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Perineal Tear

What is a Perineal Tear?

A perineal tear is a laceration of the skin, muscles and other soft tissues that separate the vaginal opening and the anus (back passage).1 Tears are usually graded by ‘degrees’ and you may hear the terms first, second, third or fourth degree tear. Each tear is described below, including usual treatments.

First and Second degree tears

First degree tears are small and skin-deep and can heal without sutures. Second degree tears are deeper and affect the muscles of the perineum, usually requiring stitches. An episiotomy is a cut made by a doctor or midwife to make the vaginal opening larger in order to deliver the baby. It is repaired with stitches after the birth.2

Third or fourth degree perineal tears/Obstetric Anal Sphincter Injuries (OASI)

A third degree tear extends downwards from the vagina through the deeper muscles to the anal sphincter (the part that keeps the anal canal closed). If the tear extends further into the lining of the anus or rectum it is known as a fourth degree tear.3 Approximately 4 out of every 100 women having a vaginal birth experience a third or fourth degree tear.3
Injury to the anal sphincter during birth is thought to be the most important risk factor for anal incontinence – the inability to control bowel movements, causing stool to leak unexpectedly from back passage.4 Sometimes, OASI occurs even in otherwise normal, easy deliveries, but it is most common after a forceps delivery.5 In addition to anal incontinence, OASI may cause pain, discomfort and problems with 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.6
Because any woman having a vaginal birth is at risk of a third or fourth degree tear, it is recommended that clinicians perform an examination of the perineum and anal sphincter, after obtaining consent, to ensure any trauma can be identified and repaired.7

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What will happen if I have a third or fourth degree tear?

To reduce the chance of incontinence, third or fourth degree tears are repaired surgically. This is often performed in an operating theatre where there is good access to pain relief and all the lighting and tools the surgical team need to repair the sphincter and perineum successfully.

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.
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 interfere with breastfeeding.

More Information

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’.

Normally, women feel sore in the weeks after having a vaginal birth. If you have had a tear, sex may be uncomfortable for longer. You should wait to have sex until the bleeding has stopped and the tear has healed. 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 care provider if this is the case so that you can get the help and support you need.
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 the facilities are available, women with OASI should seek an appointment in a dedicated perineal clinic with access to additional tests such as ultrasound and manometry (pressure testing). This can assist you with decisions about how you have your baby in future deliveries.

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.

Further Information has a useful information document that provides explanations of the various anal sphincter injuries at birth.