"I was lead to believe that I had achieved a relatively successful normal birth and that my body just needed time to recover"
What is a perineal tear?
Many women (90%) experience tears to some extent during childbirth as the baby stretches the vagina, especially with the first baby. Most tears occur in the perineum, the area between the vaginal opening and the anus (back passage). They are usually graded by ‘degrees’ and you may hear the terms ‘first, second degree tear’. Here is a brief overview of perineal tears with a link to more information if you need.
First and Second degree tears
First-degree tears are small and skin-deep and can heal without sutures. Second degree are deeper and affect the muscles of the perineum, and these usually require stitches. An episiotomy, is a cut made by a doctor or midwife to make more space to deliver the baby, and it's always repaired after the birth.
Third or Fourth Degree Perineal Tear
If a tear is deeper it can affect the anal sphincter (the part that keeps the anal canal closed), and this is called a '3rd degree' tear. Third degree tears extend downwards from the vagina and perineum to the anal sphincter. If the tear extends further into the lining of the anus or rectum it is known as a fourth-degree tear. Third and fourth degree tears are also sometimes referred to as ‘Obstetric anal sphincter injury (OASI).
OASI can be a much more serious consequence of vaginal delivery. It is thought to be the most important risk factor for anal incontinence (inability to control bowel movements, causing stool to leak unexpectedly from back passage). Sometimes, OASI occurs even in otherwise normal, easy deliveries, but it's commonest after a forceps delivery. In addition to anal incontinence, OASI may cause pain, discomfort and problems on intercourse. However, 60-80% of women who have sustained such an injury, have no symptoms at 12 months, and most report incontinence of wind only.
What will happen if I have an OASI?
When a third or fourth degree tear is suspected or confirmed, which sometimes requires an ultrasound image of the anal sphincter, this will usually be repaired in the operating theatre. You will need regional (epidural or spinal) anaesthetic but occasionally a general anaesthetic may be necessary. The obstetrician will then stitch the tear including the damaged anal sphincter. After the operation you will be:
- offered pain-relieving drugs such as paracetamol, ibuprofen or diclofenac to relieve any pain
- 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 to make it easier and more comfortable to open your bowels.
- catheterised to drain the urine until you are able to walk to the toilet.
- referred to the Physiotherapist or Continence Nurse Advisor for perineum/pelvic floor muscle strengthening exercises to prevent possible problems with bowel control.
- referred to a Perineal Clinic (if such services exist in your area) to check on healing and the quality of the repair.
Once you have opened your bowels and your stitches have been checked to see that they are healing properly, you should be able to go home. None of the treatments offered will prevent you from breastfeeding.
What can I expect afterwards?
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 painkillers when you go home. The stitches usually dissolve within a couple of weeks and 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: 6–8 in 10 women will have no symptoms a year after birth.
What can help me recover?
Keep the area clean. Have 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 it’s 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 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 beneficial to have a pelvic floor physiotherapist assess you doing pelvic floor muscle training to ensure that you are doing it effectively.
Looking after a newborn baby and 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.
When should I seek medical advice after I go home?
You should contact a doctor, preferably a gynaecologist, if:
- the stitches become more painful or smelly – this may be a sign of an infection
- 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 if you're lucky there will be a dedicated service ('perineal clinic').
When can I have sex?
Normally, many women feel sore in the weeks after having a vaginal birth. If you have had a tear, sex can be uncomfortable for longer. You should wait to have sex until the bleeding has stopped and the tear has healed which may take up to 6-8 weeks. After that you can have sex when you feel ready to do so. A small number of women may continue to have painful sex. Talk to your gynaecologist if this is the case so that you can get the help and support you need.
Your follow-up appointment
You may be offered a follow-up appointment at the hospital 6–12 weeks after you have had your baby to check that your stitches have healed properly. If facilities are available, follow-up of women with OASIS should be in a dedicated perineal clinic with access to perineal ultrasonography and anal manometry as this can aid decision making regarding future delivery. You will be asked questions about whether you have any problems controlling your bowels. You will also have the opportunity to discuss the birth and any concerns that you may have.
Can I have a vaginal birth in the future?
Most women go on to have a straightforward birth after a third- or fourth-degree tear. However, there is an increased risk of this happening again in a future pregnancy. Between 5 and 7 in 100 women who have had a third- or fourth-degree tear will have a similar tear in a future pregnancy. If you have recovered well and do not have any symptoms, you can consider a vaginal delivery. If you continue to experience symptoms from the third or fourth degree tear, you may wish to consider a planned caesarean section.
You will be able to discuss your options for future births at your follow-up appointment or early in your next pregnancy. Your individual circumstances and preferences will be taken into account.
For more information you may wish to view: www.masic.org.uk