Perineal Trauma During Childbirth
Perineal trauma is a common occurrence in childbirth, with up to 50-60% of women needing stitches after a vaginal delivery. This article looks at the varying degrees of perineal trauma, how it should be treated, and what to do if you have experienced perineal damage which was not recognised at the time of birth.
Guidelines For Perineal Trauma
More than 85% of women sustain some form of perineal trauma during vaginal delivery in the UK. Due to this high frequency rate, it has become a requirement for all women who have undertaken a normal vaginal delivery to undergo an assessment for genital trauma (including a digital rectum examination) soon after giving birth. This is to determine whether there has been any damage to the perineal muscles or the sphincter – both internally and externally.
Perineal trauma, sometimes referred to as a 'vaginal tear', varies in terms of levels of severity, and can be classified in the following way:
- 1st degree - Injury to the skin only
- 2nd degree - Injury to the perineal muscles, but not the anal sphincter
- 3rd degree - Injury involving the anal sphincter complex
- 3a. Less than 50% of external anal sphincter torn
- 3b. More than 50% of external sphincter torn
- 3c. Internal anal sphincter torn
- 4th degree. Injury involving the anal sphincter complex and the anal epithelium.
Perineal Trauma Repair
If any trauma is detected then a repair should be carried out as quickly as possible in order to minimise the risk of infection and blood loss. In the case of 1st degree trauma, a repair is not necessary unless there is bleeding. For 2nd degree trauma, a repair can be performed by a midwife in the delivery room. For all 3rd and 4th degree perineal trauma, repairs must be carried out in theatre where an obstetric consultant or colorectal surgeon will suture the wound.
After the repair, women should be given appropriate advice on hygiene, medication and postnatal care. This will include things such as how to keep the perineum clean, methods of pain relief, and the importance of doing pelvic floor exercises. Additionally, women who have sustained a 3rd and 4th degree of trauma should be given laxatives to aid the softening of stools.
Perineal trauma should continue to be assessed after discharge from hospital, with particular attention being paid to signs and symptoms of infection, inadequate repair, and wound breakdown. Women who have suffered a 3rd or 4th degree of trauma should also be offered an appointment in an antenatal clinic 6-12 weeks after giving birth.
What Happens If A Perineal Trauma Goes Undetected?
Occasionally, perineal trauma goes undetected, or the degree of trauma a woman has suffered is underestimated. This can happen for a number of reasons, such as: the doctor or midwife failed to perform an assessment of genital trauma and/or a digital rectal examination, the doctor or midwife failed to recognise the trauma at all, or detailed the trauma under the wrong level of severity. In fact, in one study that audited the anatomical knowledge of doctors and midwives, 41% of medical trainees and 16% of midwives incorrectly classified a partial or complete tear of the external anal sphincter as a 2nd degree tear, instead of correctly identifying it as a much more serious 3rd degree tear.
A woman with perineal trauma is likely to experience a number of complications, including:
- Perineal pain;
- Infection;
- Pain during sexual intercourse, known as Dyspareunia;
- Faecal urgency;
- Anal incontinence.
If you are experiencing any of these symptoms after childbirth, you should talk to your GP immediately, as you may have an underlying perineal or sphincter injury which has not been identified.
Undetected Perineal Damage And Medical Negligence
If you have suffered perineal damage during childbirth which was not recognised at the time of birth, then it is likely this will amount to medical negligence, and you might be entitled to compensation. To assess whether this is possible, you should seek expert legal advice from a medical negligence solicitor, who will not only investigate the circumstances of the tear but also consider any other treatment that might be available for you.
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