Third and Fourth Degree Perineal Tears after Childbirth

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1 Third and Fourth Degree Perineal Tears after Childbirth Information for Patients Excellent care with compassion

2 Introduction This leaflet aims to give you more information about the repair and aftercare of the perineal tear you experienced when your baby was born. What is a perineal tear? The area of skin and muscle between your vagina and back passage (anus) is called the perineum. The perineum is stretched during childbirth and tears in more than 6 in every 10 first births. Tears are called 1st, 2nd, 3rd or 4th degree depending upon their severity as described below Tear First degree Second degree Third degree Fourth degree Description Involves the superficial skin of the vagina and perineum As 1 st degree tear and also some of the underlying muscles Also involves the ring of muscle at the lower end of your bowel that helps to control the passage of wind and stools (external anal sphincter) As 3 rd degree tear but with damage to the bowel lining (rectal mucosa) Why and how do tears happen? The perineum may tear when the baby s head or shoulders are delivering through the vagina. Tears occur more commonly with forceps delivery, after episiotomy, after rapid delivery, after prolonged labour and when the baby is large, or delivers in an unusual position. There is no treatment that can be given during pregnancy or labour that effectively prevents tears. 2

3 How are 3rd or 4th degree tears repaired? A third or fourth degree tear is repaired by a specially trained doctor in an operating theatre. Each layer of skin and muscle is sutured (stitched) separately starting with the lining of the bowel and then the anal sphincter muscle followed by the vaginal wall. The skin of the perineum is the last layer to be repaired. The diagram below shows the final stages of a perineal repair. Urethra (passage from the bladder) Vagina Stitches to perineal skin Anal sphincter What are the complications of 3rd and 4th degree tears? Perineal tears usually heal very well and in most cases will not cause long-term problems. Occasionally the skin wound can become infected. Antibiotic treatment would be prescribed. Bowel urgency (the sudden urge to pass a motion) and occasionally not making it to the toilet in time can occur in the first few days. Leakage of wind may also occur (flatus incontinence). These symptoms generally improve with time and your physiotherapist will suggest exercises to help. Some women complain of temporary discomfort during sex. 3

4 What happens after the repair? You will have a catheter (tube into your bladder) for about 8 hours following the operation. You will be given antibiotics to prevent infection. You will be offered painkillers. You will be given a medicine to soften your bowel motions. Specialist physiotherapists will see you and advise you on pelvic floor exercises to strengthen your muscle tone. Please feel free to discuss your delivery with the doctors and midwives before you are discharged home. There is also a Birth Afterthoughts service that you can access at a later stage if you find you have any further questions. The contact number is on the final page of this leaflet. What can I do to promote healing? Personal hygiene Try to keep your perineum as clean and dry as possible. Change your pad regularly, washing your hands before and after. If you can, have one or two warm baths a day, but do not soak for long periods. Avoid using soap or other scented products in the bath. Dry your perineum gently but thoroughly with a clean towel and do not use talcum powder. Rest Although you are encouraged to start moving around as soon as possible after your baby s birth, for the first couple of weeks at least, you should try not to stand for long periods of time or walk long distances. This prevents overstraining the muscles of your pelvic floor and any stitches you may have. Try to lie down and rest whenever your baby is sleeping. Use of cool packs If you have pain or swelling a cool pack may be helpful. You can make a cool pack by filling a rubber glove or a strong clean 4

5 polythene bag with water, adding some crushed ice and tying a knot in the top. Lie on your side, place the cool pack over your perineum and support it in place with a pillow. Leave in place for 5 to 10 minutes only. Never sit on an ice pack. It could give you an ice burn and it also slows blood circulation interfering with the healing process. You may see ice packs for sale in shops, but these can be too cold. Bladder care You may not experience the normal feelings of wanting to pass water for the first couple of days after your baby s birth. It is important that you pass water within 6 hours of giving birth or having a catheter removed. After this you should try to pass water regularly every three to four hours while you are awake. Your bladder will gradually return to normal, but it is important that you do not let it overstretch at this time. Equally, do not try to empty tiny amounts very frequently. Sit and relax on the toilet, do not hover over it. Do not strain when the flow stops, remain in the same position for another 30 seconds and you may find that the flow starts again. If the muscles that support your bladder have been damaged during your baby s birth, you may find that you leak when you stand, cough, laugh or need to go to the toilet. You can find information on exercises that will help your muscles return to normal in the leaflet Fit for the Future. This leaflet is available from your midwife or physiotherapist if you have not already received it. Do not restrict your drinks thinking it will help your problem. It is important that you drink at least 2 litres of fluid a day. If you continue to have problems with sensation, flow or leakage, 5

6 tell your midwife or physiotherapist. Opening your bowels Adopt a forward lean position whilst sitting on the toilet with your heels raised so that you are on tiptoes. When you first open your bowels after your baby s birth, wrap some toilet roll around the fingers of one hand, and place them over your perineum. As you push to empty your bowel, push gently upwards with your fingers, supporting the stitches and pelvic floor. It may be helpful to carry on doing this for the first few weeks, until your pelvic floor is back to normal. Try not to strain too much. Don t be afraid to push to empty your bowel but make sure you can still breathe out gently as you do. Try to avoid becoming constipated by drinking plenty of water and eating fibre containing foods such as fruit and vegetables, brown bread and cereals. Do not take pain killers containing codeine, such as Dihydrocodeine, for more than a few days after the birth as these can cause constipation. If you have problems with constipation speak to your midwife or GP. Sex You should avoid sex for at least 6 weeks and, when you are ready to resume, it may be helpful to use additional lubrication (such as KY jelly) and to start very gently. Recognising problems The majority of perineal tears heal very quickly and your midwife will check regularly to make sure all is well but you should tell her promptly if you experience any of the following signs that might indicate a problem such as infection or a haematoma (a blood clot that forms beneath the skin). Severe pain that is not improving. A noticeable swelling that makes sitting very uncomfortable. An unpleasant smell, with or without a discharge. 6

7 Feeling hot or shivery. Your perineal skin stitches will dissolve and should disappear completely within a few weeks. The stitches in the sphincter muscle take a lot longer to dissolve and can sometimes be felt as a sharp discomfort through the skin near the back passage (commonly when wiping after a bowel motion). This is nothing you need to be concerned about. Postnatal check up You should see your GP for a postnatal check 6 weeks after your baby s birth. In addition, you will be sent an appointment for the perineal tear clinic about 4 months after the birth to ensure that your tear has healed properly and that you are not experiencing any problems. Your midwife or GP can refer you back sooner if there are any complications before this time. Future pregnancies If your wound heals well and your bladder and bowel functions are normal, you should be able to deliver any future babies vaginally. This will be discussed further at your postnatal visit with the consultant and again during future pregnancies. 7

8 Sources of further information Your midwife or doctor Maternity Ward, Sharoe Green Unit Physiotherapy Birth Afterthoughts Lancashire Teaching Hospitals NHS Foundation Trust is not responsible for the content of external internet sites. Please ask if you would like help in understanding this information. This information can be made available in large print and in other languages. Department: Women s Health Division: Women s Health Production date: May 2015 Review date: May 2017 Excellent care with compassion