Third and fourth degree perineal tears

What is a perineal tear?

Most birthing women or people, 8.5 of 10 (85%), will sustain a tear during childbirth. Tears usually occur in the perineum, the area between the vagina and the anus (back passage).

Of the birthing women or people who tear, 3 of 100 (3%) have a more extensive tear. This may be:-

• a third degree tear – involves the vaginal wall, perineum and the anal sphincter (the muscle that controls the back passage)
• a fourth degree tear – also involves the lining of the back passage

What is the difference between an episiotomy and a tear?

An episiotomy is a cut made by a doctor or midwife through the vaginal wall and perineum to make more space for the baby. A tear happens as the baby stretches the vagina during birth. Although an episiotomy makes more space for the baby to be born it does not prevent a third or fourth degree tear.

Why did I tear?

It is not possible to predict or prevent these types of tears, but the risk of tearing can be increased when:-

• this is the first vaginal delivery
• there is a very long second stage of labour (pushing stage)
• there is a previous perineal trauma (tear or episiotomy)
• there is an assisted delivery (forceps or ventouse)
• the baby’s shoulders get stuck behind the pubic bone (shoulder dystocia)
• a large baby (more than 4kg/8lbs 13oz)
• age higher than 35 years old
• South Asian ethnicity

What happens if I have a third or fourth degree tear?

It may be difficult to be certain how severe the tear is immediately after the birth. If your midwife or doctor suspects a third or fourth degree tear you will be moved to the Rosie Theatres where an experienced surgeon can carry out an examination under anaesthetic with good lighting and sterile conditions. If you already have an epidural in place this will be continued otherwise you will be offered spinal anaesthesia or rarely a general anaesthetic. The repair may take up to an hour and a urinary catheter (tube) will be in place to drain the bladder until sensation returns. It is important that you pass urine within six hours of the catheter coming out. If you are unable to pass urine, have bladder pain, feel that your bladder is overfull, or only pass small amounts, then let your midwife know within the first day.

Medication

• Antibiotics – you will be given antibiotics to minimize the risk of infection.
• Analgesia – this will be prescribed to relieve local pain, which will lessen quickly but may persist for some weeks after.
• Laxatives – you will be given a stool softener for 14 days to help to keep your bowel movements regular and soft as it is important to avoid constipation.

Day one

Do:-

• Take regular pain relief.
• Start gentle pelvic floor exercises when your catheter has been removed. The squeezing action of the muscles will help to relieve swelling and bruising. These are safe to start from day one.
• Try to keep mobile.
• Rest on your side if you feel uncomfortable or ask the physiotherapist about using a ‘valley cushion’ which is a pressure relieving cushion. These are usually available on postnatal wards but are also available through the NCT. Alternatively use two rolled up towels, one under each buttock.
• Check sanitary towel.

Bowel care

• Drink 1.5 – 2 litres of fluid each day.
• Eat a healthy balanced diet.
• Do not delay if you have an urge to empty your bowel.
• Sometimes it is helpful to use a footstool or large book to raise your feet while you are sitting on the toilet and lean forward. This can help to make passing a bowel motion easier.

Pelvic floor exercises/bladder care

It is important that you practise pelvic floor exercises regularly. These muscles have been weakened by pregnancy as well as by the tear.

To do pelvic floor exercises, imagine that you are trying to stop yourself passing urine or passing wind. Try to ‘squeeze and lift’ the pelvic floor muscles.

Start gently and rhythmically, you may not feel that much is happening at first but keep trying. Hold the squeeze for a few seconds and relax, try not to hold your breath.

Gradually increase the holding time and the number that you do until you can hold a squeeze for 10 seconds and repeat 10 times, try to do these four or five times a day. A good way of remembering to do pelvic floor exercises is to do them every time you feed your baby.

At home - during the first six weeks

A relaxing but brief warm bath can help to soothe the perineum and also keep it clean, although birthing women or people often add salt to bath water, there is no evidence that it has any antiseptic properties. Ensure that the perineum and this area are thoroughly dried.

Ice packs can help to relieve pain and reduce swelling in the short term, crushed ice or frozen bags of peas placed in a bag and wrapped in damp cloth can be placed against the perineum while lying on your side or back for 5 to 10 minutes and repeated three to four times per day. Feme pads may also be used, these are gel shaped pads which can be frozen and then placed in a gauze sleeve before applying to the perineum.

The specialist clinic

You will be given an appointment to our specialist multidisciplinary clinic for a 12 week check up. At this clinic there is access to a Consultant Obstetrician and Urogynaecologist as well as a specialist midwife and specialist physiotherapist. Both third and fourth degree tears can lead to a decrease in bladder and/or bowel control and it is important to have an expert evaluation to identify or prevent problems.

It also gives the opportunity to check that stitches have healed and to answer questions about what happened or to discuss future births.

Sexual intercourse

Birthing women or people may resume sexual intercourse at varying intervals after the birth of their baby. For birthing women or people who have experienced perineal trauma it may be several months before they feel ready to attempt intercourse and many women or birthing people will report vaginal dryness, particularly if they are breastfeeding. If there are any concerns ask for advice when attending the follow-up clinic or discuss this with your GP.

What are the complications of this type of tear?

Birthing women or people with tears into the anal sphincter are at increased risk of incontinence of wind urgency to open their bowels or even incontinence of faeces either immediately after giving birth or sometime later. If you have any of these symptoms, and would like advice before attending the clinic, please contact the Rosie physiotherapists on 01223 217422.

Some birthing women or people develop an infection in their stitches following a perineal tear. You should contact your midwife or GP if you have any of the following symptoms:

• increased pain
• redness or increased swelling around the perineal area
• an offensive smelling discharge

Data protection

During your visit to the clinic we may ask you to complete a form which will help us to assess your recovery. This information is kept in your notes and is only seen by the staff immediately involved in your care. We may also send information to your GP. Some this data may be used for audit purposes with the intention of improving the service we provide.