The Importance of the Perineum in Childbirth

The perineum is the area between the genitals and anus. During childbirth, this fleshy area is strained as you bear down and push out your baby. The pressure can lead to tears in the perineum.

If you're at risk for tearing, your doctor may recommend making a cut to open up the area before you start pushing. This can allow for an easier delivery, but it could lead to some complications.

This article will explain what the perineum is and its role during childbirth, including how it may tear or be surgically cut. It also covers how to treat a torn perineum.

What Is the Perineum?

Just behind the vagina is the pubis symphysis (the joint between the two pubic bones). Resting on this joint is the perineum. The area has less hair than the rest of the genitals.

At the center of the perineum is the perineal body, which is made up of tissue and muscle that strengthen the pelvic floor. The pelvic floor supports organs such as the intestines and bladder. It plays a key role in bathroom function to help control urine and bowel movements.

The perineum is like a bridge supporting the muscles and functions of the reproductive, urinary, and digestive systems. If the tissue, nerves, or muscles that make up this bridge are damaged, it can cause problems with these systems.

Perineum Tears During Childbirth

Perineum tears, also known as perineum lacerations, are rips in the skin and muscle of the perineum. These tears occur as the baby is being pushed out of the birth canal. If the perineum is strained and can't stretch any further, the skin and, possibly, muscle tissue, will naturally tear.

These tears are most likely to occur if it's your first time giving birth, if your baby is "sunny side up" (face up) during delivery, or if your baby weighs more than 8 pounds.

Perineum tears are very common during childbirth. In fact, more than half of all women who give birth vaginally (as opposed to those who have a C-section), have some sort of perineal laceration.

There are four degrees of perineum tears, ranging from least severe to most severe.

• First-degree tear: This is a small injury that only cuts through the first layer of tissue in the perineal area.
• Second-degree tear: The most common type of tear, this extends further and goes into the muscle tissue.
• Third-degree tear: This type of tear goes from the vagina all the way to the anus. It cuts through muscle tissue and may affect the muscles that control your bowel movements.
• Fourth-degree tear: This type of tear is uncommon. It extends past the anus and to the sphincter muscles and rectum. This is a very severe injury and can result in long-term pain, pelvic floor dysfunction, and painful intercourse.

What Is an Episiotomy?

To prevent perineal tearing, doctors used to routinely make a cut in the perineum to allow the baby to be pushed out more easily. This medical cut or incision is called an episiotomy. This type of cut is made once the baby's head is seen, allowing the doctor or midwife to ease the head and chin out.

Today, the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) recommend that episiotomies be used only in limited cases. This is because research has shown that an episiotomy may make you more likely to develop a severe third- or fourth-degree tear. If your perineum tears naturally during labor and delivery, you may heal better than if a doctor forces a cut.

If an episiotomy is necessary, your doctor will numb the perineum to reduce pain. If you've already had an epidural or other anesthetics, though, you may not need any more medication.

Healing After Childbirth

Following childbirth, it's common to have pain in the perineum whether or not you have an tear or episiotomy.

After an episiotomy or perineum laceration, your doctor may recommend the following to ease soreness and speed healing:

• Applying cooling pads to the area after delivery
• Using a small water bottle to clean yourself after going to the bathroom
• Gently patting yourself dry rather than wiping the area
• Soaking in a sitz bath, a shallow, warm water bath in which you only soak your genital or anal area
• Limiting physical activity

Over-the-counter pain relievers may also help, but be sure to check with your doctor about which ones you can take, especially if you're nursing or taking any other medication. You can also discuss the use of medicated creams or numbing sprays.

Perineum tears usually heal within two weeks. If you received stitches, they should dissolve within six weeks.

Complications

There is a risk of infection with a perineum tear. Signs of an infection may include an unusual odor or discharge from the wound, fever, or pain that can't be managed with medication. If you have any of these symptoms, call your doctor.

With more severe tears, there are risks of long-term problems such as:

• Pain during sexual intercourse
• Urinary fistula, an abnormal connection between the vagina and bladder
• Rectal fistula, an abnormal connection between the vagina and rectum
  
• Urinary incontinence, being unable to control urination, which can lead to "accidents"
• Fecal incontinence, being unable to control bowel movements
• Pelvic prolapse, when the organs that are supported by the pelvic floor drop from their normal position
  

Preventing Perineal Tears

During pregnancy, you can work on stretching the perineum and preventing tearing through regular perineum massages. Also known as birth canal widening, perineum stretching can be done at home during the final weeks leading up to your due date.

The goal is to learn to relax your pelvic floor muscles and stretch the vaginal opening. Your obstetrician or midwife can show you how to give a perineal massage.

Summary

The perineum is an often-overlooked area of your body, but it supports your internal organs. It also houses nerves and muscles that are important to a range of body functions.

During childbirth, this area needs to stretch to allow the baby to pass through the birth canal. You can prepare for this by spending time massaging the area before your delivery date. However, it's common for the perineum to tear during childbirth.

In some cases, your doctor may think it's best to make a small cut in the tissue to prevent you from tearing too much. Whether you have a cut from a doctor or one that occurs naturally while you push, you need to take care of a perineum laceration after childbirth to ensure that it heals well and that there are no long-term problems from damaged nerves or muscles.