Remote Primary Health Care Manuals

Tears of the birth canal

 

  • Can be tear of perineum, vagina, vulva or cervix
  • Common after birth —  always check carefully for tears, especially if heavy blood loss
  • Tears more likely to happen if quick birth or large baby
  • If bright blood loss, placenta delivered and uterus is firm and well contracted
    • Look at vaginal area for tear
    • If heavy bleeding ​but can't see bleeding tear — suspect cervical tear
Red Flags — Urgent Medical Consult

Heavy bleeding more than 500ml at any time (1 soaked pad is equal to about 100ml) — see Rubbing up a contraction and Primary postpartum haemorrhage

Types of tears

Table 3.2   Tears of the birth canal

Classification Type of damage Repair needed
Graze or 1st degree tear — Figure 3.21 Tear involves skin and subcutaneous tissue of perineum and vaginal epithelium only
  • Usually doesn’t need repair
  • Apply pressure to stop bleeding
2nd degree tear — Figure 3.22 Tear extends into fascia and muscle of perineum but anal sphincter remains intact

Should be repaired — can be done in community, if trained

3rd degree tear — Figure 3.23 Tear extends into anal sphincter Needs to be repaired in hospital by specialist
4th degree tear — Figure 3.24 Tear extends beyond anal sphincter to involve rectal mucosa Needs to be repaired in hospital by specialist
Episiotomy
  • Cut made through perineum and posterior vaginal wall
  • Can extend into complex 2nd degree tear or even a 3rd or 4th degree tear
 Simple episiotomy can be repaired in community, if trained
Anterior genital tear Peri-urethral, labial or clitoral tears

May need repair if bleeding or large — specialist consult

Cervical tear Tear involving the cervix If bleeding, needs repair in hospital by specialist

Figure 3.21   

 

tear - 1st degree_labelled.jpg

Figure 3.22   

 

tear - 2nd degree_labelled.jpg

Figure 3.23   

 

tear - 3rd degree_labelled.jpg

Figure 3.24   

 

tear - 4th degree_labelled.jpg

Do not

Do not suture tear or episiotomy unless trained

Check

  • Woman often very sore and embarrassed about this examination — be gentle, careful, sensitive and reassure woman
  • Offer nitrous oxide,​ if available — for pain relief and to help her relax
  • Position woman lying down with bottom at edge of bed, knees bent up and feet supported
  • Use good light — positioned properly
  • Put on sterile gloves
  • Mop up blood in vagina entrance with sterile gauze swabs
  • Check perineum, vulva, urethra, labia and clitoris
    • Separate labia and look at vaginal opening
    • Wrap sterile gauze around fingers and use to gently separate the walls of vagina
    • If tear/bleeding high up in vagina or hard to see — may need sterile speculum exam
  • Check for 3rd or 4th degree tear
    • Put gloved index finger into rectum and feel for anal sphincter between thumb on outside and finger on inside — should feel circular ridge of muscle around anus
    • Check for small fibres that may indicate partial 3rd degree tear ​
    • Change gloves after rectal exam
  • Follow each tear to end to see where it stops

Do

  • Repairing tear properly will control bleeding — start as soon as possible

Table 3.3  

Type of tear Treatment

Superficial graze OR

1st degree tear — ​not bleeding
  • Don't need to be sutured
  • If stinging when passing urine — advise to drink plenty of water and use urinary alkalinizer
1st degree tear — ​bleeding
  • Apply pressure with sterile pad for 5–10 minutes or until bleeding stops
  • Add ice pack into combine pad
2nd degree tear
  • Suture unless woman refuses — see Repairing tear or episiotomy
  • If not confident about doing repair — control bleeding AND medical consult to send to hospital
3rd or 4th degree tear

Medical consult to send to hospital for repair by specialist

  • If being sent to hospital — ice pack to perineum for pain relief and to ease swelling and bleeding — 20 minutes on, 20 minutes off
    • Do not put ice pack directly on skin

If tear bleeding

  • Apply pressure with sterile pad for 5–10 minutes
    • If bleeding continues — ask helper to apply pressure
    • Recheck for bleeding after another 10 minutes pressure
    • If still bleeding — medical consult — may suggest putting in large stitches at bleeding point, clamping bleeding point and/or packing vagina — record what and how much/many used
  • Keep applying pressure for as long as needed — weigh pads to work out blood loss — 1g increase = 1ml loss
    • If bleeding still continues — put in IV cannula, largest possible AND start normal saline 1L at 125mL/hr
  • Medical consult — are antibiotics ​needed
  • If woman unable to pass urine — put in indwelling urinary catheter
  • Reassure woman and family
  • Encourage woman to hold and breastfeed baby, unless feeling very unwell
  • Do routine observations including checking uterus is firmly contracted — every 30 minutes until evacuation