What is a Perineal Tear?
First and Second degree tears
Third or fourth degree perineal tears/Obstetric Anal Sphincter Injuries (OASI)
What will happen if I have a third or fourth degree tear?
Often the anaesthetics doctor, will discuss the pain relief options with you which may include an epidural or spinal anaesthetic or a general anaesthetic. While you are in the theatre, your baby will be looked after by your partner, a family member or a midwife. Support SHOULD have been provided to them. To ensure the tear heals well and that you can look after your baby, your care team will provide the following after the operation:
- offered regular pain-relieving drugs such as paracetamol, anti-inflammatory medications e.g. ibuprofen or diclofenac, and stronger medications.
- advised to take a course of antibiotics to reduce the risk of infection (because the stitches are very close to the anus)
- advised to take laxatives e.g. lactulose, movicol, to make it easier and more comfortable to open your bowels. Some stronger pain relief medications e.g. panadeine forte, endone, may cause constipation, so it is even more important to use the laxatives when taking these medications
- a catheter (rubber tube in the bladder) to drain urine until the perineum pain improves and you are able to walk to the toilet
- assessment and discussion with a physiotherapist or continence nurse advisor for perineum/pelvic floor muscle strengthening exercises to prevent possible problems with bowel control, and
- referral to a perineal clinic or with an experienced clinician to check on healing, the success of the repair and any further tests or treatment
- A discussion with the care team explaining the type of tear, anything that may have contributed to the tear, how the repair was done, things to look out for that may indicate a complication, and how you will be followed up.
It is normal to feel pain or soreness around the tear or cut for two to three weeks after giving birth, especially when walking or sitting. Passing urine may also cause stinging. You can continue to take your pain relief when you go home, which will be prescribed by your care team. The skin stitches usually dissolve within three weeks, with the deeper stitches taking up to 3 months. Full healing can take up to 6-8 weeks. As healing takes place, the stitches can irritate or you may notice some stitch material fall out but this is normal.
Some women feel that they pass wind more easily, or need to rush to the toilet to open their bowels. Most women make a good recovery, particularly if the tear is recognised and repaired at the time of the birth.6 If this occurs, 6-8 in 10 women will have no symptoms a year after birth.6
- Keep the area clean by having a bath or a shower at least once a day and change your sanitary pads regularly. This will reduce the risk of infection.
- An ice pack may be helpful if your perineum is bruised and/or swollen. Rolling up a couple of towels and placing them side by side in a parallel position may make sitting more comfortable.
- You should aim to drink at least 2-3 litres of water every day (possibly more if you are breastfeeding and/or it is summertime).
- Try to eat a diet rich in fibre (fruit, vegetables and wholegrains) and avoid processed food and sugar as much as possible. This will ensure that your bowels open regularly and will prevent you from becoming constipated.
- Avoid heavy lifting, pushing or pulling (including heavy prams). while allowing the perineum to heal.
- Also, avoid straining while emptying your bowel. If you aren’t having soft stools, then you may want to consider taking a stool softening supplement recommended by your chemist.
- Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help healing. It is important to do pelvic floor exercises as soon as you can after birth. You should be offered physiotherapy advice about pelvic floor exercises in hospital. It may also be very helpful to be assessed by a pelvic health physiotherapist to ensure that you are doing your exercises correctly and effectively.
- Looking after a newborn baby while recovering from an operation for a perineal tear can be hard. If you are offered help, don’t be afraid to accept it. You need support from family and friends when possible.
You should contact your hospital or a doctor, preferably a gynaecologist, if your stitches become more painful or smelly – this may be a sign of an infection. Medical advice is also required if you find you cannot control your bowels or flatus (passing wind).
Talk to your obstetrician/ gynaecologist if you have any other worries or concerns. You can be referred back to the hospital before your follow-up appointment if you wish, and some hospitals provide a specialised ‘perineal/pelvic floor clinics’.
There are many factors that may guide your decision about whether to have a vaginal birth.
If the repair is successful, with an intact sphincter and no bowel symptoms, many women will be supported in having another vaginal birth. There is however a 10% risk of having another third of fourth degree tear 8, and this may increase the risk of incontinence, most women will have a successful vaginal birth. However every pregnancy is different, and there may be some factors that increase your risk of another tear.
For some women, the sphincter may not have healed successfully, or there may be bowel symptoms, and these women will often be offered a caesarean section, to reduce any further trauma to the sphincter.
For some women, even though the repair has been successful, the trauma of their last birth will cause them to choose a caesarean section.
In your next pregnancy, it is important that your maternity care providers are aware you have had a third-or-fourth degree tear. A consultation with an experienced obstetrician should ensure that you are assessed and aware of your options so you can be fully informed when choosing how to have your next baby.