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Perineal tears during childbirth
Last reviewed: 07.07.2025
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[ Risk factors for perineal rupture
Perineal ruptures are more often observed with developed muscles, low tissue compliance in older primiparous women, a narrow vagina with inflammatory tissue changes, tissue edema, cicatricial changes after previous births. The shape and size of the mother's bony pelvis, the size of the fetal head and the density of its bones, as well as the size of the shoulders are of great importance. Overstretching of the vulvar ring occurs with an incorrect biomechanism of labor, when the head erupts not with the smallest small oblique size, but with a straight, large oblique size, etc.
During operative delivery, ruptures of the perineum and vaginal walls most often occur as a result of the application of obstetric forceps.
Depending on the degree of tissue rupture, a distinction is made between perineal ruptures of degree I-III (complete and incomplete).
- In a first-degree perineal rupture, the posterior commissure, the posterior vaginal wall within the scaphoid fossa, and the perineal skin are torn. As a rule, this rupture is not accompanied by bleeding.
- In case of a second-degree perineal rupture, in addition to the posterior commissure, the posterior vaginal wall and the perineal skin, the fascia and muscles of the tendinous center of the perineum are additionally torn (in this center the muscles and fascia of all three floors of the gaseous fundus converge). This rupture is accompanied by bleeding.
- A perineal rupture, especially grade III, should be diagnosed and sutured immediately after delivery. To do this, insert a finger into the rectum and, pressing on its anterior wall, check the integrity of the intestine and sphincter.
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Treatment of perineal rupture
In a grade III perineal rupture, in addition to the skin and muscles of the perineum, the sphincter is torn (incomplete grade III rupture), and sometimes the mucous membrane of the rectum (complete grade III rupture); before suturing the ruptures, it is necessary to excise the crushed and necrotic tissue.
In the process of suturing a grade III rupture, it is very important to clearly navigate its topography, for which it is necessary to expose the edges of the wound with Kocher clamps so that the injured tissues after suturing lie in the same way as before the rupture.
Particular attention should be paid to suturing a complete third-degree perineal rupture. First, the upper angle of the rectal rupture is sutured, and the edges of the intestinal wall are connected with knotted catgut sutures (without puncturing the rectal mucosa). After the integrity of the intestine is restored, it is necessary to find and suture the torn sections of the sphincter, connecting both its ends along the midline.
When suturing a central perineal rupture, the remaining tissues of the posterior commissure are first dissected with scissors, and then the wound is sutured layer by layer.
Hygienic toilet of the external genitalia is carried out 2-3 times a day with a solution of potassium permanganate, dried and treated with a 1% solution of iodopyrone or a 1% alcohol solution of brilliant green, etc. Skin sutures are removed from the perineum on the 5th-6th day.
In case of a third-degree perineal rupture, a diet that does not form fecal matter is recommended. On the eve of the stitches being removed, the woman in labor is prescribed laxatives - magnesium sulfate, vaseline oil, etc.
If the stitches become suppurated, they should be removed and the wound surface should be cleaned daily from purulent and necrotic masses of hydrogen peroxide, rivanol and furacilin solution. UFO is also recommended. A gauze bandage with a hypertonic sodium chloride solution is applied to the wound (until the amount of purulent discharge decreases), and then with a 1% iodopyrone solution for 4-5 hours. After this, an ointment pad is applied (0.25% methyl uracil ointment, solcoseryl ointment or jelly, iruksol, vulnosan, etc.). After the wound is cleaned, the perineum is sutured a second time.