Third or fourth degree tears
This leaflet will provide you with information following a third or fourth degree perineal tear.
What is a perineal tear?
Many women experience tears to some extent during childbirth as the baby stretches the vagina. Most tears occur in the perineum, the area between the vaginal opening and the anus (back passage).
Small, skin-deep tears are known as first-degree tears and usually heal naturally. Tears that are deeper and effect the muscle of the perineum are known as second- degree tears. They usually require stitches.
What is a third or fourth degree tear?
For some women the tear may be deeper. A tear that also involves the muscle that controls the anus (the anal sphincter) is known as a third degree tear. If the tear extends further into the lining of the anus or rectum it is known as a fourth degree tear.
How common are third or fourth degree tears?
Overall, a third or fourth degree tear occurs in about 3 in100 women, being slightly more common with a first vaginal birth.
What happens in the days and weeks following a repair?
- It is normal to feel pain or soreness around the tear or cut for 2-3 weeks after giving birth, particularly when walking or sitting. Passing urine can also cause stinging.
- Continue to take your painkillers as necessary.
- To reduce the risk of infection keep the area clean. Have a bath or shower at least once a day and change your sanitary pads regularly (wash your hands both before and after you do so).
- You should drink at least 2-3 litres of water every day and eat a healthy balanced diet (fruit, vegetables, cereals, whole meal bread and pasta). This will prevent you from becoming constipated which might put strain on the recovering tissues. You may find that the posture below helps you to pass stools easier
If you experience any problems seek advice from your midwife or GP.
Pelvic floor exercises
It is important to learn how to strengthen the pelvic floor and anal (back passage) sphincter muscles which might have been affected by the tear.
The pelvic floor muscles are the firm supportive muscles that stretch from your pubic bone at the front of your pelvis, to your tail bone (coccyx) at the base of your spine. They support bladder, bowel and womb (uterus) and help to close your bladder outlet and back passage.
The anal sphincter is a circle muscle surrounding the anus and divided into Internal and external layers.
The external anal muscle helps control bowel movements and wind (flatus) and can be strengthened by exercise.
The internal anal sphincter works constantly to keep the back passage closed, and also gives you the feeling of needing the loo for bowel movements. This muscle cannot be strengthened with exercises, but exercising your external muscle can help lessen problems.
How to do pelvic floor exercises
Pelvic floor exercises will help to build up strength in both the pelvic floor and external anal sphincter muscle.
You can start your exercises straight away after the birth of your baby. During the first 5 days the area will feel numb, sore and it will be difficult to exercise during this period but keep practicing.
Initially practice lying on your side. When you can start doing them well you can start doing them sitting and then standing up and walking.
How to do them
- Imagine you are trying to stop yourself passing wind by pulling up your back passage up inside and forwards towards your pubic bone.
- At the same time, pull in as though you are stopping yourself from passing urine.
- Keep breathing normally. You may also feel your lower tummy muscles pulling in but your upper tummy muscles, legs and buttocks should all stay relaxed.
- Do not hold your breath.
There are two types of contraction
Long contractions: help build up the endurance of your muscles. Initially hold for a few seconds, relax fully for 4 seconds and try not to hold your breath. Repeat this exercise up to 10 times.
Short contractions: helps prevent you leaking urine with coughing or sudden movements. Tighten your pelvic floor as quickly as you can, hold for 1 second before fully relaxing. Repeat this exercise up to 10 times.
How often?
Work the exercises into your daily routine, aiming for a set of each, three times a day.
Remember– It will take a while for these muscles to improve. As well as doing the exercises, try activating your muscles when you lift your baby, or with coughing and sneezing, to help them work when you need them most. If you get a sense of urgency or need to rush to the toilet to open your bowels, try to stop still first and try to pull the back passage muscle in and hold until the feeling of needing to go eases. These muscles can give more control and more time to get to the toilet.
Healing – What to expect?
Most of the stiches are dissolvable and the wound should heal within a few weeks, although it can take longer. The stitches can irritate as healing takes place but this is normal. You may notice sore stitch material fall out which is also normal.
The scar formed will be quite raised initially. This usually starts to soften and flatten down after 6 weeks. Gentle massage to your scar can help with this. In the bath and shower use your thumb to apply gentle pressure and massage the scar at the back of your vagina in all directions. Try this for 5-10 minutes on a daily basis to help soften and flatten your scar and prevent it becoming sensitive.
When can I have sex?
You should wait to have sex until the bleeding has stopped and the tear has healed. This make take several weeks. After that you can have sex when you feel ready to do so.
You may find that lubrication such as aqueous gel may make intercourse more comfortable.
If you feel apprehensive about sex or experience pain it is important that you speak to your doctor, health visitor or pelvic health physiotherapist.
Will there be any hospital follow up?
All women that have had a third or fourth degree tear will receive an appointment with an obstetrician and physiotherapist.
Royal College of Obstetricians and Gynaecologists - www.thepogp.co.uk
To contact the Physiotherapy Service about an appointment:
Cumberland Infirmary Carlisle: 0333 014 2876
West Cumberland Hospital: 01946 523636
Penrith Hospital: 01768 245585
Confidentiality
‘The Trust’s vision is to keep your information safe in our hands.’ We promise to use your information fairly and legally, and in-line with local and national policies. You have a right to understand how your information is used and you can request a copy of the information we hold about you at any time.
For further information on confidentiality contact the Information Governance Team:
Information.Governance@ncic.nhs.uk | 01228 603961
Feedback
We appreciate and encourage feedback, which helps us to improve our services. If you have any comments, compliments or concerns to make about your care, please contact the Patient, Advice & Liaison Service:
pals@ncic.nhs.uk | 01228 814008 or 01946 523818
If you would like to raise a complaint regarding your care, please contact the Complaints Department:
complaints@ncic.nhs.uk | 01228 936302