Complications of birth healing of the dam (perinea)
Complications of birth injury to the perineum
Around 85% of women suffer some form of injury to the perineum or to the structure of the pelvic floor during delivery. Due to the high numbers of these injuries as well as the extent of such a wide variety of potential problems, there are no precise figures available on the percentage of women who suffer some form of healing problem of the perineum after vaginal delivery. It can, however, be supposed to be a large number.
Even in cases where the perineum remained entirely unharmed, 42% of women register feeling pain in this area, and for one in nine of these the pain persists even beyond one week. Up to 2/3 of women who suffer no injuries during delivery register pain during their first experience of sexual intercourse after delivery, and this pain is even still persistent in one in every seven women one year after the delivery.
It can be assumed that problems concerning the perineum after delivery are frequent, and that a large majority of women keep these problems to themselves and, as a result, suffer with them over a long period of time, even though in many cases we would be able to help them.
The following text should therefore be a wake-up call for anyone who has some kind of pelvic floor problem: please do not hesitate or be afraid to contact us. We believe that some method or approach can be found to help improve your postnatal health.
What is the cause
Birth trauma is injury occuring as a result of the tautness at the perineum as the head or shoulders of the baby pass through it. Complications are related to its inadequate healing.
Fuctional complications of a perineum injured during delivery include fragility with repeated tearing and bleeding, pain (spontaneous or from contact), dyspareunia (pain during sexual intercourse) or, on the other hand, insufficient arousal during sexual intercourse, anal incontinence, postnatal occurence of hemorrhoids, or bleeding after defecation. A common related problem is urinary incontinence.
The general rule is, not surprisingly, the more extensive the injury, the higher the risk of problems occuring.
Most women hide their perineal problems after childbirth and suffer from them for a long time.
Types of birthing injury
Spontaneous rupture of the perineum
Rupture of the perineum has four levels of classification:
1st degree is injury to the skin and subcutaneous tissues.
2nd degree is injury to the perineal muscles except for the anal sphincter.
3rd degree is injury to the anal sphincter.
4th degree means injury also to the bowel wall.
Episiotomy (a cut made by a doctor to the perineum) should be performed to accelerate the birth in cases of faetal distress (risk to the baby, which is evaluated on the basis of faetal heart frequency) or to lower the risk of injury to the anal sphincter when a surgical vaginal birth must be performed. The international classification of an episiotomy and its adequate treatment was contributed to by members of our own team and are available.
Injury to the anal sphincter is the third and fourth degree of injury to the perineum. It is further subdivided into:
3A degree is injury to to the external anal sphincter to an extent of less than 50%.
3B degree is injury to the external anal sphincter to an extent of more than 50%.
3C degree means injury to the internal anal sphincter.
4 degree is injury to the bowel wall (rectum).
· Perineal injury can lead to concurrent injury to
the vaginal walls
the inner labia
the area around the urethra
the area around the clitoris
Types of complications concerning the healing of the perineum:
Infection
Infection in a birthing wound occurs at a frequency of 0.1 – 23.6% according to the type of injury and the quality of postnatal care. It is not always possible to identify an infection with the aid of a microbiological examination.
Dehiscence
Dehiscence is the separation of the edges of a sutured injury leading to a secondary complication. Dehiscence is often the result of a previous infection.
Granulation tissue
Granulation tissue eventually fills in a defect occuring from the separation of these edges. This is a form of secondary healing. Some women, however, have no history of infection or dehiscence associated either primarily, or with this type of healing.
How the problem is diagnosed
The main symptoms (but not the only ones), are pain and bleeding. The diagnosis is performed with a combination of expert understanding of the type of birthing injury and the subsequent healing. It is important, if not essential, to have a knowledge of the course of of the delivery.
How the problem is treated
The problem is treated according to both the type of defect and the particular functional problems being faced. In cases of infection, general treatment with antibiotics is essential, while at the same time placing emphasis on hygiene in the specific area where the infection has occured, i.e. very near to the opening of the anus, where it may come into contact with feces. A seated herbal bath, for example using witch hazel (leaves, bark, twigs), oak bark, agrimony, etc., with the subsequent drying they have astringent and antiseptic affect. It is sometimes possible to use these in the form of an ointment or balsam.
Shortly afterwards it is very common for there to be a secondary surgical correction whereby it is necessary to perform debridement, which means the removal of tissue situated around the edges of the defect that is either dead, altered by infection, or less functional. There follows the drawing together of the edges of the wound with the aid of a few absorbable stitches.
In some cases, other approaches can be used, such as local laser use. It must be stressed that these new methods are not yet sufficiently scientifically proven, but they should not make the current situation any worse.
Functional problems are solved according to the specific function. We therefore refer patients to adequate websites.
The risks of surgery, postoperative care
After surgery, it is necessary to undergo careful and regular checks because the risk of a recurring complication of the healing process is significantly higher. It is more frequently ncessary to employ antibiotics and local treatment than in uncomplicated cases, such as described already in the preoperative section.
Official sick leave from work
The length of sick leave depends on the complexity of the surgical intervention. This usually continues until the healing process is complete. It is necessary to maintain a quiet regime at home to ensure successful healing and recovery after the operation. In the event of any problems (pain, reddening, bleeding, high temperature) we recommend having an immediate check up. The examination is planned individually, based upon the extent of the treatment.