Perineal Tears; the research
Following on from my birth story I’d like to take a bit of time to explain perineal injuries and break down some of the myths. I was that woman strolling out of hospital with her perfect little baby and some stitches I didn’t really know a lot about.
So the Perineum- It’s a pretty scary area to think about injuring! The perineum is that stretchy (not so stretchy in my case) bit of skin that extends down from the entrance of your vagina to the anus. Sometimes you only have to mention the words perineum for Barbara in I.T to tell you her horror story, “oooh I tore from here to there, blood everywhere, absolutely horrendous!” I heard A LOT of those stories when I was pregnant mainly from ladies in supermarkets. I’d always smile and listen but try my best to not worry too much about the prospect of sustaining a perineal injury. Like my mum always says worrying won't help matters do everything that’s in your power, don’t dwell and move on. We’re both massive worriers.
With this in mind I did start perineal massage at around 36 weeks. Being a Physiotherapist I’m not shy of massage! This however was a very different sort of massage, it was pretty uncomfortable but the idea is to stretch the perineum and make it as pliable as possible ready for babies head. In the lead up to having my daughter I was happy that I’d done everything I could to prevent a perineal injury. If you actually read some of the research about perineal massage the jury is still out. I’ve read a couple of systematic reviews for Antenatal Perineal Massage (APM) and there is certainly support (Beckman & Garrett 2006). Doubts around the efficacy of APM may be occurring due to the large amounts of women needed to take part in studies (Jones & Marsden 2008). This also presents it’s own problem with drop out rates, even where women have chosen to be in the massage group (Eogan et al. 2006). AMP is very much an individual choice and I wanted to try and do everything I could to prevent a perineal injury.
Below is a little information on perineal tears. Please if you haven’t had your baby don’t see this and be terrified. This is a journey I and many other ladies have been on. I am not for one second saying you will sustain a tear. We’ll come on to prevalence and research a bit later. This graphic (RCOG 2019) highlights the grading system from 1-4. They are also sub categorised into A B and C when you get to grade 3 but we don’t need to worry too much about that (well I did but we’ll just stick with the graphic!) If anybody has any questions about the A B and C bit just leave a comment on this post and I’ll do my best to answer it.
I know this pretty awful and makes you pull that face where you scrunch up your eyes. Let’s have a look at some of the research into perineal injuries;
The most common complication of childbirth is perineal trauma, which occurs in 48% of vaginal deliveries (GSSDH 2005). The use of the word complication isn’t a nice one I must admit but please bear with whilst I explain a bit more about the types of trauma and their statistics.
In one small study during the research period of 7th July to 25th July there were a total of 117 births at Raigmore Hospital Maternity Unit. Ninety of these were a vaginal delivery and 27 by Caesarean Section. Seventy-four audit forms were completed by physiotherapy staff in the 3-week audit. Of that cohort 8% of those ladies remained intact, 18% had grazes, 29% had an Episiotomy, 18% had a first degree tear, 26% had a second degree tear and 1% had a third degree tear. There were no fourth degree tears during the audit timeframe. (K. Brandie & A. MacKenzie 2009.) That’s a great little snap shot of three weeks in the life of a maternity hospital and some figures to think about.
The grade 3 and 4’s really are not all that common when considering the above. These types of tears have one of those jazzy medical acronym names of OASI (Obstetric Anal Sphincter Injury), we’ll stick with OASI shall we! This is due to the involvement of the anal sphincter in the tear. 3rd and 4th degree tears occur in around 3 in 100 women who have a vaginal birth. This increases slightly to 6 in 100 if it’s your first baby. (RCOG 2019.) That’s not a lot is it? I remember thinking this as I researched my tear post surgery when my husband and daughter were both sleeping and I was frantically trying to wiggle my toes whilst googling, post anaesthetic. Just as a side note the leaflet I have referenced above RCOG 2019 is extremely helpful and is written by the people who are very much in the know! I’m just a Physiotherapist sharing her experience with a smattering of research because I like to read. I will be sharing my thoughts, experience and how my recovery went on another post. If you or your partner/friend/neighbour/cousin etc has sustained a 3rd or 4th degree tear please point them in the direction of this website it really is brilliant. I have copied the link to the website below in the references. (If my University lecturer Dr Fazakerley is reading this I apologise for my Harvard- or non Harvard referencing system in advance.)
Please remember that your midwife will be doing absolutely everything in their power to prevent you from having a tear too. This includes having a warm compress on your perineum and of course coaching you through those important pushes. They are experts in their field and know what intervention is best when. I distinctly remember saying to my incredible midwife “Just shout at me any instruction, you’re in charge down there!” I of course as the patient remain fully in control of my care and any decisions but ultimately my midwife has done this more that a few times, I had not. All the healthcare professionals you meet on your journey through the hospital are working within their standard operating procedures which are set by people like the Department of Health (DoH) and the National Institute for Health and Care Excellence (NICE.) At a local level the Trust that is responsible for the hospital you are in will implement these standards across the departments. Individual health professional also have a governing body like the Chartered Society of Physiotherapists (CSP), the Nursing and Midwifery Council (NMC), the General Medical Council (GMC). These governing bodies are responsible for codes of conduct and promoting research (amongst many other things), which will in turn promote best practice. I can actually tick off almost in chronological order the suggested standards of care I received from my midwife and then the Obstetrics registrar. He took me through into surgery after my examination explaining what had happened and the plan going forward. I actually walked to surgery with the registrar! Seemed like a good idea at the time. The full guidelines can be found online under Interpartum care for healthy women and babies, 1.16 Care of the woman after birth. (NICE 2007.) There is most definitely no winging it when it comes to healthcare in the UK, we’re incredibly lucky.
I really hope this hasn’t been difficult to read if you are expecting your little one and I hope it has helped answer a few questions if you have had a tear or know someone who has. I’ll always remember giving feedback (which was asked for), to a lady who took a well known national pre natal class my husband and I paid to attend. I suggested that perhaps there should be a little more information on perineal tears as there was literally not even a whisper about them on the course. I was met with “Well we don’t want to terrify the bejesus out of everyone.” I was sat there living that life and I know for a fact so were several other girls in the group. There is no need to be terrified or to feed into the loop of scaremongering. We need to be talking about this potential secondary to childbirth, knowledge is power, remember those numbers and percentages from the research. If you have any questions find me on instagram or leave a comment below this post. Thank you for reading! V x
References
Beckmann M. M. & Garrett A. J. (2006)Antenatal perineal massage for reducing perineal trauma. Cochrane data base of systematic reviews 2006, Issue 1. Art No.: CD005123. DOI: 10.1002/14651858.CD005123.pub2.
K. Brandie & A MaKenzie., 2009. Perineal trauma Following Vaginal Delivery. Clinical Paper. Journal of Association of Chartered Physiotherapists in Women’s health, Autumn 2009. Issue 105, 40-55.
Eogan M., Daly L. & O’Herlihy C. (2006)The effect of regular antenatal perineal massage on postnatal paining anal sphincter injury: a prospective observational study. The journal of Maternal-Fetal and Neonatal Medicine 19 (12), 225-229.
Government Statistical service for the Department of Health (GSSDH). (2005). NHS Maternity Statistics, England:2003-4. Deprtment of Health. London
Jones E. L. & Marsden .N. (2008) The application of antenatal perineal massage: a review of literature to determine instruction, dosage and technique. Journal of Association of Chartered Physiotherapists in Women’s Health. Spring 2008. Issue 102, 8-11
Royal Collage of Obstetricians and Gynaecologists. (2019). Care of third- or fourth- degree tear that occurred during childbirth (also known as obstetric anal sphincter injury). Information leaflet, accessed online at; https://www.rcog.org.uk/en/patients/patient-leaflets/third--or-fourth-degree-tear-during-childbirth/ accessed on 10/02/2020.
National Institute for Health and Care Excellence. 2007. Interpartum care for healthy women and babies. Published 2014- updated 2017. Found online at;https://www.nice.org.uk/guidance/cg190/chapter/recommendations#care-of-the-woman-after-birth accessed on 10/02/2020.