Clinical and Experimental
Health Sciences
3rd and 4th Degree Perineal Tears that Occurs During Vaginal
Delivery
Mustafa Senturk1 , Yusuf Yavuz2
1
2
Necmettin Erbakan University, Meram School of Medicine, Department of General Surgery, Konya, Türkiye.
Sanliurfa Training and Research Hospital, Clinic of General Surgery, Sanliurfa, Türkiye.
Correspondence Author: Mustafa Senturk
E-mail: m-sntrk@hotmail.com
Received: 29.04.2021
Accepted: 04.04.2022
ABSTRACT
Objective: Perineal injuries are common in vaginal delivery. In this study, we aimed to investigate the factors affecting the degree of perineal
injury and the effect of injury degree on incontinence.
Methods: Fifteen patients, underwent sphincter repair by the general surgery unit, who had perineal tear during normal vaginal delivery
between January 2018 and March 2019 in our hospital and were retrospectively evaluated. Those with grade 3a and 3b perineal tears were
divided into 2 groups as group-1, and those with grade 3c and grade 4 perineal tears as group-2. Episiotomy type, fetal characteristics [head
circumference and birth weight], early postoperative continence findings were compared in between groups.
Results: The average age of the patients was 30 ± 8.7 years. When the groups were compared, there was no significant superiority of episiotomy
in terms of perineal injury (p=0.07). 4 patients had 3a, 3 patients had 3b, 6 patients had 3c and 2 patients had fourth-degree perineal injuries.
F-florbetaben
The average birth weight of the newborns was 3438 ± 492 g, and the head circumference was 34.33 ± 1.23 cm. There was no significant
difference in incontinence between the groups (p=0.55).
Conclusion: The treatment of anorectal injuries is surgery. The method of treatment varies according to the time elapsed between injury
and intervention, fecal contamination, degree of injury, general condition of the patient, presence of accompanying injury, experience and
preference of surgeon. We think that sphincter damage during delivery can be looked after successfully with early diagnosis and intervention
before tissue edema develops.
Keywords: Perineal
Tears, Fecal
incontinence,
Sugical
treatment
Our findings
of positive
association
of plasma
transthyretin levels with global and regional
1. INTRODUCTION
Perineal injury is one of the major complications during
vaginal delivery. Perineal injury can develop during urological,
gynecological and coloproctological interventions. [1,2].
and has 2 definitive
are
Classification
of perineal pathological
injury is usedfeatures,
for gradingwhich
perineal
neurofibrillary
tangles
(NFTs)
of
intracellular
aggregation
injury. Obstetric anal sphincter injury, including third and fourth
degree perineal tears, occurs in approximately 3% of women
after their first birth and 0.8% of women who have had at least
one previous birth [3]. It has also been reported that the true
incidence can be as high as 11% in some series [4]. There are
publications in England and Norway showing that the incidence
has increased in recent years [5,6]. It is unclear whether these
changes are due to an actual uplift or greater awareness.
A perineal tear during delivery is an important cause of short
and long term maternal morbidity. Urinary incontinence, anal
incontinence, perineal pain, sexual dysfunction may cause
many problems after perineal injury. Anal incontinence has
been reported by 4.3% of women aged 15 to 60 years with
Clin Exp Health Sci 2022; 12: 396-400
ISSN:2459-1459
or without injury to the perineum. [7]. Intestinal symptoms
have
a significantly
greater
progression
to
in women
with perineal
injuries risk
vary of
between
7.6% and
61% depending on parity and injury type. [8]. Risk factors for
perineal injuries involving anal sphincter include gestational
age, nulliparity, duration of delivery, occipitoparietal diameter
and birth weight. Episiotomy is controversial some studies have
shown that the risk is reduced with a mediolateral incision,
while in others it is increased or unchanged [9]. In this study,
we aimed to investigate the factors affecting the degree of
perineal injury and the effect of injury degree on incontinence.
2. METHODS
We retrospectively evaluated patients who have perineal
injuries during normal vaginal delivery and underwent
fibrillation.
In anbyingeneral
vivo AD
transgenic
mouse
model,
sphincter repair
surgery
unit in our
hospital
between
January 2018 and March 2019. The study was conducted
according to the Declaration of Helsinki. The patients identified
Copyright © 2022 Marmara University Press
DOI: 10.33808/clinexphealthsci.929691
Content of this journal is licensed under a Creative Commons
Attribution-NonCommercial 4.0 International License.
Original Article
Anal Sphincter Injury
for this series were retrieved from the surgical department
records. Ethics committee approval was received for this
study (E2-22-1623). During this period, the total number of
35.614 deliveries takes place in our hospital, including 23.816
spontaneous vaginal delivery and 11.798 cesarean delivery.
Patients with first degree and second-degree perineal injury
were not included in the study. Only perineal injury of 3rd
degree and above was included [Table-1] [10]. The perineal
injury classification was used to determine treatment and the
degree of rectal injury. The degree of injury was determined by
intraoperative physical examination.
We used the Cleveland Clinic Florida Fecal Incontinence Score
(CCFIS) system [Table-2] [11]. Scoring was done according to
the follow-up data in the system. Patients whose follow-up
did not come were called for control. There was no anorectal
manometry in our hospital; Therefore, patients were referred
to comprehensive centers.
Table 2. Cleveland Clinic Florida Fecal Incontinence Score (CCFIS)
Frequency
Never
Table 1. Classification of perineal injury
Grade 1
Grade 2
Grade 3
3A
3B
3C
Grade 4
Laceration of the vaginal mucosa or perineal skin only
Laceration involving the perineal muscles
Laceration involving the anal sphincter muscles, being further
subdivided into 3A, 3B, 3C:
Where <50% of the external anal sphincter is torn
Where >50% of the external anal sphincter is torn
Where the external and internal anal sphincters are torn
Laceration extending through the anal epithelium (resulting
with a communication of the vagina epithelium and anal
epithelium)
Solid stool leakege
0
1
2
3
4
Liquid stool leakege
Gas leakege
Pad use (for stool)
Lifestyle restriction
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
Never = 0; Rarely = <1/month; Sometimes = <1/week but >1/month;
Usually = <1/day but >1/week; Always = >1/day.
2.2. Statistical Analysis
Social Science Statistical Package 22.0 (SPSS Inc., Chicago,
IL, USA) software was used for biostatistical analysis.
Kolmogorov-Simirmov and Shapiro-Wilk tests were used
to check the distribution of parameters. Mann Whitney U
test was used for comparison of independent groups and
Fisher’s exact chi-square tests in cross tables were used
for categorical data. In the interpretation of the statistical
hypothesis tests, a type 1 error was accepted as 0.05.
Those with grade 3a and 3b perineal tears were divided into
2 groups as group-1, and those with grade 3c and grade 4
perineal tears as group-2. Age, parity, episiotomy type,
fetal characteristics [head circumference and birth weight],
anesthesia type, first intervention time, instrumentation
during delivery, perineal injury classification, surgical
intervention, and early postoperative continence findings
were compared in between groups. Data of 18 patients were
collected. Fifteen patients with complete data were included.
Written consent was obtained from all patients for surgical
procedures.
3. RESULTS
The average age of the patients was 30 ± 8.7 years. The
mean number of delivery was 3 (min-max: 1-7). 14 patients
underwent spinal anesthesia and 1 received general
anesthesia during normal vaginal delivery and underwent
surgery due to third and fourth-grade perineal tears. The
mean duration of the first intervention was 70 minutes
(min-max: 30-90 minutes). Episiotomy was performed in 11
patients (73.3%). When the groups were compared, there
was no significant superiority of episiotomy in terms of
perineal injury (p = 0.07). 4 patients had 3a, 3 patients had 3b,
6 patients had 3c and 2 patients had fourth-degree perineal
injuries [Figure 1]. In 3 of the cases, birth weight was over
4000 g. The average birth weight of the newborns was 3438 ±
492 g, and the head circumference was 34.33 ± 1.23 cm . On
the postoperative first day, rectal examination of the patients
it was showed that sphincter tone decreased. On the 7th
day, rectal examination showed that sphincter tones were
more active than the first day examination but decreased
compared to normal. Colostomy was not performed in any
patient. 2 patients (13.4%) had less than one gas incontinence
per month, 1 patient (6.7%) had less than one gas and stool
incontinence per month. There was no significant difference
in incontinence between the groups (p=0.50) [Table-3]. The
average follow-up period was 9.8 ± 4 months. None of the
patients developed surgical complications.
2.1. Surgical Technique
End-to-end repair was performed in all our cases. The ends
of the torn muscle were grasped with Allis forceps and endto-end repair was performed with 3/0 or 2/0 polyglactin
sutures. Because overlap can be technically difficult, a torn
internal sphincter mattress or single interrupted sutures
should be approximated.
In addition to preoperative antibiotic prophylaxis, all patients
were administered with post-operative broad-spectrum
antibiotics. Medical constipation was achieved with the
drug containing diphenoxylate + atropine sulfate active
ingredients, preventing the wound from contacting with
stool. Medical constipation was achieved for three days
postoperatively. Oral food intake was started on the third
postoperative day. Perineal examination and digital rectal
examination was done at the postoperative follow-up and
regular policlinic examination. They were advised to avoid
vaginal delivery. In all patients, treatment with laxatives was
started to promote bowel.
Clin Exp Health Sci 2022; 12: 396-400
Rarely Sometimes Usually Always
397
DOI: 10.33808/clinexphealthsci.929691
Original Article
Anal Sphincter Injury
Table 3. Properties of the groups and comparison results
Yes
No
Episiotomy
Done
No
Head circumference(cm)
(mean±SD)
Birth weight (g) (mean±SD)
SD: Standart Deviation
Incontinens
Group-1
(Grade 3a-3b)
1 (14.2%)
6(85.8%)
7(100%)
0(0%)
34.1 ± 1.4
Group-2
P
(Grade 3c-4)
2(25%)
0.55
6(75%)
4(50 %)
0.07
4(50%)
34.5 ± 1
0.69
3335 ± 424
3527 ± 558
0.53
Figure 2. Post-repair image
Figure 2. Post-repair image
Figure 1. A patient with type 3b injury
4. DISCUSSION
Table 4. Demographic characteristics of patients (n=15)
n
Age (Years)
Number of delivery
Anesthesia type
General
Spinal
Time to first intervention (Minute)
Grade of injury
Grade 3A
Grade 3B
Grade 3C
Grade 4
Episiotomy
Done
None
Birth weight of the newborns (gr)
Head circumference (cm)
İncontinens
Gas
Gas+stool
None
Average follow-up (month)
Clin Exp Health Sci 2022; 12: 396-400
%
The morbidity rate is high in perineal tears during delivery.
Fecal incontinence is one of the most important of these.
Obstetric trauma or sphincter defects after perianal field
surgery are the main causes of stool incontinence. During
vaginal delivery, 53% to 79% of patients have varying degrees
of perineal injury. [8,12]. Rectal examination should be
performed in vaginal deliveries so that perineal tears are not
overlooked. Maternal or fetal features may cause perineal
injuries. Fetal factors include abnormal presentation,
birth weight, and head circumference, while maternal
factors include rapid presentation, pelvic length, and tissue
characteristics. [13]. A large volume study reported an
association between shoulder dystocia and perineal injury
[8]. Every 100 grams increase in birth weight caused a 10%
increase in the rate of perineal injury. There were 3 children
with shoulder dystocia. Their weight was over 4000 grams.
One of the patients had a fetus over 4000 g, the other had
a fetus transverse position and althought the last one had a
low fetus weight, a perineum injury occurred for the pelvic
incompatibility groove [Table-4].
Mean±SD
30±8.7
3(1-7)
1
14
70±24
5
3
5
2
33.3%
20%
33.3%
13.4%
11
4
73.3%
26.7%
3438±492
34.33 ± 1.23
2
1
12
13.4%
6.7%
80%
The rate of anal sphincter injury in vaginal deliveries is
approximately 18% [14]. In patients with sphincter injury
at birth, the rate of fecal incontinence is 7.7% [15]. The
incontinence rate is 6.3% in nulliparous women, 8.8% in
9.8 ± 4
398
DOI: 10.33808/clinexphealthsci.929691
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Anal Sphincter Injury
uniparous women and 8.4% in secundiparous women and
11.5% in triparous women and women with more than 3
deliveries [16]. In a study of patients with normal vaginal
delivery, it was reported that complaints about incontinence
ranged from 13% to 25% [17]. Two patients (13.4%) had less
than 1 gas incontinence per month, 1 patient (6.7%) had less
than 1 gas and stool incontinence per month. 3 patients (20%)
were nulliparous and 12 patients (80%) were multipara.
5. CONCLUSION
Sphincter repair should be done in experienced centers to
obtain better results. Surgical repairs should be made in the
early stages of injuries. It is known that the sphincter ends
torn in the late intervention will separate more with time
and repair in the late period may be more difficult. We think
that sphincter damage during delivery can be looked after
successfully with early diagnosis and intervention before
tissue edema develops.
It is reported in the literature that early intervention is a
key factor in recovery [13]. The mean duration of the first
intervention was 70 minutes (min-max: 30-90 minutes).
Authors’ contributions (Authors initials)
There are publications stating that episiotomy increases or
decreases the risk of perineal injury [8]. In our study, 73.3%
of our patients underwent episiotomy. When the groups
were compared, there was no significant superiority of
episiotomy in terms of perineal injury (p = 0.07). We found
that episiotomy did not affect the risk of 3rd or 4th degree
perineal injury. The low number of patients is also a factor
in this result.
Design of the study: MS
There is insufficient data to determine whether the next
delivery of a patient with perineal injury after vaginal delivery
is vaginal or caesarean section delivery. A vaginal delivery
performed in a patient with perineal injury has been reported
to have a 3% risk of re-anal sphincter injury [8]. We do not
recommend vaginal delivery to prevent possible injury.
Conflicts of interest
Acquisition of data for the study: YY
Analysis of data for the study: MS, YY
Interpretation of data for the study:
Drafting the manuscript: MS
Revising it critically for important intellectual content: MS, YY
All authors have disclosed no conflicts of interest.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
The first option in anal sphincter defect is sphincter
repair. Perioperative second-generation cephalosporin
antibiotic prophylaxis has been shown to reduce the rate of
postoperative infection [19]. In sphincter repair performed
after vaginal delivery injury, the infection rate can reach up
to 20% [20]. None of our patients had surgical site infections.
We use metronidazole and third generation cephalosporin for
prophylaxis in our patients and we complete this treatment
for 5 days. We think that the susceptibility to infection
increases in the surgical area if vaginal discharge is high after
delivery. For this reason, we pay attention to vaginal dryness.
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How to cite this article: Senturk M, Yavuz Y. 3rd and 4th Degree Perineal Tears that Occurs During Vaginal Delivery. Clin Exp Health Sci
2022; 12: 396-400. DOI: 10.33808/clinexphealthsci.929691
Clin Exp Health Sci 2022; 12: 396-400
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DOI: 10.33808/clinexphealthsci.929691