Abstract
Introduction
Postnatal perineal pain is prevalent following childbirth and can impact women both physically and emotionally. The aim of the study was to study the effect of collegial midwifery assistance on perineal pain and pain medication 1 month after birth and to investigate the associations between the type of tear and perineal pain, satisfaction with healing, and resumption of intercourse.
Material and Methods
A follow‐up questionnaire was sent 1 month postpartum to women with a first spontaneous vaginal birth participating in a randomized controlled trial (Oneplus trial). Data were collected from December 2019 to May 2020. Differences in perineal pain between women attended by one or two midwives were analyzed according to intention‐to‐treat using bivariate analyses. Associations between the type of tear and perineal pain, satisfaction with healing, and resumption of sexual intercourse were investigated using univariable and multivariable logistic regression. The category no tear/first‐degree tear was compared separately to each of the other tear categories. Trial registration number: ClinicalTrials.gov, NCT03770962.
Results
Out of 2233 women, 1762 responded within 30–60 days postpartum. Of women in the no tear/first‐degree tear category, 27.7% reported perineal pain during the past week, in contrast to women with OASI, where 64.2% reported perineal pain. Women with OASI experienced the highest odds of perineal pain (aOR 4.51, 95% CI 2.72–7.47) compared to those with no tear/first‐degree tear, followed by women with major second‐degree tears (aOR 1.87, 95% CI 1.45–2.41), women with an episiotomy (aOR 1.78, 95% CI 1.11–2.87), and those with minor second‐degree tears (aOR 1.43, 95% CI 1.06–1.94). Women with episiotomy reported the highest odds ratios for dissatisfaction with tear healing (aOR 3.48, 95% CI 1.92–6.31). No significant differences in perineal pain and pain medication were observed between women allocated to collegial midwifery assistance and those allocated to standard care.
Conclusions
Women with OASI reported the highest odds of perineal pain 30–60 days after birth compared to women with no tear or first‐degree tear, followed by women with major second‐degree tears. Women subjected to an episiotomy reported highest odds ratios of dissatisfaction with tear healing.
Keywords: dyspareunia, episiotomy, perineal pain, second‐degree tears, OASI
The aim of the study was to study the effect of collegial midwifery assistance on perineal pain and pain medication 1 month after birth and to investigate the associations between the type of tear and perineal pain, satisfaction with healing, and resumption of intercourse. There were no statistically significant differences between being assisted by one or two midwives with regard to perineal pain and pain medication. Women with OASI reported the highest odds of perineal pain, while women with episiotomy expressed the highest odds of dissatisfaction with tear healing.
Abbreviations
- CI
confidence interval
- CRF
case report forms
- OASI
obstetric anal sphincter injuries: defined as third‐ or fourth‐degree tears
- OR
odds ratio
Key message.
This study investigated postpartum perineal pain, including minor and major second‐degree tears 30–60 days after birth. Women with OASI reported the highest odds of perineal pain, while women with episiotomy expressed the highest odds of dissatisfaction with tear healing.
1. INTRODUCTION
Postpartum perineal pain is prevalent following childbirth 1 and can impact women both physically and emotionally, hindering their ability to care for their baby and engage in daily activities, consequently having a negative influence on the transition to motherhood. 2 The rate and intensity of perineal pain are affected by mode of birth, 3 , 4 duration of the second stage, 5 suture material and repair technique, 6 , 7 and analgesia used. 8 Several studies have examined perineal pain in relation to different degrees of perineal trauma and episiotomy. 1 , 9 , 10 , 11 , 12 Compared to episiotomy or second‐degree injuries, women with an obstetric anal sphincter injury (OASI) 13 report the most severe pain following birth. 1 , 10 , 14
Furthermore, perineal trauma has been shown to influence the resumption of sexual intercourse after birth. 15 Among women resuming sexual intercourse, dyspareunia is common, with reported incidences of 42% up to 2 months after birth. 16 Both OASI, episiotomy, and second‐degree tears have been associated with dyspareunia. 1 , 17 As a result of the association between OASI and maternal morbidity, 11 , 17 , 18 , 19 first‐ and second‐degree tears have often been considered as minor.
However, second‐degree tears can be highly complex 20 involving several muscles, including the bulbocavernosus muscle, the superficial transversus perinei muscle, and the deep transversus perinei muscle, with the muscle fibers converging and intersecting with the perineal body, while also connecting to the deeper vaginal structures and rectovaginal fascia. 21 , 22 Additionally, they may involve the levator ani muscle, with the median portion of the puboperineal muscle attached to the perineal body.
Considering the diverse extent of trauma observed within the category of second‐degree tears, 12 , 20 this topic has been increasingly discussed. In Sweden, a subclassification system for second‐degree tears has been established. 23 However, there remains a lack of knowledge regarding the impact of minor and major second‐degree tears on women's health. This includes investigating short‐term outcomes such as perineal pain following birth, resumption of intercourse, and dyspareunia.
The Oneplus trial is a multicenter randomized controlled trial designed to evaluate the effectiveness of collegial midwifery assistance during the late second stage, 24 hypothesizing that women assisted by two midwives would sustain fewer OASI. All the primary and secondary outcomes in the trial were predefined and based on specific hypotheses. Our hypothesis posited that should the intervention reduce various types of perineal trauma, this could further impact women's short‐ and long‐term pelvic floor health, including perineal pain.
The aim of the study was therefore to study the effect of collegial midwifery assistance on perineal pain and pain medication 1 month after birth and to investigate the associations between the type of tear and perineal pain, satisfaction with healing, and resumption of intercourse.
2. MATERIAL AND METHODS
This study uses a cross‐sectional design with patient‐reported outcomes utilizing data from the Oneplus multicenter randomized controlled trial and a secondary analysis of the collected trial data. The material consists of data from the trial together with a follow‐up questionnaire sent to trial participants 1 month after birth.
The questionnaire was sent to women included in the trial, aged 18–47, with a singleton live fetus in vertex presentation at gestational week 37 + 0, who had experienced their first spontaneous vaginal birth, and who were proficient in Swedish or English. Women who underwent an operative birth were excluded from participation. The data collection for the questionnaire took place between January 2019 and May 2020.
No power calculation was performed for any of the outcomes related to perineal pain and pain medication. To be able to ascertain the effect of the intervention on second‐degree tears and other grades of perineal trauma, the trial was designed to enable sub‐classification of second‐degree tears into minor and major second‐degree tears. The full details of the trial have been described in detail elsewhere. 24
To compare perineal pain and pain medication between the intervention group and the standard care group in the trial and to further investigate the associations between the exposures and outcomes, only questionnaires returned between 30 and 60 days after birth were included.
2.1. Study context
The routine in Sweden is to offer all women who have undergone vaginal birth a visual and digital vaginal and rectal examination after birth in order to assess and classify the tear. Subsequent to the delivery of the placenta, and following consent, the midwife responsible for the birth undertakes the initial examination of the tear. 16 Swedish midwives undergo training in assessment of perineal trauma and perineal repair during their education and all hospitals provide further training. Midwives classify and suture vaginal and perineal tears, while obstetricians classify and suture complicated vaginal and perineal trauma, including OASI. If episiotomy is considered, a mediolateral or lateral episiotomy is recommended. 23 For the suturing of second‐degree tears and episiotomies, braided absorbable multifilament sutures are recommended, that is, polyglactin 910 (Vicryl) or glycolide/lactide (Polysorb), whereas monofilament is the recommended practice for skin repair. 23
2.2. Procedures
Prior to the initiation of the Oneplus trial, educational sessions were conducted with the midwives at the participating obstetric units. The education was standardized and included comprehensive training in pelvic floor anatomy and classification of perineal trauma. The sessions had a specific focus on identification and classification of anatomical structures involved in second‐degree tears.
2.3. Variables and outcomes
Data used for the present study include questions from the 1‐month questionnaire and data from case report forms (CRFs) completed by the midwives after each birth or the obstetric units' local databases (Obstetrix Cerner or Cosmic Cambio). First‐degree tears, second‐degree tears, and vaginal tears were not recorded in the medical records at any of the study sites during the time period for the data collection, and therefore these variables were obtained in the CRFs. To ensure accuracy of the classification of tears, it was stated in the study protocol that the primary midwife should examine the woman together with an independent assessor (midwife or an obstetrician) to classify the tear. The CRF included questions regarding the classification of the tear, the anatomical structures involved in the tear, suturing material, and suturing techniques. Data regarding OASI were retrieved from medical records with ICD‐codes O70.2 or O70.3. Data from the CRFs were used for reporting other types of tears: intact perineum (no tear), first‐degree tear, second‐degree tear, vaginal tear, labial tears, and periurethral tears. The sub‐classifications of second‐degree in this study are based on the data reported in the CRFs. A minor second‐degree tear was defined as involving only the m. bulbocavernosus, whereas a major second‐degree tear included a tear involving both m. bulbocavernosus and m. transversus perinei, and if the assessors reported a tear where the sphincter was visualized but not torn. Only 27 women had an isolated vaginal tear, and it was therefore decided not to use this variable as an exposure due to the limited number of cases. Data on episiotomy was retrieved from the local databases, cross‐checked, and merged with episiotomies reported in the CRFs. Available data in these databases included information on whether the episiotomies were mediolateral or midline. No data on angle or length were collected in the CRFs. For the episiotomies documented in the CRFs, midwives could specify the anatomical structures involved. These structures were documented in 55% of the cases. Four episiotomies extended to OASI and were consequently categorized as such. Perineal tears were exclusively categorized into a single category meaning that those involving several anatomical structures, such as OASI, were solely categorized within the OASI group.
2.3.1. The 1‐month questionnaire
The questions concerning perineal pain and dyspareunia in the 1‐month questionnaire were developed by the researchers, inspired by previous research 9 , 10 , 25 (Box S1). To evaluate perineal pain while resting, sitting, walking, urinating, and when passing stool, a 7‐point Likert‐type scale was used from 1 (no pain) to 7 (worst imaginable pain). A composite pain variable named “any perineal pain” was further created. It included any positive response to pain in any of the other pain variables. All pain variables were dichotomized into no/slight pain (response options 1–2) and moderate/severe pain (response options 3–7). For dyspareunia, a 5‐point Likert‐type scale was used from 1 (no pain) to 5 (intolerable pain), and it was further dichotomized into no pain (response option 1) and pain (response option 2–5).
Perineal pain, satisfaction with healing of the tear, and resumption of intercourse were chosen as outcomes. The exposures included minor second‐degree tears (yes/no), major second‐degree tears (yes/no), OASI (yes/no), and episiotomy (yes/no) and the reference categories chosen were no tear or first‐degree tears (yes/no).
2.4. Statistical analyses
Continuous variables were described using the median and range, and categorical variables as numbers and percentages. To evaluate the effect of the collegial midwifery assistance compared to standard care on perineal pain, resumption of sexual intercourse and pain during intercourse t‐tests, chi‐squared tests, and Wilcoxon rank‐sum tests were conducted. For all analyses, the significance level was set at <0.05. To investigate the association between the type of tear and perineal pain, satisfaction with healing, resumption of sexual intercourse, and univariable and multivariable logistic regression analyses were conducted, using no tear/first‐degree tear as reference to calculate crude and adjusted odds ratios with a 95% confidence interval (CI). Each tear category was compared separately to the reference category no tear/first‐degree tear. For some of the exposures (mainly episiotomy and OASI), the number of observations was limited, and for those, only crude odds ratios were calculated. Based on Directed Acyclic Graphs (DAGs) 26 (Figure S1) and clinical reasoning, age and BMI were considered as confounders. All analyses were performed using SPSS© version 27 (IBM SPSS Software).
3. RESULTS
Of the 3059 women who gave birth spontaneously and were assigned to either the intervention or standard care, 2831 (92%) consented to participate in the 1‐month questionnaire. Of these, a total of 2233 women completed the questionnaire, resulting in a response rate of 78.9%. Late responders, that is, those responding after 60 days, were more often of non‐Nordic origin and had lower socioeconomic attainment. After exclusion of women answering before 30 or after 60 days and of missing response dates, the final dataset included responses from 1762 women, 893 from the intervention group and 869 from the standard care group (Figure 1).
FIGURE 1.
Flowchart of the women randomized in the Oneplus trial and participation in the 1‐month follow‐up questionnaire.
The majority of the participants were between 26 and 35 years old, and the mean maternal age was 30.2 in both groups (Table 1). The most prevalent type of second‐degree tears in both groups was the major type involving both the bulbocavernosus muscle and the transversus perinei muscle (28.3% in the intervention group vs 28.7% in the standard care group) (Table 2). Furthermore, there were no significant differences between the groups in how women rated their perineal pain during the past week, resumption of intercourse, dyspareunia, and satisfaction with the healing of the tear (Table S1).
TABLE 1.
Background information and characteristics of the participants.
| Intervention group—two midwives | Standard care group—one midwife | |
|---|---|---|
| n (%) | n (%) | |
| N = 893 | N = 869 | |
| Mean maternal age at birth (SD) | 30.2 (4.3) | 30.2 (4.2) |
| Mean maternal first trimester BMI a (SD) | 24.3 (4.4) | 24.4 (4.4) |
| Missing data | 47 (5.3) | 47 (5.4) |
| Parity | ||
| Nulliparous | 843 (94.4) | 814 (93.7) |
| VBAC | 50 (5.6) | 55 (6.3) |
| Maternal chronic disease b | 120 (13.4) | 126 (14.5) |
| Tobacco use at the start of pregnancy | 21 (2.4) | 15 (1.7) |
| Missing data | 34 (3.8) | 48 (5.5) |
| Educational level | ||
| Compulsory school | 18 (2.0) | 13 (1.5) |
| Upper secondary school | 190 (21.3) | 196 (22.6) |
| University 1–3 years | 233 (26.1) | 217 (25.0) |
| University >3 years | 429 (48.0) | 422 (48.6) |
| Other | 21 (2.4) | 20 (2.3) |
| Missing data | 2 (0.2) | 1 (0.1) |
| Married or living with a partner | 804 (90.0) | 788 (90.7) |
Abbreviation: VBAC, vaginal birth after cesarean section.
Body Mass Index kg/m2—categories according to WHO definition.
Composite variable including diabetes, chronic hypertension, asthma/pulmonary diseases, heart disease, epilepsy, endocrine diseases, chronic kidney diseases, Crohn's disease, ulcerative colitis, and systemic lupus erythematosus.
TABLE 2.
Obstetric outcomes.
| Intervention group—two midwives | Standard care group—one midwife | p‐value | |
|---|---|---|---|
| n (%) | n (%) | ||
| N = 893 | N = 869 | ||
| Postpartum hemorrhage >500 mL | 278 (31.1) | 287 (33.0) | 0.404 |
| Missing data | 25 (2.8) | 23 (2.6) | |
| Birth weight (mean, SD) | 3528 (434) | 3510 (432) | 0.393 |
| Missing data | 1 (0.1) | 1 (0.1) | |
| Tear assessed by two assessors | 778 (87.6) | 677 (78.2) | <0.001 |
| Missing data | 5 (0.6) | 3 (0.3) | |
| Rectal examination | 851 (97.3) | 831 (97.3) | 0.949 |
| Missing data | 18 (2.0) | 15 (1.7) | |
| Perineal trauma | |||
| No tear | 94 (10.5) | 97 (11.2) | 0.662 |
| Missing data | 13 (1.5) | 14 (1.6) | |
| First‐degree tear | 243 (27.2) | 226 (26.0) | 0.577 |
| Second‐degree tear (total) | 448 (50.2) | 429 (49.4) | 0.775 |
| Minor second‐degree tear a , c | 153 (17.3) | 147 (17.0) | 0.879 |
| Major second‐degree tear b , c | 250 (28.3) | 248 (28.7) | 0.833 |
| Missing data | 45 (5.0) | 34 (3.9) | |
| Vaginal tear | 346 (40.4) | 351 (42.8) | 0.322 |
| Missing data | 37 (4.1) | 49 (5.6) | |
| Episiotomy | 59 (6.6) | 54 (6.2) | 0.744 |
| OASI d | 36 (4.0) | 48 (5.5) | 0.142 |
| Labial tears | 561 (65.0) | 529 (63.7) | 0.744 |
| Missing data | 37 (3.4) | 38 (4.4) | |
| Periurethral tears | 74 (8.6) | 65 (7.8) | 0.572 |
| Missing data | 30 (3.4) | 38 (4.4) | |
| Suture material for vaginal and perineal muscles e | N = 799 | N = 771 | 0.301 |
| Vicryl 2–0 | 598 (84.3) | 566 (81.3) | |
| Vicryl Plus 2–0 | 111 (15.7) | 130 (18.8) | |
| Missing data | 90 (11.3) | 75 (9.7) | |
| Suturing technique e | |||
| Continuous suturing technique | 530 (68.4) | 522 (69.7) | 0.582 |
| Interrupted suturing technique | 515 (66.5) | 473 (63.2) | 0.177 |
| Missing data | 24 (3.0) | 22 (2.9) | |
Note: p‐values were calculated using students t test and chi‐squared test. The different tear categories add up to >100% as women could have several types of tears, that is, a first‐degree tear and a vaginal tear etc.
Includes m. bulbocavernosus.
Includes m. bulbocavernosus, m. transversus perinei and/or a tear where the anal sphincter is visible but not ruptured.
Information on which muscles and structures affected were not defined in 45 cases in the intervention group and 35 cases in the standard care group.
OASI, obstetric anal sphincter injury. This category includes 4 episiotomies (2 in the intervention group and 2 in the standard care group) that extended to OASI.
Only include women with a perineal and/or vaginal tear, or episiotomy.
Only a small proportion of women who did not tear or who had a first‐degree tear reported severe or moderate pain when resting (4.3%) (Table 3). Regarding the composite variable any perineal pain related to their tear, 27.7% of women in this category reported pain during the past week. The corresponding rate for women who sustained OASI was 64.2%, and it varied between 36.6% and 44.3% for minor second‐degree tears, episiotomy, and major second‐degree tears. Among women with OASI, 3.7% had resumed intercourse after birth compared to 29.5S% of the women with no tear or a first‐degree tear. Dyspareunia was common in all categories ranging from 65.0% to 78.6% (Table S2). Women who had sustained minor second‐degree tears did not experience higher odds of pain when sitting (aOR 1.05, 95% CI 0.71–1.57) and walking (aOR 1.02, 95% CI 0.70–1.50) compared to women in the reference group with no tear/first‐degree tears. However, they reported higher odds of pain when passing stool (aOR 1.63, 95% CI 1.16–2.28) and for any perineal pain (aOR 1.43, 95% CI 1.06–1.94) (Table 3) compared to the reference group. The highest adjusted odds ratios for the various situations of perineal pain, including any perineal pain and the need for pain medication, were observed within the OASI category when compared to the reference group. However, the adjusted odds for perineal pain while sitting and walking increased for women with major second‐degree tears, episiotomy, and OASI compared to women with no tear or first‐degree tear (Table 3). Moreover, among the different tear categories, women in the episiotomy group reported the highest odds ratios for dissatisfaction with the healing of the tear when compared to the reference group no tear or a first‐degree tear (aOR 3.48, 95% CI 1.92–6.31) and the highest odds of reported signs of tear infection at discharge from the hospital (aOR 2.81, 95% CI 1.24–6.36) (Table 3). However, we have no information from medical records regarding confirmed tear infection or wound dehiscence.
TABLE 3.
Perineal pain, use of pain medication, satisfaction with tear healing, and resumption of intercourse according to tear category.
| No tear/first‐degree tears | Minor second‐degree tears | Major second‐degree tears | Episiotomy | OASI | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| N = 648 | N = 300 | N = 498 | N = 113 | N = 84 | ||||||
| n (%) | Reference | n (%) | aOR | n (%) | aOR | n (%) | aOR | n (%) | aOR | |
| Moderate/severe perineal pain during the past week while resting | 23 (4.3) | 1.00 | 18 (6.2) | N/A | 58 (11.9) | 2.30 (1.46–3.61) | 9 (10.2) | N/A | 17 (21.0) | N/A |
| Missing | 114 (17.6) | 10 (3.3) | 9 (1.8) | 25 (22.1) | 3 (3.6) | |||||
| Moderate/severe perineal pain during the past week while sitting | 77 (14.4) | 1.00 | 44 (15.2) | 1.05 (0.71–1.57) | 109 (22.3) | 1.62 (1.18–2.22) | 21 (23.9) | 1.85 (1.06–3.23) | 30 (37.0) | 3.16 (1.86–5.37) |
| Missing | 112 (17.3) | 10 (3.3) | 10 (2.0) | 25 (22.1) | 3 (3.6) | |||||
| Moderate/severe perineal pain during the past week while walking | 82 (15.4) | 1.00 | 49 (17.0) | 1.02 (0.70–1.50) | 116 (23.8) | 1.52 (1.12–2.05) | 24 (27.3) | 1.93 (1.14–3.30) | 32 (40.0) | 3.16 (1.88–5.31) |
| Missing | 116 (17.9) | 11 (3.7) | 10 (2.0) | 25 (22.1) | 4 (4.8) | |||||
| Moderate/severe perineal pain during the past week when urinating | 83 (15.5) | 1.00 | 43 (14.9) | 0.93 (0.62–1.38) | 88 (18.0) | 1.11 (0.80–1.53) | 17 (19.3) | N/A | 18 (22.5) | N/A |
| Missing data | 112 (17.3) | 12 (4.0) | 10 (2.0) | 25 (22.1) | 4 (4.8) | |||||
| Moderate/severe perineal pain during the past week when passing stool | 91 (17.0) | 1.00 | 76 (26.3) | 1.63 (1.16–2.28) | 159 (32.6) | 2.11 (1.59–2.80) | 26 (29.5) | 2.07 (1.23–3.49) | 41 (51.2) | 4.75 (2.87–7.87) |
| Missing data | 114 (17.6) | 11 (3.7) | 10 (2.0) | 25 (22.1) | 4 (4.8) | |||||
| Moderate/severe perineal pain (any pain) during the past week a | 149 (27.7) | 1.00 | 106 (36.6) | 1.43 (1.06–1.94) | 217 (44.3) | 1.87 (1.45–2.41) | 36 (40.9) | 1.78 (1.11–2.87) | 52 (64.2) | 4.51 (2.72–7.47) |
| Missing data | 110 (17.0) | 10 (3.3) | 8 (1.6) | 25 (22.1) | 3 (3.6) | |||||
| Use of pain medication during past week | 60 (11.1) | 1.00 | 51 (17.5) | 1.69 (1.14–2.51) | 91 (18.5) | 1.71 (1.21–2.40) | 19 (21.8) | N/A | 33 (40.2) | 5.09 (2.99–8.66) |
| Missing data | 107 (16.5) | 8 (2.7) | 7 (1.4) | 26 (23.0) | 2 (2.4) | |||||
| Dissatisfaction with healing of tear | 42 (7.8) | 1.00 | 45 (15.6) | 2.11 (1.36–3.28) | 92 (18.9) |
2.63 (1.80–3.84) |
21 (24.7) | 3.48 (1.92–6.31) | 18 (22.0) | N/A |
| Missing data | 112 (17.3) | 11 (3.7) | 12 (2.4) | 28 (24.8) | 2 (2.4) | |||||
| Signs of infection at discharge b | 18 (2.8) | 1.00 | 49 (16.3) | 2.21 (1.18–4.16) | 71 (14.3) | 2.63 (1.52–4.55) | 23 (20.4) | 2.81 (1.24–6.36) | 12 (14.3) | N/A |
| Resumed intercourse | 189 (29.5) | 1.00 | 46 (15.6) | 0.52 (0.36–0.75) | 59 (12.0) | 0.35 (0.25–0.49) | 14 (12.6) | N/A | 3 (3.7) | N/A |
| Missing data | 7 (1.1) | 5 (1.7) | 6 (1.2) | 2 (1.8) | 2 (2.4) | |||||
Note: Valid % is displayed for all variables in this table. Information on which muscles and structures affected were not defined in 80 cases of the second‐degree tears and were missing for 12 women in the no tear/first degree tear group. Furthermore, there were 27 women who only had a vaginal tear, which were excluded in this analysis. Odds ratios with 95% confidence interval adjusted for maternal age and BMI compared to the reference group with no tear/first‐degree tear. Adjusted ORs are only calculated for variables with numbers of observations >20. The difference between adjusted and unadjusted odds ratios was marginal.
Abbreviations: aOR, adjusted odds ratios; CI, confidence interval; N/A, not applicable.
Combined variable, including any pain from the different alternatives that is, pain while resting, sitting, walking, urinating or when passing stool.
Assessed by caregivers at discharge from the hospital, not verified in medical records.
4. DISCUSSION
The results of this study showed no significant differences regarding postpartum perineal pain and pain medication for women assigned to collegial midwifery assistance compared to those allocated to standard care. Additionally, the study showed associations between the type of tear, including subclassifications of second‐degree tears, and perineal pain between 30 and 60 days postpartum. Women with OASI experienced the highest odds of perineal pain compared to those with no tear/first‐degree tear, followed by women with major second‐degree tears, women subjected to an episiotomy, and those with minor second‐degree tears. Women with episiotomy further reported the highest odds ratios for dissatisfaction with tear healing.
To the best of our knowledge, this is the first comprehensive study where second‐degree tears have been categorized into minor and major tears and where not only any perineal pain is investigated but also a differentiation between perineal pain during rest and activity. This contributes to the understanding regarding the instances in which the specific tear categories lead to perineal pain. Overall, our study adds to the evidence that perineal pain is proportional to the severity of perineal trauma, where women with OASI report highest levels of perineal pain. 9 , 10 , 27 When differentiating second‐degree tears into minor and major tears, women with minor second‐degree tears did not report significantly more perineal pain when resting, sitting, or in motion compared to those with no tears or first‐degree tears. This is reassuring, as high levels of perineal pain when sitting and walking have been reported to interfere with breastfeeding and hinder physical activities. 28
Previously women with a mediolateral episiotomy have been expected to experience increased perineal pain compared to a midline episiotomy or a second‐degree tear. 9 , 10 However, in our study, women with major second‐degree tears and those subjected to an episiotomy reported perineal pain quite similarly. This might be attributed to the fact that both categories involve the same anatomical structures. Furthermore, the births in the present study were conducted by midwives, and previous research shows that midwives tend to perform shorter episiotomies and closer to the midline than obstetricians. 29 , 30 It is likely that the greater the similarity between episiotomies and major second‐degree tears, the more comparable the pain they will induce. As we did not measure the length or angle of the episiotomy, we cannot know if this applies to our study. However, when compared to the reference group, women with episiotomy reported highest adjusted odds for perineal pain while walking, while women with major second‐degree tears reported highest adjusted odds for any perineal pain. If the episiotomy is cut at the recommended 45–60‐degree angle, this could hypothetically result in tissues being stretched and pulled when the woman is in an upright position or moving, thus causing more pain. Additionally, women subjected to an episiotomy reported the highest odds of being dissatisfied with the healing compared to the reference group. It has been hypothesized that the lateral or mediolateral episiotomy may present challenges during suturing owing to difficulty in aligning the anatomical structures. This was reported in a study where spontaneous tears were easier and took less time to suture. 31 We have no information on why women were not satisfied with their healing. Women with episiotomies could have had more complicated births. A longer labor or an instrumental birth is known to affect the birth experience, 32 and a recent study showed that perineal pain was associated with depressive symptoms 4–6 weeks after birth. 33 Dissatisfaction with healing may therefore be a multifactorial issue. However, this study only includes women with spontaneous vaginal births, and if a longer second stage or other complications were present, it would have applied to women with OASI to the same extent, which was not observed. Other reasons for dissatisfaction with healing include complications, for example, wound dehiscence or wound infection. Even though we have no information on verified tear infection or wound dehiscence in women with episiotomies, caregivers reported the highest odds of signs of tear infection at discharge for women in this category. This aligns with findings from a recent trial on lateral episiotomy in operative births, which found that while episiotomy reduced sphincter injuries, women in the episiotomy group had a higher risk of wound dehiscence and tear infection. 34 In 2022, the Swedish prevalence of episiotomy was 6.5% during spontaneous vaginal birth. 35 Midwives therefore both perform and suture fewer episiotomies than second‐degree tears. Given the dissatisfaction with tear healing in the episiotomy group, training in both performing and suturing episiotomies is required. Although our results did not demonstrate that collegial midwifery assistance influenced the outcomes in this study, the intervention could be of great value if extended to assessment of tears and in suturing.
Our findings further align with some studies 12 , 27 while contradicting others. In the study by Manresa et al. (2020), women reported less perineal pain compared to women in the present study, and they found no differences in perineal pain between the different categories of second‐degree tears at 7 weeks. 20 Since all the studies used slightly different ways to categorize the subtypes of second‐degree tears, 20 , 36 this could partially explain the differences in the results. As only a few women in our study experienced an isolated deeper vaginal tear, and the vaginal tears could not be distinguished from second‐degree tears, this prevented us from investigating any associations between deep vaginal tears and perineal pain. Furthermore, we cannot exclude the possibility that the pain reported by women may also encompass discomfort related to a levator ani muscle injury. 37 However, symptoms of this type of injury typically present as pelvic pain 38 rather than perineal pain. Nonetheless, it is conceivable that pain, particularly while standing, could encompass this form of discomfort as well. Altogether, our results indicate that women with major second‐degree tears and episiotomies may need more attention than caregivers have previously assumed. Currently, follow‐up in many Swedish Regions focuses solely on women with OASI for whom national guidelines exist regarding postnatal care. 23 Some obstetric units have established clinics where women can book an appointment if they experience problems related to tear healing and pain, while women in other regions are referred to midwives at the antenatal care clinic.
The strength of this study is the detailed data collected regarding tearing, where either two midwives or a midwife and a physician jointly classified the tears, thus validating their classification and enabling the sub‐categorization of second‐degree tears. Another strength is the educational sessions conducted at the labor wards prior to the commencement of the study, which placed emphasis on the anatomical structures and classification of second‐degree tears. Furthermore, the present study achieved a high response rate to the follow‐up questionnaire.
In addition to the strengths of the study, there are several limitations that have to be acknowledged. The questionnaire was distributed to women 1 month after birth, with the majority of the women responding between 30 and 60 days after birth. Early responders differed from those responding later, and we aimed to balance, on one hand, being as accurate as possible, and on the other hand, including those responding later as they were more often of non‐Nordic origin and had lower educational attainment. Another limitation is the absence of a power calculation conducted for the secondary analyses conducted in this study. For less prevalent injuries like OASI or episiotomy, the results need to be interpreted with caution. If we had limited our sample further, by including only those who responded at either 1 or 2 months after the birth, the limited sample size would have hindered the possibility to conduct adjusted analyses for many of the outcomes. Furthermore, we lack information on the anatomical structures involved in the episiotomies, as the midwives to a high extent did not report this in the CRFs. Therefore, we are unable to further classify the episiotomies.
Addressing perineal pain using a cross‐sectional design has limitations which include the inability to establish causality, and the difficulty in capturing the temporal variations in pain perception and severity. Perineal pain was evaluated using a 7‐point Likert‐type scale instead of a numerical rating scale. As the responses were subsequently dichotomized, a certain degree of variation was lost. Altogether, despite our results being consistent with previous studies, 12 , 20 it is important to acknowledge that these decisions have resulted in less precise pain ratings.
Additionally, there was a high number of missing data on reported perineal pain both for women with no tearing and/or first‐degree tears as well as for those who underwent an episiotomy. Since none of the questions in the web‐based questionnaire were mandatory to complete, a higher rate of missing data can be expected. A possible explanation for the higher number of missing data may be related to the fact that women who did not experience any tearing or an episiotomy may consider the questions regarding perineal pain related to tearing irrelevant. Especially since the questions referred to pain related to tears, where an episiotomy may not be considered a tear by some. A stratified analysis conducted with responses for women with first‐degree tears showed a more acceptable rate of missing values around 10% confirming this assumption.
5. CONCLUSION
Women with OASI reported the highest odds of perineal pain compared to women with no tears or first‐degree tears 30–60 days postpartum, followed by those with major second‐degree tears. Conversely, women who sustained minor second‐degree tears did not report significantly more pain at rest or in motion, compared to those with no tears or first‐degree tears. Women subjected to an episiotomy reported the highest adjusted odds for being dissatisfied with tear healing among the different tear categories compared to those with no tear/first‐degree tears.
AUTHOR CONTRIBUTIONS
Malin Edqvist and Christine Rubertsson designed the study with input from Gunilla Ajne, Pia Teleman, and Gunilla Tegerstedt. Malin Edqvist and Christine Rubertsson were responsible for the data collection. The data analysis was performed by Malin Edqvist, and all authors were involved in the interpretation of the results. Malin Edqvist wrote the first draft of the article, and all authors contributed to and approved of the final version.
FUNDING INFORMATION
This study was funded by the Swedish Research Council for Health, Working Life and Welfare number 2018‐01192; Jan Hain's Foundation for Scientific Clinical Medical Research; and Skane County Council's Research and Development Foundation.
CONFLICT OF INTEREST STATEMENT
The authors state explicitly that there are no conflicts of interest in connection with this article.
ETHICS STATEMENT
The study was approved on July 27, 2018 by the Regional Ethics Committee in Lund, Sweden (reference no. 2018‐476). The trial is registered at ClinicalTrials.gov, NCT03770962.
Supporting information
Figure S1.
Box S1.
Table S1.
Table S2.
ACKNOWLEDGMENTS
We are grateful to all midwives and physicians that completed the detailed CRFs with great care. Furthermore, we would like to thank statistician Susann Ullén for input on statistical matters.
Edqvist M, Ajne G, Teleman P, Tegerstedt G, Rubertsson C. Postpartum perineal pain and its association with sub‐classified second‐degree tears and perineal trauma—A follow‐up of a randomized controlled trial. Acta Obstet Gynecol Scand. 2024;103:2314‐2323. doi: 10.1111/aogs.14938
REFERENCES
- 1. Manresa M, Pereda A, Bataller E, Terre‐Rull C, Ismail KM, Webb SS. Incidence of perineal pain and dyspareunia following spontaneous vaginal birth: a systematic review and meta‐analysis. Int Urogynecol J. 2019;30:853‐868. [DOI] [PubMed] [Google Scholar]
- 2. Salmon D. A feminist analysis of women's experiences of perineal trauma in the immediate post‐delivery period. Midwifery. 1999;15:247‐256. [DOI] [PubMed] [Google Scholar]
- 3. McDonald E, Gartland D, Small R, Brown S. Dyspareunia and childbirth: a prospective cohort study. BJOG. 2015;122:672‐679. [DOI] [PubMed] [Google Scholar]
- 4. de Souza A, Dwyer P, Charity M, Thomas E, Ferreira CHJ, Schierlitz L. The effects of mode delivery on postpartum sexual function: a prospective study. BJOG. 2015;122:1410‐1418. [DOI] [PubMed] [Google Scholar]
- 5. Leeman L, Fullilove AM, Borders N, Manocchio R, Albers LL, Rogers RG. Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables. Birth (Berkeley, Calif). 2009;36:283‐288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev. 2010;2010:CD000006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second‐degree tears. Cochrane Database Syst Rev. 2012;11:Cd000947. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Wuytack F, Smith V, Cleary BJ. Oral non‐steroidal anti‐inflammatory drugs (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev. 2021;1:Cd011352. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. AmJ Obstet Gynecol. 2004;191:1199‐1204. [DOI] [PubMed] [Google Scholar]
- 10. Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of postpartum perineal pain and dyspareunia—a prospective study. EurJ Obstet Gynecol Reprod Biol. 2008;137:152‐156. [DOI] [PubMed] [Google Scholar]
- 11. Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J. 2016;27:1513‐1523. [DOI] [PubMed] [Google Scholar]
- 12. Åhlund S, Rådestad I, Zwedberg S, Lindgren H. Perineal pain the first year after childbirth and uptake of post‐partum check‐up—a Swedish cohort study. Midwifery. 2019;78:85‐90. [DOI] [PubMed] [Google Scholar]
- 13. Doumouchtsis SK, de Tayrac R, Lee J, et al. An International Continence Society (ICS)/International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders. Int Urogynecol J. 2023;34:1‐42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Huber M, Larsson C, Lehmann JP, Strigård K, Lindam A, Tunón K. Sonographic postpartum anal sphincter defects and the association with pelvic floor pain and dyspareunia. Acta Obstet Gynecol Scand. 2023;102:1290‐1297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Rådestad I, Olsson A, Nissen E, Rubertsson C. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow‐up. Birth (Berkeley, Calif). 2008;35:98‐106. [DOI] [PubMed] [Google Scholar]
- 16. Banaei M, Kariman N, Ozgoli G, et al. Prevalence of postpartum dyspareunia: a systematic review and meta‐analysis. Int J Gynaecol Obstet. 2021;153:14‐24. [DOI] [PubMed] [Google Scholar]
- 17. Cattani L, de Maeyer L, Verbakel JY, Bosteels J, Deprest J. Predictors for sexual dysfunction in the first year postpartum: a systematic review and meta‐analysis. BJOG. 2022;129:1017‐1028. [DOI] [PubMed] [Google Scholar]
- 18. Jangö H, Langhoff‐Roos J, Rosthøj S, Sakse A. Mode of delivery after obstetric anal sphincter injury and the risk of long‐term anal incontinence. Am J Obstet Gynecol. 2016;214:733.e1‐733.e13. [DOI] [PubMed] [Google Scholar]
- 19. Priddis H, Dahlen H, Schmied V. Women's experiences following severe perineal trauma: a meta‐ethnographic synthesis. J Adv Nurs. 2013;69:748‐759. [DOI] [PubMed] [Google Scholar]
- 20. Manresa M, Pereda A, Goberna‐Tricas J, Webb SS, Terre‐Rull C, Bataller E. Postpartum perineal pain and dyspareunia related to each superficial perineal muscle injury: a cohort study. Int Urogynecol J. 2020;31:2367‐2375. [DOI] [PubMed] [Google Scholar]
- 21. Shafik A, Sibai OE, Shafik AA, Shafik IA. A novel concept for the surgical anatomy of the perineal body. Dis Colon Rectum. 2007;50:2120‐2125. [DOI] [PubMed] [Google Scholar]
- 22. Zifan A, Reisert M, Sinha S, et al. Connectivity of the superficial muscles of the human perineum: a diffusion tensor imaging‐based global tractography study. Sci Rep. 2018;8:17867. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Swedish Pelvic Floor Educational Program 2023 . https://backenbottenutbildning.se/index.php/metodik/metodik
- 24. Edqvist M, Dahlen HG, Häggsgård C, et al. The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden. Lancet. 2022;399:1242‐1253. [DOI] [PubMed] [Google Scholar]
- 25. Mohamed H, El‐Nagger NS. Effect of self perineal care instructions on episiotomy pain and wound healing of postpartum women. J Am Sci. 2012;8:640‐650. [Google Scholar]
- 26. Shrier I, Platt RW. Reducing bias through directed acyclic graphs. BMC Med Res Methodol. 2008;8:70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Risløkken J, Dalevoll Macedo M, Bø K, Ellström Engh M, Siafarikas F. The severity of second‐degree perineal tears and perineal pain during three months postpartum: a prospective cohort study. Midwifery. 2024;131:103930. [DOI] [PubMed] [Google Scholar]
- 28. Lindberg I, Persson M, Nilsson M, Uustal E, Lindqvist M. “Taken by surprise”—women's experiences of the first eight weeks after a second degree perineal tear at childbirth. Midwifery. 2020;87:102748. [DOI] [PubMed] [Google Scholar]
- 29. Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevic Z. Differences in episiotomy technique between midwives and doctors. BJOG. 2003;110:1041‐1044. [PubMed] [Google Scholar]
- 30. Wong KW, Ravindran K, Thomas JM, Andrews V. Mediolateral episiotomy: are trained midwives and doctors approaching it from a different angle? Eur J Obstet Gynecol Reprod Biol. 2014;174:46‐50. [DOI] [PubMed] [Google Scholar]
- 31. Sagi‐Dain L, Kreinin‐Bleicher I, Shkolnik C, Bahous R, Sagi S. In women with spontaneous vaginal delivery, repair of perineal tears might be easier compared to episiotomy. Int Urogynecol J. 2021;32:1727‐1732. [DOI] [PubMed] [Google Scholar]
- 32. Waldenström U, Hildingsson I, Rubertsson C, Rådestad I. A negative birth experience: prevalence and risk factors in a national sample. Birth. 2004;31:17‐27. [DOI] [PubMed] [Google Scholar]
- 33. Chang S‐R, Chen K‐H, Lee C‐N, Shyu M‐K, Lin M‐I, Lin W‐A. Relationships between perineal pain and postpartum depressive symptoms: a prospective cohort study. Int J Nurs Stud. 2016;59:68‐78. [DOI] [PubMed] [Google Scholar]
- 34. Bergendahl S, Jonsson M, Hesselman S, et al. Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial. BMJ. 2024;385:e079014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Graviditetsregistret . Graviditetsregistrets årsrapport . https://www.medscinet.com/GR/uploads/hemsida/dokumentarkiv/Graviditetsregistrets%20%C3%85rsrapport%202022.pdf 2023.
- 36. Macedo MD, Ellström Engh M, Siafarikas F. Detailed classification of second‐degree perineal tears in the delivery ward: an inter‐rater agreement study. Acta Obstet Gynecol Scand. 2022;101:880‐888. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Alshiek J, Shobeiri SA. The practical value of levator ani muscle injury repair. Tech Coloproctol. 2019;23:83‐85. [DOI] [PubMed] [Google Scholar]
- 38. Brandon C, Jacobson JA, Low LK, Park L, DeLancey J, Miller J. Pubic bone injuries in primiparous women: magnetic resonance imaging in detection and differential diagnosis of structural injury. Ultrasound Obstet Gynecol. 2012;39:444‐451. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1.
Box S1.
Table S1.
Table S2.