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Acute injuries and lacerations of the perineum, vagina, uterus, and support tissues can occur during childbirth. Injury can include bruising, lacerations, or intentional cutting of the vaginal or perineal tissue. Interventions such as the application of warm compresses and gentle perineal massage and stretching while the woman is pushing have been suggested as measures to decrease perineal lacerations and trauma. Some women practice perineal massage during the last month of pregnancy to reduce perineal trauma during birth and pain afterward for patients who have not previously given birth vaginally. The tendency to sustain lacerations varies with each patient; that is, the soft tissue in some patients may be less distensible. Damage is usually more pronounced in nulliparous patients because the tissues are firmer and more resistant than those of multiparous women.
Other risk factors associated with perineal trauma include:
Heredity
Maternal nutritional status
Birth position
Pelvic anatomy (e.g., narrow subpubic arch with a constricted outlet)
Fetal malpresentation
Position (e.g., breech, occiput posterior position)
Macrosomic (large) infants
Use of forceps or vacuum to facilitate birth
Prolonged second-stage of labor
Precipitous (rapid) labor in which there is insufficient time for the perineum to stretch
Perineal Lacerations
Perineal Lacerations
Perineal Lacerations are spontaneous tears in the skin of the vagina and perineum. They are repaired with suture after delivery by the provider. There are different types of lacerations which are classified depending on the extent of the tearing.
First Degree Lacerations extend through the skin of the vagina and introitus; it is superficial to the muscles
Second Degree Lacerations extend extends through skin and muscles of the perineal body
Third Degree Lacerations continue through the external anal sphincter muscle
Fourth Degree Lacerations extend completely through the anal sphincter and the rectal mucosa
OBGYNAcademy (n.d.) Obstetrical Lacerations. https://obgynacademy.com/obstetrical-lacerations/
Vulvar, Vaginal, and Urethral Lacerations
Vulvar, Vaginal, and Urethral Lacerations
OBGYNAcademy (n.d.) Obstetrical Lacerations. https://obgynacademy.com/obstetrical-lacerations/
Vulvar and vaginal lacerations often occur in conjunction with perineal lacerations. They tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations are often circular and may result from use of forceps to rotate the fetal head, rapid fetal descent, or precipitous birth. Trauma to the periurethral area is often an abrasion, but caution to evaluate it is necessary as the swelling to the tissue surrounding the urethra may be significant enough to close the urethral opening and cause urinary retention. Clitoral and labial tears and abrasions may not be repaired if bleeding from the area is minimal.
Cervical Injuries
Cervical Injuries
Vulvar and vaginal lacerations often occur in conjunction with perineal lacerations. They tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations are often circular and may result from use of forceps to rotate the fetal head, rapid fetal descent, or precipitous birth. Trauma to the periurethral area is often an abrasion, but caution to evaluate it is necessary as the swelling to the tissue surrounding the urethra may be significant enough to close the urethral opening and cause urinary retention. Clitoral and labial tears and abrasions may not be repaired if bleeding from the area is minimal.
OBGYNAcademy (n.d.) Obstetrical Lacerations. https://obgynacademy.com/obstetrical-lacerations/
Episiotomy
Episiotomy
An episiotomy is an incision made in the perineum to enlarge the vaginal outlet. Different types of episiotomies may be performed, classified by the site and direction of the incision. Both types have advantages and disadvantages, and it is unclear which, if either, is a better choice. Midline episiotomies are associated with a higher incidence of third- and fourth-degree lacerations. However, mediolateral episiotomies may be more painful. Routine episiotomy has no role in modern obstetric care and should be avoided whenever possible. An indicated episiotomy may still be performed in specific situations, such as the need to hasten birth when fetal distress is present.
OBGYNAcademy (n.d.) Obstetrical Lacerations. https://obgynacademy.com/obstetrical-lacerations/
Other Resources
Other Resources
Cichowski,S. & Rogers R. (2011, June). Prevention and Management of Obstetric Lacerations at Vaginal Delivery. ACOG Practice Bulletin Number 198. http://unmfm.pbworks.com/w/file/fetch/140666574/ACOG%20Practice%20Bulletin%20No.%20198_Prevention%20%26%20Mgt%20of%20Obstetric%20Lacerations%20at%20Vag%20Delivery.pdf
peri lac acog bulletin.pdfOBGYNAcademy (2023) Obstetrical Lacerations. https://obgynacademy.com/obstetrical-lacerations/
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