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Journal of the Association of Chartered Physiotherapists in Women’s Health, Autumn 2009, 105, 40–55

CLINICAL PAPER

Perineal trauma following vaginal delivery

K. Brandie & A. MacKenziePhysiotherapy Department, Raigmore Hospital, NHS Highland, Inverness, UK

AbstractOver 85% of women who give birth vaginally sustain some form of perinealtrauma and 60–70% receive stitches. This study investigated the incidence andextent of perineal trauma with respect to a variety of risk factors within theMaternity Unit of Raigmore Hospital, NHS Highland, Inverness, UK, over a3-week period. The authors also examined utilization of the treatments availablewithin the Maternity Unit by medical staff and midwives, and attempted toestablish whether up-to-date written patient information would be of value withinthe unit. Questionnaires and an audit form were used to gather information.Information was obtained for 74 of the 90 women who had vaginal deliveriesduring the study period. The results showed a questionnaire response rate of 42%and 31% for medical staff and midwives, respectively. It was found that treatmenttechniques such as pelvic floor muscle exercises, ice and advice regarding activitiesof daily living were not routinely given by all respondents. Because not all patientswere seen by a physiotherapist postnatally, it was concluded that an up-to-datewritten patient information leaflet would be of value within the Maternity Unit atRaigmore Hospital.

Keywords: leaflet, perineal trauma, risk factors, treatment, vaginal delivery.

Introduction

Perineal trauma following vaginal birth is acommon postnatal occurrence. It has been sug-gested that as many as 85% of women suffersome form of perineal trauma, with 60–70%requiring stitches (Kettle 2006). Kettle (2006,p. 1904) reported that:

‘Perineal trauma affects women’s physical,psychological and social wellbeing in theimmediate postnatal period as well as in thelong term. It can disrupt breastfeeding, familylife and sexual relations.’

Glazener et al. (1995) stated that 7–10% ofwomen continue to have long-term pain 3–18months after delivery.

It is clear that the effects of perineal traumacan be lasting and, in some cases, severe, leadingto significant dysfunction and distress for theindividual involved. MacLeod & Murphy (2008)reported that, following operative delivery,

short-term complications include perinealtrauma, and consequently, pain, infection andpotential haemorrhage; long-term effects includedyspareunia, incontinence of urine, flatus orfaeces and prolapse.

Therefore, effective management is veryimportant in the early postnatal period so as tominimize the impact of both the acute symptomsand any sustained effects caused by perinealtrauma. Within the Maternity Unit at RaigmoreHospital, National Health Service (NHS) High-land, Inverness, UK, it was thought that perinealtrauma may represent a significant postnatalcomplication, and in order to optimize physio-therapy management of this condition, a retro-spective study was initiated in July 2008 toexamine the incidence of perineal trauma andthe care delivered.

Raigmore Hospital is the main acute generalhospital in NHS Highland, which serves a popu-lation of approximately 240 000 people spreadover a geographical area that is approximatelyequivalent to Belgium.

The Maternity Unit at Raigmore Hospitalprovides antenatal clinics, a day-case service,

Correspondence: Karen Brandie, Physiotherapy Depart-ment, Raigmore Hospital, NHS Highland, Old Perth Road,Inverness IV2 3UJ, UK (e-mail: [email protected]).

40 � 2009 Association of Chartered Physiotherapists in Women’s Health

parentcraft education, community midwiferyservices and in-patient maternity beds. Thelabour ward has seven delivery rooms, includingone containing a birthing pool. A dedicatedobstetric theatre is adjacent to the ward. Thereare two maternity wards, one catering for high-risk patients who require a greater level ofmedical intervention and the other being amidwifery-managed ward for low-risk patients.The Maternity Unit has a total 46 beds.

In 2007, there were 1947 births: 1150 (59%)were spontaneous vaginal deliveries; 518 (27%)were Caesarean sections; 171 (9%) involvedforceps; 97 (5%) were ventouse deliveries; nine(0.5%) were vaginal breech deliveries; and 15(0.8%) were water births.

The primary aim of the present study was toinvestigate the incidence and extent of perinealtrauma with respect to a variety of risk factorswithin Raigmore Hospital Maternity Unit. Theintention was to establish a baseline rate ofperineal trauma following vaginal delivery at thehospital so as to facilitate optimization of post-natal management. Further aims were to inves-tigate the utilization of treatments availablewithin the unit by medical staff and midwives,and to establish whether up-to-date writtenpatient information would be of value within thewing.

At present, the aim of the women’s healthphysiotherapy team at Raigmore Hospital is tosee all postnatal women, regardless of theirmode of delivery, in order to give them adviceand information to help their recovery followingthe birth of their babies. However, there is no7-day physiotherapy service in place within theMaternity Unit, and because there is support forearly discharge following delivery, some womenare released before they have an opportunity tobe seen by a physiotherapist. Therefore, thepresent authors also investigated the infor-mation that these women are given to help themwith their postnatal recovery.

Subjects and methods

Audit tools were developed to record specificdetails relating to each vaginal delivery, and tocapture information from medical staff and mid-wives. Medical staff were asked for informationregarding specific intervention in women withdiffering degrees of tear.

Perineal tears are classified by the RoyalCollege of Obstetricians and Gynaecologists(RCOG) in their Green-Top Guideline No. 29

(RCOG 2007) according to the level of damagethat occurs. A third- or fourth-degree tear isone in which there is an injury to the peri-neum involving the anal sphincter. Table 1 con-tains details of the classification (Johnson &Rochester 2008). This classification is adhered towithin the protocol for diagnosis and repair ofanal sphincter tears utilized by the RaigmoreHospital Maternity Unit.

First-degree tears involve only the skin, whilesecond-degree tears involve the skin and perinealmuscle (Kettle 2006). Most spontaneously occur-ring perineal tears are classified as second-degreetears (Steen 2007).

Both medical staff and midwives were ques-tioned about their routine care of patients withperineal trauma following vaginal delivery.Respondents were asked to indicate their prac-tice in relation to: use of analgesia, use of ice,pelvic floor muscle exercises (PFMEs), advice ontoileting for bladder and bowels, and advice forlifting and activities of daily living. These fac-tors are regularly considered clinically and aresupported by Sapsford et al. (1999) as beingappropriate interventions in the management ofperineal trauma.

Respondents were also asked their opinionson the usefulness of a postnatal leaflet, specific torecovery from perineal trauma following vaginaldelivery. If supported, this would go some wayto fulfilling the recommendations of Johnson &Rochester (2008), who investigated the involve-ment of physiotherapy following significant peri-neal trauma. These authors concluded thatadvice given to women should highlight thesymptoms that may occur, and that there is arole for physiotherapy in the management ofwomen who experience third- or fourth-degreetears.

Individual data collection forms gatheredinformation relating to: maternal age, parity,induction of labour, type of delivery, length ofthe first and second stages, analgesia in labour,perineal trauma/episiotomy, suturing, birthweight, occipitofrontal circumference (OFC),

Table 1. Classification of perineal tears (RCOG 2007)

Classification

Damage toexternalanal sphincter

Damage tointernalanal sphincter

Damage torectalmucosa

3a <50% Nil Nil3b >50% Nil Nil3c >50% Torn Nil4 >50% Torn Torn


� 2009 Association of Chartered Physiotherapists in Women’s Health 41

ethnic background, and an incontinence riskassessment score. A number of authors havesuggested that these factors influence the risk ofperineal trauma (Renfrew et al. 1998; Alberset al. 1999; Hanretty 2003).

Study periodThe study period was 7 July 2008 to 25 July2008. This period included two weekends dur-ing which there was no routine physiotherapyservice.

Throughout this time, the PhysiotherapyObstetric Unit was fully staffed by one full-time-equivalent physiotherapist, i.e. 37 h per week,from Monday to Friday, equally dividedbetween one band 6 physiotherapist (static),previously termed senior I physiotherapist, andone band 6 physiotherapist (rotational), pre-viously termed senior II rotational physio-therapist.

Data collectionAudit forms (‘Appendix 1’) were completed bythe present authors for all vaginal deliveries inthe Raigmore Hospital Maternity Unit seen byphysiotherapy staff within the study period.Details were extracted from the patient records.

Questionnaires (‘Appendix 1’) were sent tomedical staff within the Maternity Unit, andinternal mail envelopes were included to encour-age the return of the completed forms. A total of19 questionnaires were sent to medical staff,whose names were obtained from current on-callrota sheets.

Questionnaires (‘Appendix 1’) were alsogiven to midwifery staff on the maternity wards.Thirty forms were left in each ward to coverthe number of trained midwives in each loca-tion. This number was obtained from currentoff-duty sheets within the wards. Several verbalreminders were given to midwifery staff duringthe study period to encourage completion of theforms.

Both questionnaires were anonymous andinstructions were included on the forms regard-ing the returns procedure. The medical staffcould either return the forms to the Physio-therapy Department through the hospital’sinternal mail system or post them in the enve-lopes provided in the maternity wards. Themidwives were encouraged to post their com-pleted forms in the envelopes provided in thematernity wards. The envelopes were placedon the information notice boards in the wards.Large writing was used on the outside of

the envelopes to facilitate the return of thecompleted forms.

Questionnaires were issued on the first day ofthe study period and were not collected until theMonday following the final study day (Monday28 July). Any forms returned after this periodwere not included in the study.

Results

During the study period, there were a totalof 117 births at Raigmore Hospital MaternityUnit. Ninety of these took the form of vaginaldeliveries and 27 were by Caesarean section.Seventy-four audit forms were completed byphysiotherapy staff during the 3-week audit. Itwas found that 27% of women included in thestudy had had their labour induced.

Figure 1 shows the modes of delivery withinthe study population. It should be noted that onetwin delivery has been included in the study(these were recorded on one audit form).

The proportion of patients with perinealtrauma following vaginal delivery is shown inFigure 2.

The only case of third-degree tear recordedduring the study period was an 18-year-oldprimiparous woman who underwent a mid-cavity forceps delivery. No fourth-degree tearswere recorded during the study period.

Table 2 provides further information aboutthe percentage of patients in the present studywho experienced perineal trauma followingvaginal delivery and required suturing, i.e.62% of all patients and 79% of primiparouswomen.

Figure 1. Mode of delivery of the study population.

K. Brandie & A. MacKenzie


Data were collected regarding the parity of thewomen included within the study period (Fig. 3).

In addition to this, it was found that, of thosewomen with a parity of 1+0, three had a vaginalbirth after a Caesarean section. Data were not

available on the collected audit forms for sevenother women in this category of the presentstudy.

Table 3 details further findings from the auditforms.

Information was also collected regarding theuse of analgesia in labour. Nineteen per cent ofthe women included in the present study under-went an epidural anaesthetic, and 86% of theseparticular cases required suturing for perinealtrauma.

The countries of origin of the women includedin the present study indicated that 88% wereBritish. The remaining 12% did not have Englishas their first language.

Medical staff questionnairesEight medical staff questionnaires were includedin the present study. Five were sent to thePhysiotherapy Department, all completed byconsultants, and three were collected from theward envelopes, two from consultants and onefrom a staff-grade doctor. Therefore, the overallresponse rate was 42% (100% from consultancy

Figure 2. Incidence of perineal trauma during thestudy period.

Table 2. Perineal trauma recorded during the study periodand percentage of suturing: (N/A) not applicable

Trauma category Suturing

Intact N/AGrazes 0%Episiotomy 100%First-degree tear 31%Second-degree tear 100%Third-degree tear 100%Fourth-degree tear N/A

Figure 3. Parity of the subjects: (PP) primiparous.

Table 3. Further information from audit forms

Category Average Range

Age (years) 28 16–44Length of labour (h):

first stage 6 1–19second stage 0:58 2:00–3:50

Birth weight (kg) 3.40 1.45–4.47Occipitofrontal circumference (cm) 34.5 31–37Incontinence risk assessment score 3 0–20



staff). In response to question 1, i.e. whether theywere involved in the care of postnatal womenwho experienced perineal trauma followingvaginal delivery, all respondents answered ‘yes’.Question 2 asked the respondents to providemore details of the type of perineal trauma withwhich they were involved (see Fig. 4).

A more detailed examination of the question-naires revealed that two respondents, both con-sultants, had stated that they were involved withall grades of perineal trauma. The staff-graderespondent only dealt with first-, second- andthird-degree tears.

The results for questions 3 to 7 are detailed inTable 4.

In response to question 8, all eight respond-ents stated that a separate postnatal leaflet,specific to recovery from perineal trauma follow-ing vaginal delivery, would be useful.

A number of other comments were added atthe end of the questionnaires and these aredetailed in ‘Appendix 2’.

Midwifery questionnairesThe midwifery questionnaires were completed bythe current staff of the maternity wards duringthe study period.

Overall, 16 questionnaires were completed andincluded in the present study. The total staff oftrained midwives was 51, including bank staff,and therefore, this gave a response rate of 31%.The results for all respondents are shown inTable 5.

One respondent left the tick boxes for ques-tion 2 blank and wrote beside these that she hadused to employ ice, but had now been advisedagainst using it.

In response to question 6, all the midwivesanswered that a separate postnatal leaflet,specific to recovery from perineal trauma follow-ing vaginal delivery, would be useful.

There were several supplementary comments,which are detailed in ‘Appendix 2’.

Discussion

The present study provides a significant amountof information about patients at Raigmore Hos-pital who suffered from perineal trauma follow-ing vaginal delivery. It can be seen that 92% ofwomen who had vaginal deliveries within thestudy period suffered from some degree of post-delivery perineal trauma, and thus, would havebeen at risk of both the short- and longer-term

Figure 4. Types of perineal tear treated by medicalstaff.

Table 4. Medical questionnaire responses

If you are involved in the care of a postnatal woman who hasperineal trauma following vaginal delivery, do you routinely . . . Yes No

3. give advice on the use of analgesia? 8 04. advise on the use of ice? 2 65. encourage pelvic floor exercises? 7 16. give advice on toileting for bladder/bowels? 6 27. give advice for lifting/activities of daily living? 5 3

Table 5. Midwifery questionnaire responses

When caring for a postnatal woman who has perineal traumafollowing vaginal delivery, do you routinely . . . Yes No

1. give advice on the use of analgesia? 16 02. give advice on the use of ice? 11 43. encourage pelvic floor exercises? 14 24. give advice on toileting for bladder/bowels? 16 05. give advice for lifting/activities of daily living? 4 12



dysfunctions associated with this condition.Intervention by a physiotherapist was indicatedin a large proportion of these patients, andtherefore, it is important to identify this need,and explore efficient and effective strategies todeliver appropriate physiotherapy care.

Mode of delivery, episiotomy and perinealtraumaEleven per cent of the vaginal deliveries thatwere recorded at Raigmore Hospital during thestudy period were assisted with forceps and afurther 8% were ventouse deliveries.

Research has shown that assisted deliveriesare associated with an increased risk of third-degree tears (RCOG 2007), but only one subjectin the present study suffered from such perinealtrauma, a low rate of incidence that may berelated to the small size of the study population.The average number of third-degree tears at theMaternity Unit is around 36 per annum, whichequates to an average of three per month. Thisrelatively low figure is equivalent to 2% of alldeliveries at Raigmore Hospital, which com-pares favourably with the national average ofaround 3%, although up to 9% has also beenreported (RCOG 2007).

There are many issues to consider in relationthese patients, not just regarding their earlypostnatal recovery, but also in the longer term. Ifthese women have a subsequent pregnancy, theywill almost certainly be encouraged to undergoan elective Caesarean section in order to ‘pro-tect’ the perineum and pelvic floor from furthertrauma. As operative deliveries, Caesarean sec-tions carry additional risks and potential com-plications. In addition, these types of deliveryare significantly more costly to the NHS andnecessitate a longer period of convalescence.Further examination of third-degree tears atRaigmore Maternity Unit revealed that therewas no correlation between the mode of delivery,the use of episiotomy, the size of the baby, OFCand the presence of third-degree tear followingvaginal delivery. Anecdotally, midwives wereconfident that diagnosis of significant perinealtrauma, particularly that affecting the analsphincter, has improved in recent years. This isextremely important clinically since such post-natal women are more likely to receive appropri-ate advice, information and follow-up at thegynaecology clinic in the postpartum period.

An episiotomy was performed on 30% of thestudy population, which compares favourably tothe rates reported by Williams et al. (1998), who

reported an overall UK episiotomy incidencerate of 40%. MacLeod & Murphy (2007) statedthat episiotomy is traditionally a routine compo-nent of operative vaginal delivery, and isintended to avoid injury to the anal sphincterand minimize the risk of traumatic delivery forthe baby. This finding was certainly echoed bythe present results, which revealed that 94% offorceps and ventouse deliveries at RaigmoreHospital were accompanied by an episiotomy.The one case that did not fall into this categorywas a ventouse delivery in which a second-degreetear was documented as the associated perinealtrauma. Of the remaining instances of episi-otomy, only six were carried out with spon-taneous vertex deliveries. This evidencereinforces the importance of the effective post-natal management of women who have aninstrumental delivery to prevent long-term issuessuch as incontinence and dyspareunia.

Suturing and perineal traumaNearly as many women in the present study(26%) had a second-degree tear as had an episi-otomy (30%) and it was interesting to note thatall of these tears were sutured. Fleming et al.(2003) reported that perineal wounds are suturedin order to accelerate tissue repair, minimizeinfection and restore normal function. Theseaims are consistent with the aims of physio-therapy intervention in terms of minimizingacute symptoms and lessening the risk of morechronic dysfunction.

A modified version of Fleming’s technique ofcontinuous suturing is used for episiotomies andsecond-degree tears at Raigmore HospitalMaternity Unit. This is a method in which largepieces of tissue are stitched with continuous,non-locking sutures. The wound edges areapproximated loosely to allow for swelling andthe need for several layers of suturing material isavoided. Therefore, the subcuticular sutures aresituated well below the surface of the skin, andconsequently, these are more comfortable for thewoman during activities such as sitting up whenfeeding her new baby. In turn, this reducesfeelings of distress during the early postnatalperiod and enhances mobility. Compliance withphysiotherapy may also be improved by earlyand definitive management of the acute soft-tissue injury.

Further risk factors and perineal traumaThe RCOG (2007) has reported several riskfactors for significant perineal tearing, including



nulliparity, induction of labour, epidural anal-gesia and a second stage of labour lasting longerthan one hour. In considering each of these riskfactors in turn, it was found that 79% of primi-parous women required suturing for perinealtrauma following vaginal delivery. This is con-sistent with Kettle (2006), who found that peri-neal trauma is generally more extensive after afirst delivery.

Of the women in the present study who hadtheir labour induced, 38% had episiotomies anda further 19% had second-degree tears, all ofwhich were sutured. This means that over half ofthe mothers who had their labour inducedrequired suturing for perineal trauma. Addition-ally, only two women who were not having theirfirst baby and who had to have their labourinduced required an episiotomy for delivery.This highlights the importance of antenatal edu-cation for primigravid women, particularly withrespect to PFMEs, since, in practice, many post-natal women with sutured and painful perine-ums are resistant to doing this particular form ofexercise.

It was also possible to establish a link betweenepidural anaesthesia and suturing for perinealtrauma. Of those women who underwent anepidural for analgesia in labour, 86% requiredsuturing for perineal trauma. Less than one-third of first-degree tears were sutured, but allsecond- and third-degree tears were sutured, andtherefore, it can be postulated that epidural userssuffered greater perineal trauma. This may sug-gest that a lack of mobility during labour andthe inability to optimize positions for delivery,such as high kneeling, may contribute to perinealtrauma following vaginal delivery.

The overall average length of the second stageof labour was just under an hour, but afterfurther analysis, it became clear that thosewomen who had an episiotomy and second-degree trauma had an average second stage of1:37 h. This factor correlates with previous workin relation to the development of stress inconti-nence. Sapsford et al. (1999) suggested that aprolonged second stage is linked to an increasedincidence of stress incontinence, and the devel-opment of this condition can be attributedto sustaining perineal trauma at the time ofdelivery.

Foetal size and perineal traumaConsideration was given to the influence offoetal size, but there was no relationship betweenthe average size of the foetus and the incidence

of perineal trauma in the overall study popu-lation. Renfrew et al. (1998), Albers et al. (1999)and Hanretty (2003) all proposed a causal rela-tionship between foetal size and perineal trauma,but this is not supported by the present results.

It could be that consideration of foetal sizemay be of more value in individual cases. Forexample, the heaviest baby included in thepresent study was 4.47 kg. This was the onlyrecorded instance of rotational delivery byKeilland’s forceps and an episiotomy was per-formed. The woman had an epidural for painrelief and her second stage lasted 3:50 h. Thiskind of information is clearly important whenprioritizing women for physiotherapy interven-tion.

There was also no such relationship withrespect to OFC and perineal trauma followingvaginal delivery within this study population.Indeed, the largest recorded OFC was 37 cm.This subject was a primiparous woman whorequired no suturing to her perineum followingdelivery of her baby.

Ethnicity and perineal traumaThe audit forms also dealt with ethnicity. Kettle(2006) reported that white women are more atrisk of perineal trauma, but this finding is notsupported by the present results. Only 12% ofthe study population were not British and onlythree of those women were not Caucasian.Therefore, it was concluded that the numberswere not significant and no direct conclusionscould be drawn.

For the purpose of the present audit, ethnicitywas reported in terms of country of origin. It wasdecided that little useful information could bedrawn from the relationship of ethnicity andperineal trauma, but that country of origin maybe significant with respect to the language bar-rier that can exist between the woman having herbaby and the midwife or doctor assisting herdelivery. Chapman (2003) highlighted the impor-tance of communication, particularly in relationto deliveries assisted by forceps or ventouse, andstated that explanations need to be clear andinformative. The above author emphasized thatplenty of support must be given to the womanand her birth partner, for whom such an experi-ence may be frightening. This may be difficult ifa language barrier exists.

Incontinence risk assessment scoreThe Physiotherapy Obstetric team at RaigmoreHospital use an incontinence risk assessment



score to objectively identify women who are atrisk of incontinence following delivery. This wasdeveloped following a study carried out atSandwell General Hospital, West Bromwich,West Midlands, UK, which identified variousrisk factors for postnatal incontinence (Dandy1999). An assessment tool was devised topromote continence after childbirth.

The incontinence risk assessment score of eachsubject was determined as part of the presentstudy. A score of three or more suggests thatthese women should have one-to-one instructionin PFMEs along with written information. Thehighest incontinence risk assessment score docu-mented during the study was 20. This was for apatient with a third-degree tear who would beindicated for physiotherapy follow-up to reducethe risk of ongoing problems with pelvic floordysfunction. In cases involving a third-degreetear, women follow a specific hospital regime ofstool softeners and antibiotics, and are followedup routinely at the gynaecology clinic. However,there are also a significant number of motherswith a second-degree tear who are also at risk ofdeveloping pelvic floor dysfunction. Thesewomen may not be routinely reviewed followingdischarge from the maternity ward and commu-nity midwife. Therefore, these women shouldalso be identified, and given appropriate adviceand contact details for specialist physiotherapyshould their symptoms persist beyond the initialpostpartum period.

Questionnaire responsesThe response rate for the medical staff question-naires was very low, particularly with regard tomore junior staff. However, a response rate ofover 40% may be deemed acceptable (Hicks2004, cited in Johnson & Rochester 2008). The100% return rate from consultant medical staffwas pleasing, as were the findings that they wereall involved in the care of women with a third- orfourth-degree tear following vaginal delivery.This finding is in line with departmental protocol(‘Appendix 3’), which states that, when a third-or fourth-degree tear is suspected, the registraron call should examine the patient, and informand discuss the case with the on-call consultant.Unfortunately, no registrar questionnaires werereturned, and therefore, no data could beobtained. The staff-grade responses indicatedinvolvement at first-, second- and third-degreetear levels, but not at the fourth degree. Thismay be because of the presumption of consultantinvolvement in the repair of fourth-degree tears.

Fourth-degree tears occur in only an estimated0.05% of deliveries, as demonstrated by Rizvi& Chaudhury (2008). However, the RCOGreported that the combined incidence of third-and fourth-degree tears is between 0.6% and9.0%.

The 31% return rate for the midwifery ques-tionnaires was disappointing. As with the medi-cal staff, the low response may be explained bythe study taking place within the summer monthof July, when a significant proportion of mid-wives were absent because of annual leave. Amore detailed investigation of the actual numberof staff present in the maternity wards during thestudy period could provide more accurate figuressince the questionnaires were available only tomidwives actually in the maternity wards at anyone time. Another option would be to send thequestionnaires individually to midwives in orderto aid return, although this did not enhancereturn of more junior medical staff question-naires.

Treatment of perineal traumaAnalgesia. As anticipated, the medical staffquestionnaires showed that all respondentsinformed their patients of the benefits of appro-priate and effective analgesia. This is importantbecause, as Cooper et al. (2007) stated, effectivetreatment of acute pain must come high on theagenda of all staff who look after patients post-operatively. This finding was echoed in the mid-wifery questionnaires, in which all respondentsroutinely encouraged the use of analgesia forwomen with perineal trauma following vaginaldelivery.

Ice. The respondents had mixed views aboutthe use of ice in perineal trauma. Only 25% ofmedical staff supported this treatment comparedto 69% of midwives. Meeusen & Lievens (1986,cited in Gallie et al. 2003) stated that coldtherapy dates from the fourth century BCE,when it was advocated by Hippocrates. Ice is thecommonest form of local treatment for perinealpain and is administered in the form of ice packs(Sleep & Grant 1987, cited in Sapsford et al.1999). Two midwives reported that they hadpreviously used ice, but were subsequently rec-ommended not to employ it. Work by Grantet al. (1989) suggested that the use of ice maydelay healing. More recently, Brayshaw &Wright (1994) stated to the contrary that ice, ifapplied correctly, is a valid treatment for thepainful perineum.



Pelvic floor muscle exercises. It was found that12.5% of respondents did not routinely promotePFMEs for women with perineal trauma follow-ing vaginal delivery, although the RCOG (2007)stated that these exercises are effective in reduc-ing postnatal urinary incontinence. Numerousstudies advocate PFMEs for women with peri-neal trauma. Swelling and bruising follow episi-otomy and repair of perineal tear. Pelvic floormuscle exercises involving the contract–relaxtechnique are an efficient pump mechanism toincrease circulation and decrease oedema.Sleep & Grant (1987, cited in Sapsford et al.1999) found that perineal pain was lessened at3 months post-partum in women who had per-formed more intensive PFMEs. All postnatalwomen should be encouraged to do PFMEs,particularly those who have suffered perinealtrauma. Physiotherapists study in-depthanatomy and physiology of exercise, and are wellplaced to provide advice to postnatal womenregarding these exercises. Medical staff and mid-wives also have knowledge of this very import-ant muscle group and are in a position to advisepatients. The National Institute for Health andClinical Excellence (NICE) guidelines on post-natal care recommend that advice and infor-mation regarding PFMEs should be given ateach patient contact to aid recovery in the post-natal period (NICE 2006). The present studyrevealed that 18% of patients were not seen byan obstetric physiotherapist following vaginaldelivery. However, all caregivers within theMaternity Unit should recognize the import-ance of encouraging postnatal women to doPFMEs.

Bladder/bowel advice. All midwives surveyed inthe present study were found to routinelygive advice regarding toileting, as compared to75% of the medical staff who responded. Aspreviously mentioned, urinary incontinenceand, to a lesser degree, faecal incontinence canbe a consequence of vaginal delivery. Indeed,Sapsford et al. (1999) detailed the many changesoccurring in pregnancy, and stated that vaginaldelivery can be a catalyst for lifelong change inbladder and bowel function. If required and inline with NICE Guidelines (2006), appropriatetreatments should be instituted and follow-uparranged. In relation to anorectal disturbances,Sapsford et al. (1999) reported that these too arefrequently transient and that appropriate defeca-tion technique should be taught, together withperineal support, to increase comfort.

Midwives and physiotherapists are ideallyplaced to educate postnatal women on thesematters. Johnson & Rochester (2008) high-lighted the importance of follow-up after third-or fourth-degree tears at consultant-led clinics at6–12 months postnatally. This is also recom-mended by the RCOG and is included within theprotocol for Raigmore Hospital Maternity Unit.This follow-up is particularly important withrespect to the symptom of faecal incontinence,which is the most commonly reported complica-tion associated with third- and fourth-degreetears (Johnson & Rochester 2008). Women willoften not readily volunteer this as a problem,perhaps because of embarrassment; they aremore likely to address the issue when attending adesignated clinic.

Lifting/activities of daily living advice. Only38% of respondents stated that they providedroutine advice to women with perineal traumafollowing vaginal delivery. Interestingly, a higherpercentage of medical staff were found to givethis advice compared to midwives (63% versus25%). One midwife indicated that she ‘tended togive lifting advice to ladies following Caesareansection’. Much of the evidence available consid-ers lifting and activities of daily living in relationto back care. Consultant obstetricians are wellaware of the impact of lifting on the PFMs inrelation to their work with patients followingpelvic floor repair in gynaecology, and this maybe a possible reason for the high levels of advicegiven by this group (71% of consultants). TheNICE (2006) guidelines state that all womenshould be offered advice on exercise and plan-ning activities in the postnatal period (i.e.24–168 h). Physiotherapists have traditionallybeen associated with back care, and moving andhandling advice, so they are ideally suited toprovide advice and education in relation tothis.

All respondents stated that a patient infor-mation leaflet specific to the management ofperineal trauma following vaginal deliverywould be useful. Indeed, in Green-Top Guide-line No. 29, the RCOG (2007) advocates this.Furthermore, the NICE (2008) guidelines statethat sources of written information are highlyvalued, and in order to meet individual women’sneeds, it is likely that a variety of ways of givinginformation will be required. Therefore, anevidence-based leaflet issued in the early post-natal period would be of benefit in promotingrecovery from the symptoms of perineal trauma.



Given that this is a time of enormous changein lifestyle, particularly with a first baby, thewoman would have some advice and infor-mation to keep and refer to at her leisure.The NHS Highland policy relating to patientinformation leaflets requires these to carry thename and contact details of the lead cliniciancompiling the leaflet. This allows any womanexperiencing ongoing problems following theearly post-partum period to contact a specialistphysiotherapist in their area.

Conclusion

Comparing the present findings with those ofcurrent research reveals many parallels. It can beseen that the incidence of episiotomy and peri-neal trauma in primiparous women followingvaginal delivery at Raigmore Hospital MaternityUnit is largely similar to previous research find-ings. When examining suturing, it was foundthat all second-degree and some first-degreetears were sutured, which is an area where theresearch is divided. The most interesting fact wasthe high correlation between perineal traumaand epidural use. This may be a consideration ineducating antenatal women with respect to useof an epidural for pain relief in labour.

The incontinence risk assessment score wasconsidered by the present authors to be ofimportance because the average risk score of thestudy population encouraged one-to-one inter-vention regarding PFMEs and continenceadvice.

The questionnaire responses show that womenwho suffer from perineal trauma as a result ofvaginal delivery are given appropriate infor-mation regarding analgesia, PFMEs, and adviceregarding toileting for bladder and bowels. Theuse of ice highlighted some issues and it is clearthat it may be under-used in the management ofthis type of patient. It was also apparent thatthere was a lack of information given to womenwith perineal trauma regarding lifting and activi-ties of daily living. This is an area that would beeasily rectified through the issue of an appropri-ate leaflet. Although the obstetric physio-therapist would consider all of these issues in themanagement of postnatal women, the presentservice at Raigmore Hospital is such that notevery postnatal woman is seen. Therefore, aleaflet would be of significant benefit in themanagement of women suffering from perinealtrauma following vaginal delivery.

RecommendationsThe present authors make the following recom-mendations:

+ A written information leaflet for issue towomen with perineal trauma following vagi-nal delivery should be produced.

+ Teaching sessions for medical staff and mid-wives should be conducted to encourage theincreased use of ice for perineal pain in thepostnatal period.

+ Alternative methods of gathering informationfrom medical staff and midwives should beconsidered to increase the response rates infuture studies.

+ Greater patient awareness of perineal traumaantenatally should be promoted, particularlywith respect to epidural analgesia in labour.

+ The language barrier in relation to perinealtrauma should be explored.

+ Further research involving a larger studypopulation should be carried out over alonger time period.

References

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Fleming V. E. M., Hagen S. & Niven C. (2003) Doesperineal suturing make a difference? The SUNS trial.British Journal of Obstetrics and Gynaecology 110 (7),684–689.

Gallie M., Pourghazi S. & Grant J. M. (2003) A random-ized trial of pulsed electromagnetic energy comparedwith ice-packs for the relief of postnatal perineal pain.Journal of the Association of Chartered Physiotherapistsin Women’s Health 93 (Autumn), 10–14.

Glazener C. M. A., Abdalla M. I., Stroud P., et al. (1995)Postnatal maternal morbidity: extent, causes, preventionand treatment. British Journal of Obstetrics and Gynae-cology 102 (4), 286–287.

Grant A., Sleep J., McIntosh J. & Ashurst H. (1989)Ultrasound and pulsed electromagnetic energy treatmentfor perineal trauma. A randomized placebo-controlledtrial. British Journal of Obstetrics and Gynaecology 96 (4),434–439.

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Hicks C. M. (2004) Research Methods for Clinical Thera-pists: Applied Project Design and Analysis, 4th edn.Churchill Livingstone, Edinburgh.

Johnson A. & Rochester A. P. (2008) A retrospective postalsurvey of women’s experiences of physiotherapy manage-ment following a third- or fourth-degree perineal tear.Journal of the Association of Chartered Physiotherapy inWomen’s Health 102 (Spring), 25–35.

Kettle C. (2006) Perineal care. Clinical Evidence 15 (June),1904–1918.

MacLeod M. & Murphy D. J. (2008) Operative vaginaldelivery and the use of episiotomy – A survey of practicein the United Kingdom and Ireland. European Journal ofObstetrics & Gynecology and Reproductive Biology 136(2), 178–183.

Meeusen R. & Lievens P. (1986) The use of cryotherapy insports injuries. Sports Medicine 3 (6), 398–414.

National Institute for Health and Clinical Excellence(NICE) (2006) Routine Postnatal Care of Women andTheir Babies. [NICE Clinical Guideline 37.] NationalInstitute for Health and Clinical Excellence, London.

National Institute for Health and Clinical Excellence(NICE) (2008) Antenatal Care: Routine Care for theHealthy Pregnant Woman. [NICE Clinical Guideline 62.]National Institute for Health and Clinical Excellence,London.

Renfrew M. J., Hannah W., Albers L. & Floyd E. (1998)Practices that minimize trauma to the genital tract inchildbirth; a systematic review of the literature. Birth 25(3), 143–160.

Rizvi R. M. & Chaudhury N. (2008) Practices regardingdiagnosis and management of third and fourth degreeperineal tears. Journal of Pakistan Medical Association 58(5), 244–247.

Royal College of Obstetricians and Gynaecologists(RCOG) (2007) The Management of Third- and Fourth-Degree Perineal Tears. [Green-Top Guideline No. 29.]Royal College of Obstetricians and Gynaecologists,London.

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Karen Brandie qualified with a BSc in Physio-therapy from The Robert Gordon University,Aberdeen, UK, in 1994. She has been the leadphysiotherapist in women’s health at RaigmoreHospital, Inverness, UK, for the past 5 years.Karen is involved in the planning, development anddelivery of physiotherapy services for all aspectsof maternity care and in-patient gynaecology.

Alison MacKenzie BSc(Hons) is a band 6rotational physiotherapist at Raigmore Hospital.She contributed to this article during her rotationwithin the Women’s Health Unit.



Appendix 1



Appendix 2

Comments from medical staff questionnaires:

+ ‘Specific information (written) regardingthird- and fourth-degree tears would be help-ful.’

+ ‘We have guidelines on the intranet for thecare of third-degree tears.’

Comments from midwifery questionnaires:

+ ‘Advice to reduce anxiety regarding when tocommence intercourse. Also self-examination – how and when to do this post-delivery when recovering.’

+ ‘Ice – not routinely, but at times. Activities ofdaily living – not routinely, but at times.’

+ ‘We do not recommend ice for perinealtrauma as we were told it could slow downhealing. Any new evidence to the contrary?Tend only to give advice about lifting activi-ties to Caesarean section [patients].’

+ ‘Only advise ice on swollen perineum for24 h.’

+ ‘Type of stitches – dissolvable. May fall out –don’t panic if see one in the bath. Ice packs –use for short periods (e.g. a few minutes).’

+ ‘[Leaflet] DEFINITELY! [useful].’+ ‘[Advise on the use of ice] if very tender/sore.

Sometimes speak to the physio regardingcurapuls if perineum particularly painful.’

+ ‘Probably assume physiotherapist gives moreadvice.’

Appendix 3

Anal sphincter tear: diagnosis and repairWhen anal sphincter tears are identified, thefollowing protocol should be followed.

Definition:

+ A third-degree tear involves partial or com-plete disruption of the anal sphincter:(3a) <50% thickness of the external sphincter

involved;(3b) full thickness of the external sphincter

involved; and(3c) internal sphincter also torn.

+ A fourth-degree tear is a third-degree tearwith additional disruption of the analmucosa.

Pre-theatre management:

+ The registrar on call should examine thepatient and confirm the anal sphincter injury.

+ The registrar should inform the on-call con-sultant and discuss the case.

+ The registrar should explain the situation tothe patient.

+ The registrar should inform the duty anaes-thetist and organize the theatre.

Management in theatre:

+ All repairs should be performed in theatreunder general or, preferably, regional anaes-thesia.

+ Repair should be performed by a suitablytrained practitioner.

+ Thoroughly cleanse the area.+ Site the Foley catheter.+ Good light, exposure and assistance are essen-

tial to accurately assess and repair the tear(take assistance from a scrub nurse and asenior house officer).

+ The sphincter repair tray should be used.+ Evaluate the full extent of the injury.+ Intra-operative intravenous cefuroxime 1.5 g

and metronidazole 500 mg should beemployed. This regime can be used forpatients who are allergic to penicillin; how-ever, if there has been a serious penicillinallergy, i.e. urticaria, angio-oedema, immedi-ate rash or anaphylaxis, then cefuroximeshould be replaced by an infusion of 600 mgclindamycin.

Choice of sutures:

+ Anal mucosa is best repaired with 3/0 Vicryl,with the knots tied in the lumen.

+ Both the internal and external anal sphinctershould be repaired with 3/0 polydioxanone.

+ The vaginal epithelium and perineal muscleshould be repaired with 2/0 Vicryl Rapide.

Documentation:

+ Fully document the procedure in the opera-tion notes.

+ Note any anal mucosa involvement.+ Note the extent of internal and external

sphincter involvement.+ Note the type of technique (e.g. overlap or

approximation of external anal sphincter)used.

+ Note the sutures used.+ Note the blood loss/swab count.

Post-operative management:

+ Post-operative oral antibiotics should be usedas follows: 250 mg cefalexin three times daily



for 7 days and 400 mg metronidazole threetimes daily for 7 days.

+ This regime can be used for patients wishingto breast-feed.

+ If the patient is allergic to penicillin, then oral150 mg clindamycin should be used 6 hourlyfor 7 days.

+ Laxatives should be prescribed as follows:10 mL lactulose twice daily for 7 days and onesachet of Fybogel twice daily for 7 days.

+ Remove the catheter after 24 h.

All patients with third- or fourth-degree tearsshould be reviewed 4 months postnatally at theirconsultant’s gynaecology clinic.

Management in ward:

+ Patients should be managed on Ward 10 andreviewed daily by medical staff.

Bibliography

Royal College of Obstetricians and Gynaecologists (2000)Methods and Materials Used in Perineal Repair. [Guide-line No. 23.] Royal College of Obstetricians and Gynae-cologists, London.

Royal College of Obstetricians and Gynaecologists (2007)The Management of Third- and Fourth-Degree PerinealTears. [WWW document.] URL http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT29ManagementThirdFourthDegreeTears2007.pdf

Thakar R. & Sultan A. H. (2003) Management of obstetricanal sphincter injury. Obstetrician and Gynaecologist 5(2), 72–78.



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