradict to this, stating in their research that rectal opioids has not been proven useful and effective for postpartum perineal analgesia.
Third-fourth degee teas can become contaminated with bacteria from the rectum (Fitzpatrick and Herlihy, 2007) and when that occurs, it can lead to incontinence of stool or flatus, rectovaginal fistula or sexual dysfunction. Memon and Handa (2014) qualitative study found that women with a sphincter laceration had a severity of anal incontinence and sexual dysfunction. In preventing this, a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo is given for the third-fourth degree perineal tears (ref). Evidence by (ref) proved that patient who received prophylactic anti-biotics at the time of third-fourth degree laceration repair had a lower rate of perineal wound complications than patients who received placebo by 2 weeks post-partum. RCOG (2007) stated that for women with third-fourth degree tears, they are presecribed broad spectrum anti-biotics and prophylactic laxitives (lactulose or fybogel) for around 10 days post-birth to prevent wound infection or possible wound dehiscene. Besides, advice on diet, drinking plenty of fluids, vegetables and fruit rich in vitamin c are offered to women (Bick and Basset, 2013) as observed in practice. This will prevent constipation and support wound healing (Bick and Basset, 2013).
Women have personal preferences for self-care and their choices may be equally individual and varied (Wickham, 2000). Indeed Chou et al (2010) stated that some women may not wish to take medication for perineal pain due to the concerns about side effects and transmission of drugs through breast milk. For some women who do not take medications, Complementary and alternative medicine (CAM) is used for perineal analgesia. According to Adams (2006) and Hall, McKenna & Griffiths (2010) CAM therapy is an important component of midwifery practice as it seen to be related to professional autonomy and women-centered care.
Cooling has been customarily been in form of handmade ice packs prepared by midwives or women themselves, these includes fingers of latex gloves or condoms which have been filled with water then tied off and frozen (Petersen 2011 & Bick et al 2008). East et al (2011) quantitative study on perineal pain following child-birth in Australia found from their study that 59% of women interviewed rated the analgestic effect as extremely effective. They also identify that the application of ice following perineal suturing provides a cooling treatment to reduce pain and oedema. However, Petersen (2011) argued the use of ice being a vector for infection from contamination during their creation and this can increase the risk of ice burns and delay healing. Research by Navvabi, Abedian & Steen-greaves 2009 and Steen & Marchant (2007) has shown that the comfort of manufactured gel pads is preferred over ice packs. However East et al (2012) noted that manufactured gel pads were not widely used, Petersen (2011) explained that the low use could be due to the high cost of manufactured cooling gel pads. Pelvic floor exercises has been reported to promote healing of the perineal trauma (Fox 2011), decrease oedema, reduce perineal pain and promote circulation. It is important to ensure that women are familiar with the correct techniques and importance of long term adherence as supported by (ref).
A topical application of tea free oil has been shown to help the perineal tissue recover and helps prevent infection (ref). In support to this tea tree oil according to (ref) is a natural anti-septic that penetrates below the upper skin layer, soothes and relieves pain. However, Ernst & Huntley (2004) systematic review of the topical application of tea tree oil concluded that there was no compelling evidence of efficiency but there was risk of allergy. Fox (2011) reports that the local reaction of perineal skin in response to tea tree oil may have contributed to association between infection of second degree tears. Further to Fox Study, they found Irish women with second degree had been advised and encouraged to bath twice a day in water containing up to 10 drops of tea tree oil dissolved in a tablespoon of milk. Fox (2011) also proposed that after cessation of the oil, the infection rate of the fifth day postpartum reduced 5.9% to 3.9%.
Recommendations has been made by NICE guidelines for all midwives to take a minimal approach asking women about their perineal wound discomfort at each post-natal visit but to rather offer a physical assessment only if women complain of pain or discomfort or stinging, offensive odour or dyspareunia. Coversely, experienced community midwives report evaluating and examining perineal healing while simultaneously keeping women’s perception of their own perineal healing at the core of their clinical judgement (Jones, 2011); as also observed in practice during clinical experience at the community.
In concusion, in this essay, the student has highlighted that women who have vaginal birth sustain perineal trauma, which can range from different degrees of tears and its management at post-natal stage. Ultimately, it is important that women are offered with advice on how to care for their perineum, incuding information on signs and symptoms of infection and what requires immediate medical referral (NICE, 2006).
Baston, H. and Hall, J. (2009). Midwifery essentials. 1st ed. Edinburgh: Churchill Livingstone Elsevier.
Brandie, K & Mackenzie, A. (2009). Perineal trauma following vaginal delivery. Journal of the Association of Chartered Physiotherapists in Women’s Health, Autumn, 105, 40-55. Retrieved from www.csp.org.uk/sites/files/csp/secure/brandiemackenzie_hr.pdf
Kyle, T. and Ricci, S. (2009). Study guide for Ricci and Kyle’s Maternity and pediatric nursing. [Adobe Digital Editions Version]. ISBN:13:978-0-7817-8055-1.
Vercellini, P. (2011). Chronic Pelvic Pain. [Adobe Digital Edition Version]. ISBN: 978-1-4443-3066-3.
Alcamo, E. (2003). Anatomy Coloring Workbook. [Adobe Digital Edition Version]. ISBN: 0-375-76342-2.
Terfera, D. and Jegtvig, S. (2012). Clinical anatomy for dummies. ISBN: 978-1-118-11643-2
Stanton, S. & Zimmern, P. (2003). Female pelvic reconstructive surgery. 1st ed. London: Springer.
Carroli,G & Mignini, L .(2009). Episiotomy for vaginal birth. Cochrane Database Syst Rev, 21(1). doi: 10.1002/14651858.
Dahlen, H., Priddis, H., Schmied, V., Sneddon, A., Kettle, C., Brown, C. & Thornton, C. (2013). Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study. BMJ Open, 3(5), p.e002824. doi: 10.1136/bmjopen-2013-002824.
Soong, B. & Barnes, M. (2005). Maternal Position at Midwife-Attended Birth and Perineal Trauma: Is There an Association?. Birth, 32(3), 164-169. doi: 10.1111/j.0730-7659.2005.00365.x.
DESOUZACAROCIDACOSTA, A. & GONZALEZRIESCO, M. (2006). A Comparison of “Hands Off” Versus “Hands On” Techniques for Decreasing Perineal Lacerations During Birth. Journal of Midwifery & Women’s Health, 51(2), 106-111. doi: 10.1016/j.jmwh.2005.10.017.
Aasheim, V., Nilsen, AB., Lukasse, M. & Reinar, LM. (2011). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev, 7(12). doi: 10.1002/14651858.CD006672.
Smith, L., Price, N., Simonite, V. and Burns, E. (2013). Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy and Childbirth, 13(1). doi: 10.1186/1471-2393-13-59.
Landy, H., Laughon, S., Bailit, J., Kominiarek, M., Gonzalez-Quintero, V., Ramirez, M., Haberman, S., Hibbard, J., Wilkins, I., Branch, D., Burkman, R., Gregory, K., Hoffman, M., Learman, L., Hatjis, C., VanVeldhuisen, P., Reddy, U., Troendle, J., Sun, L. and Zhang, J. (2011). Characteristics Associated With Severe Perineal and Cervical Lacerations During Vaginal Delivery. Obstetrics & Gynecology, 117(3), 627-635. doi: 10.1097/AOG.0b013e31820afaf2.
Keriakos, R. and Gopinath, D. (2015). Obstetric anal sphincter injuries. Journal of Acute Disease, 4(4), 259-265. doi: 10.1016/j.joad.2015.04.014.
Iyer, S. (2017). Women With Severe Vaginal Tear May Want To Consider C-Section For Future Deliveries. Medical Daily. Retrieved April 17, 2017, from http://www.medicaldaily.com/severe-perineal-tear-during-first-childbirth-increases-risk-recurrent-vaginal-tear-future-deliveries
Hanratty, KP. (2003). Obstetrics Illustrated. Churchill Livingtone: Edinburgh.
Gould, D. (2007). Perineal tears and episiotomy. Nursing Standard, 21(52), 41-46. doi: 10.7748/ns2007.09.21.52.41.c6596.
Daniilidis, A., Markis, V., Tzafetas, M., Loufopoulos, P., Hatzis, P., Vrachnis, N., & Dinas, K. (2012). Third degree perineal lacerations-How, why and when? A review analysis. Open Journal of Obstetrics and Gynecology, 02(03), 304-310. doi: 10.4236/ojog.2012.23064
Essa, R., & Ismail, N. (2015). Effect of second stage perineal warm compresses on perineal pain and outcome among primiparae. Journal of Nursing Education and Practice, 6(4). doi:
Leeman, L., Fullilove, A., Borders, N., Manocchio, R., Albers, L., & Rogers, R. (2009). Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma, Labor Care, and Birth Variables. Birth, 36(4), 283-288. doi: 10.1111/j.1523-536X.2009.00355.x.
Amorim Francisco, A., Junqueira Vasconcellos de Oliveira, S., Barbosa da Silva, F., Bick, D., & Gonzalez Riesco, M. (2011). Women’s experiences of perineal pain during the immediate postnatal period: A cross-sectional study in Brazil. Midwifery, 27(6), e254-e259. doi: 10.1016/j.midw.2010.10.012.
Gurol-Urganci, I., Cromwell, D., Edozien, L., Mahmood, T., Adams, E., Richmond, D., & Templeton, A. et al. (2013). Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG: An International Journal of Obstetrics & Gynaecology, 120(12), 1516-1525. doi: 10.1111/1471-0528.12363.
Groutz, A., Hasson, J., Wengier, A., Gold, R., Skornick-Rapaport, A., Lessing, J., & Gordon, D. (2011). Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. American Journal of Obstetrics and Gynecology, 204(4), 347.e1-347.e4.
Mora-Hervás, I., Sánchez, E., Carmona, F., & Espuña-Pons, M. (2015). Perineal Trauma in Primiparous Women with Spontaneous Vaginal Delivery: Episiotomy or Second Degree Perineal Tear?. International Journal of Women’s Health and Reproduction Sciences, 3(2), 84-88. doi: 10.15296/ijwhr.2015.16.
Räisänen, S., Vehviläinen-Julkunen, K., & Heinonen, S. (2010). Need for and consequences of episiotomy in vaginal birth: a critical approach. Midwifery, 26(3), 348-356. doi: 10.1016/j.midw.2008.07.007
Dahlen, H., Rayan., M. & Homer, S.E. (2007). An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth. Midwifery, 23, 196-203.
National Insitute for Care and Clinical Excellence. (2007). Intrapartum Care; care of healthy women and their babies during childbirth (CG190). Chichester: NICE.
Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., Lohr, K.N. (2005). Outcomes of routine episiotomy: a systematic review. Journal of the American Medical Association, 293(17), 2141–2148. doi: 10.1001/jama.293.17.2141.
Grigoriadis, T., Athanasiou, S., Zisou, A., & Antsaklis, A. (2009). Episiotomy and perineal repair practices among obstetricians in Greece. International Journal of Gynecology & Obstetrics, 106(1), 27-29. doi: 10.1016/j.ijgo.2009.03.013
Royal College of Obstetricians and Gynaecologists (2015). A third- or fourth-degree tear during birth: Information for you. London: RCOG;
Johnson A, Thakar R, Sultan AH. (2012). Obstetric perineal wound infection: is there underreporting? Br J Nurs, 21(5),28-32.doi: 10.12968/bjon.2012.21.Sup5.S28
Fleming, V. (2003). Does perineal suturing make a difference? The SUNS trial. BJOG: An International Journal of Obstetrics and Gynaecology, 110(7), 684-689.doi:10.1016/s1470-0328(03)02353-x
East, C., Sherburn, M., Nagle, C., Said, J., & Forster, D. (2012). Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery, 28(1), 93-97.doi:10.1016/j.midw.2010.11.009.
Beckmann, M., & Garrett, A. (2008). Antenatal Perineal Massage for Reducing Perineal Trauma. Birth, 33(2), 159-159. 10.1111/j.0730-7659.2006.00095.x.
Francisco, A., Kinjo, M., Bosco, C., Silva, R., Mendes, E., & Oliveira, S. (2014). Association between perineal trauma and pain in primiparous women. Revista da Escola de Enfermagem da USP, 48, 39-44.doi:10.1590/s0080-623420140000600006.
Bick, D., Ismail, K., Macdonald, S., Thomas, P., Tohill, S., & Kettle, C. (2012). How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice. BMC Pregnancy and Childbirth, 12(1).doi:10.1186/1471-2393-12-57.
Chou, D., Abalos, E., Gyte, G.M.L., Gulmezoglu, A.M. (2013). Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database of Systematic Reviews , 31(1). doi: 10.1002/14651858.CD008407.
Kapoor, D., Thakar, R., Sultan, A. (2005). Combined urinary and faecal incontinence.International Urogynecology Journal and Pelvic Floor Dysfuction, 16, 321–328.doi: 10.1007/s00192-004-1283-0.
Hedayati, H., Parsons, J., Crowther, C. (2005). Topically applied anaestheics for treating perineal pain after childbirth. Cochrane Database of Systematic Reviews, 18(2). doi:10.1002/14651858.CD004223.pub2
Rogers, R.G., Borders, N., Leeman, L.M., Albers, L.L. Does spontaneous genital tract trauma impact postpartum sexual function?. (2009). Journal of Midwifery and Women’s Health,54 (2), 98–103. doi: 10.1016/j.jmwh.2008.09.001.
East, C., Sherburn, M., Nagle, C., Said, J., & Forster, D. (2012). Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery, 28(1), 93-97.doi:10.1016/j.midw.2010.11.009
Akil, A., Api, O., Bektas, Y., Yilmaz, A., Yalti, S., & Unal, O. (2013). Paracetamol vs dexketoprofen for perineal pain relief after episiotomy or perineal tear. Journal of Obstetrics and Gynaecology, 34(1), 25-28.doi:10.3109/01443615.2013.828026.
Koren, G., Cairns, J., Chitayat, D., Gaedigk, A., & Leeder, S. (2006). Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother. The Lancet, 368(9536), 704.doi:10.1016/S0140-6736(06)69255-6
Yildizhan, R., Yildizhan, B., Sahin, S., & Suer, N. (2009). Comparison of the efficacy of diclofenac and indomethacin suppositories in treating perineal pain after episiotomy or laceration: a prospective, randomized, double-blind clinical trial. Archives of Gynecology and Obstetrics, 280(5), 735-738.doi:10.1007/s00404-009-1006-3.
Achariyapota, V. & Titapant, V. (2008). Relieving perineal pain after perineorrhaphy by diclofenac rectal suppositories: a randomized double-blinded placebo controlled trial. J Med Assoc Thai, 91(6), 799-804.
Srimaekarat, T. (2011). Tramadol Suppository versus Placebo for the Relief of Perineal Pain after Perineorrhaphy: A Randomized Controlled Trial in Thailand. J Med Assoc Thai, 94 (1): 17-20
Fitzpatrick, M., & O’Herlihy, C. (2007). Postpartum care of the perineum. The Obstetrician & Gynaecologist, 9(3), 164-170.doi: 10.1576/toag.220.127.116.11336.
Memon, H., & Handa, V. (2014). Comparison of Forceps and Vacuum-Assisted Vaginal Deliveries in Terms of Levator Ani Muscle Injury. Obstetrics & Gynecology, 123, 194S.doi: 10.1097/01.AOG.0000447224.29066.b0
Sultan, A., Thakar, R. Low genital tract and anal sphincter trauma. Best practice and research. Clinical Obstetrics and Gynaecology. 2002;16:99–115.
Kettle, C., Hills, R.K., Ismail, K.M.K., 2007. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews CD000947, doi:10.1002/14651858.CD000947.pub2.
Royal College of Obestericians and Gynaelogists. (2007). The management of third- and fourth-degree perineal tears. Green Top Guideline 29. London: RCOG.
Bick, D. & Bassett, S. (2013). Examine the best way to manage postnatal perineal trauma and pain. Midwives magazine, 2.
http://www.ijwhr.net/pdf/pdf_IJWHR_107.pdf (mora hervas).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3877300/ (Memon and handa)
it may interfere with the overall experience of motherhood Recommendations for appropriate pain relief and promotion of advice on perineal hygiene are provided in the NICE guideline for routine postnatal care  which highlighted a lack of appropriate information for women on this aspect of their post-birth recovery. Although a commonly experienced symptom, it was apparent that in many cases midwives did not have access to provide women with information on how to manage recovery of their perineal trauma post-birth
Women also revealed the extent of their fears relating to an altered body image, with thoughts of being deformed.
Most women spoke about the feeling of isolation and not being able to leave the house as soon as they had expected either as a result of the pain or feelings of anxiety and lacking in confidence
- Marx S,
- Williams A,
While these qualitative studies have focused primarily on women’s experiences of perineal trauma following Obstetric Anal Sphincter Injuries, the commonalities of both the physical and psychosocial findings of these studies have the potential to be applicable to women who sustain perineal wound dehiscence
, Hence, pain requires care and attention whenever present, irrespective of the trauma or underlying contributing factors.
A retrospective audit by Johnson and colleagues4 in 2012 suggested that 1 in 10 women who sustained a perineal tear at vaginal delivery that required suturing developed perineal wound infection. The authors defined wound infection as the presence of any two of the following markers: perineal pain, wound dehiscence or purulent vaginal discharge. The majority of these wounds will dehisce in the first 7–14 days following childbirth.5–7 However, robust systems to track wound dehiscence following hospital discharge are lacking and has led to the wide disparity of prevalence from 0.59%8 to 13.5%.9
Pain and discomfort related to perineal trauma have been reported to interfere with women’s daily activities postpartum, such as sitting, walking and lifting the baby.
Improving breast feed with perineal pain.
Both episiotomy and perineal laceration are strongly associated with the presence of perineal pain during the immediate postpartum period Perineal pain
and allowing delivery with less force applied to the baby’s head
Studies suggest that using episiotomy in normal delivery results in fewer perineal laceration and trauma
In the present study, the strongest risk factors for episiotomy were vacuum assistance and the maternity hospital (Table 4). Episiotomy rates ranged from 42% to 63% between the hospitals studied, with an overall episiotomy rate for all primiparous women of 55%. If the two hospitals with the higher rates had a lower (42%) incidence of episiotomies, there would have been 55 fewer episiotomies among the primiparous women.
- Recent studies have shown that episiotomy does not serve its putative benefits of preventing pelvic floor damage and incontinence. Rather, the procedure increases the risk of severe perineal tear, need for suturing, wound complications and impaired sexual function (Hartmann et al., 2005, Viswanathan et al., 2005 and Carroli and Mignini, 2009). Reported rates of episiotomy for both multiparous and primiparous women vary widely worldwide, from 9% to over 90% (Graham et al., 2005), despite increasingly compelling evidence and national practice guideline recommendations to minimise use of the procedure (World Health Organization, 1985, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 1997, National Institute for Health and Clinical Excellence, 2007 and Munro and Jokinen, 2008). A reduction in use of episiotomy among primiparous and multiparous women is associated with benefits of improved healing, less pain and faster recovery post partum (National Institute for Health and Clinical Excellence, 2007 and Munro and Jokinen, 2008), with secondary benefits of improved maternal–infant bonding and restoration of normal sexual function (Hartmann et al., 2005, Viswanathan et al., 2005 and Carroli and Mignini, 2009).
- A considerable number of studies have been published regarding how to avoid an episiotomy. It is known that uncoached pushing in the second stage of labour is associated with lower episiotomy rates (Sampselle and Hines, 1999). An episiotomy is less common if a woman is in the lateral position compared with the half-sitting position when giving birth (Downe et al., 2004; Hastings-Tolsma et al., 2007), and the lateral position also decreases the risk of perineal laceration (Hastings-Tolsma et al., 2007). Correspondingly, the lateral and all fours positions during the second stage of labour are associated with fewer sutures compared with the half-sitting position (Soong and Barnes, 2005). Lindgren1, 2Email author,
- Åsa Brink†1 and
- Marie Klingberg-Allvin
In the present study, the strongest risk factors for episiotomy were vacuum assistance and the maternity hospital (Table 4). Episiotomy rates ranged from 42% to 63% between the hospitals studied, with an overall episiotomy rate for all primiparous women of 55%. If the two hospitals with the higher rates had a lower (42%) incidence of episiotomies, there would have been 55 fewer episiotomies among the primiparous women.
Women who had an episiotomy were less likely to experience a severe perineal tear, regardless of the mode of delivery. Across the different modes of delivery, women who had a non-instrumental or a ventouse delivery with an episiotomy had the lowest rates of third- or fourth-degree tears. Use of forceps increased the risk of a tear, with a forceps delivery without an episiotomy increasing the odds of a tear six-fold compared with a vaginal delivery without an episiotomy
Severe perineal (third- or fourth-degree lacerations) and cervical lacerations sustained during delivery can have significant short-term and long-term effects. 1–4 Various risk factors have been reported for severe perineal lacerations developing during child birth, including increased maternal age, Asian race, nulliparity, higher birth weight, instrumented vaginal delivery, occiput posterior fetal position, and midline (median) episiotomy
Midline epistomy and vaginal delivery should be avoided in this population wherever possible, especially in the presse
A total of 2,516 third- or fourth-degree perineal lacerations (2.9%) and 536 cervical lacerations (0.8%) were noted. Third- or fourth-degree lacerations were sustained in 2,223 nulliparous women (5.8%) and in 293 multiparous women (0.6%). Cervical lacerations were sustained in 324 nulliparous (1.1%) and in 212 multiparous women (0.5%).
We found a three-fold increase in the rate of reported third- or fourth-degree perineal tears in England, with the rate rising from 1.8% in 2000 to 5.9% in 2011. An increased risk of a severe tear was associated with a maternal age above 25 years, forceps and ventouse delivery,
Mild perineal tears are also very common and were reported to occur in up to 73% of nulliparous parturients. So concluded thatEven in mild tears, second degree perineal trauma deserves special consideration as it affects the muscular structure. The muscular damage classified as a second degree tear is equal to or worse than that which results from a routine episiotomy, if it affects the levator ani muscle
One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection
Both episiotomy and perineal laceration are strongly associated with the presence of perineal pain during the immediate postpartum period. In the hours, days and months following childbirth, perineal trauma may be painful (Sleep et al., 1984, Glazener et al., 1995, Albers et al., 1999, East et al., 2009 and Leeman et al., 2009). Perineal pain can result in decreased mobility, discomfort when passing urine or faeces (Sultan and Sultan and Thakar, 2002, Kapoor et al., 2005 and Leeman et al., 2007), may negatively impact on the woman’s ability to breast feed or to care for her new infant and may contribute to depression or mental exhaustion (Hedayati et al., 2003 and Hedayati et al., 2005). Rajan (1994) reported improved breast-feeding rates following effective analgesia for perineal discomfort. Perineal trauma and pain that persists beyond the immediate postpartum period may also have longer-term effects, such as painful sexual intercourse for up to 18 months after giving birth (Buhling et al., 2006 and Rogers et al., 2009). Pain requires attention whenever present, regardless of the trauma or underlying contributing factors.
Not all perineal tears are sutured
How women feel as a result of the perineal trauma
Perineal tears are classically divided into four categories
Rasha Mohamed Essa ∗, Nemat Ismail Abdel Aziz Ismail
The aim of this study was to determine the effect of second stage perineal warm compresses on perineal pain and outcom+99e among primipara. A non-randomized controlled clinical trial was utilized at the labor and delivery unit of National Medical Institution in Damanhour, Albehera Governorate,
Klein et al. in a prospective study in 1994  demonstrated that women sustaining OASIS had significantly more perineal pain and analgesic requirements up to 10 days postpartum than women with second degree tears or an intact perineum (79% versus 50% versus 42%, respectively). More recently, Macarthur and Macarthur  has also shown more perineal pain with increasing degree of perineal trauma at 7 days postpartum (38% intact perineum versus 60% first and second degree tears versus 91% with third and fourth degree tears). Our study confirmed the findings of Klein  and demonstrated that women with first degree tears and intact perineii had less analgesic requirements than women with greater degrees of perineal trauma up to the fifth postnatal day.
Factor that contribute
Episiotomy and/or perineal lacerations increase the mother’s risk of pain, infection, and hemorrhage, and prolong recovery time (MacLeod et al., 2008).
In Brazil, there are few studies that have tracked the prevalence of perineal lacerations during childbirth
This study reported that lacerations occurred in 43% of women, with an intact perineum rate of 50%
with Also, in studies where the use of episiotomies was limited, the rate of spontaneous perineal tearing was recorded to be from 44-79% ().and with focepts and vacuum assistance.
An increased risk of severe perineal trauma in primiparous women was found in this study, supporting findings of other research (Green and Soohoo, 1989; Wilcox et al., 1989; Moller et al., 1992; Sultan et al., 1993a; Leeuw et al., 2001). Assisted vaginal delivery was found to be associated with an increase in severe perineal trauma, which is again supported by other studies (Moller Bek and Laurber, 1992; Sultan et al., 1993b; Poen et al., 1998; Leeuw et al., 2001).
Tearing during childbirth is a common occurrence among women who have a vaginal birth. In studies where the use of episiotomies was restricted, the rate of spontaneous tearing was recorded to be anywhere from 44-79% (Soong and Barnes 2005; Dahlen, Homer et al. 2007). Studies have consistently shown that women are more likely to experience tearing during a first vaginal birth and with forceps and vacuum assistance (Aasheim, Nilsen et al. 2011).
, however (ref) explains that, in some circumstances episiotomy is considered if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered. There are other reasons why episiotomy may be considered as highlighted by (ref)
The classification of the degree of perineal tearing was based on the standard definitions used in American obstetric practice: third-degree laceration, perineal laceration involving the anal sphincter; and fourth-degree perineal laceration, an injury involving both the anal sphincter and the anorectal mucosa.14
An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby’s head is being delivered. This procedure may be used if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered.
https://books.google.co.uk/books?id=NiTLf7g1n04C&pg=PA78&dq=anatomy+of+perineum+female&hl=en&sa=X&ved=0ahUKEwit9tmNiuLRAhXKLsAKHd8ND7QQ6AEIKTAB#v=onepage&q=anatomy%20of%20perineum%20female&f=false (Alcamo, 2003)
Persico G, Vergani P, Cestaro C, Grandolfo M, Nespoli A. Assessment of postpartum perineal pain after vaginal delivery: prevalence, severity and determinants. A prospective observational study. Minerva Ginecol 2013;65(6):669-78.
Leal NV, Amorim MM, Franca-Neto AH, Leite DF, Melo FO, Alves JN. Factors associated with perineal lacerations requiring suture in vaginal births without episiotomy. Obstet Gynecol 2014;123 (Suppl 1):63S- 4S. doi:10.1097/01.AOG.0000447369.00977.4c.
. Rodriguez A, Arenas EA, Osorio AL, Mendez O, Zuleta JJ. Selective vs routine midline episiotomy for the prevention of third- or fourth- degree lacerations in nulliparous women. Am J Obstet Gynecol. 2008;198:285.e1–4. [PubMed]
23. Minaglia SM, Kimata C, Soules KA, Pappas T, Oyama IA. Defining an at-risk population for obstetric anal sphincter laceration. Am J Obstet Gynecol. 2009;201:526.e1–6. [PubMed]
24. Kominiarek MA, VanVeldhuisen P, Hibbard J, Landy H, Haberman S, Learman L, et al. The maternal body mass index: a strong association with delivery route. Am J Obstet Gynecol. 2010;203:264.e1–7. [PMC free article] [PubMed]
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03210.x/full (hiryama support point).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132187/ (Landy at al).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907946/ (Keetle 2008).
http://www.sciencedirect.com/science/article/pii/S0266613808000752 (Loads of references).
http://www.sciencedirect.com/science/article/pii/S0266613812002264 (Loads of references).
Johnson A, Thakar R, Sultan AH. Obstetric perineal wound infection: is there underreporting? Br J Nurs 2012;21:S28, S30, S32–5.
- Hankins GD,
- Hauth JC,
- Gilstrap LC III., et al. Early repair of episiotomy dehiscence. Obstet Gynecol 1990; 75:48–51
- RCOG. (2007) The management of third- and fourth-degree perineal tears. Green Top Guideline 29. RCOG: London.
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