What are the types of tears during childbirth?
Most women tear to some extent during childbirth. Most tears occur in the perineum, the area between the vaginal opening and the anus (back passage). They may be:
- first degree tears – small, skin-deep tears which usually heal naturally
- second degree tears – deeper tears affecting the muscle of the perineum as well as the skin. These usually require stitches.
In around 3 in 100 women having a vaginal birth, the tear may be more extensive. This may be:
- a third degree tear extending downwards from the vaginal wall and perineum to the anal sphincter, the muscle that controls the anus.
- a fourth degree tear extending further into the anus.
What is the difference between an episiotomy and a tear?
An episiotomy is a cut made by a doctor or midwife through the vaginal wall and perineum to make more space to deliver the baby. A tear happens as the baby stretches the vagina during birth.
Can a third or fourth degree tear be predicted?
It is not possible to predict or prevent these types of tears. There are some factors that may indicate when a third or fourth degree tear is more likely, such as when:
- one of your baby’s shoulders becomes stuck behind your pubic bone (a shoulder dystocia)
- the second stage of labour (the time from when the cervix is fully dilated to birth) is longer than expected
- this is your first vaginal birth
- you have a large baby (over 8 pounds 13 ounces / 4kg)
- labour needs to be started (induced)
- you have an assisted birth (e.g. forceps, ventouse)
- you have had a previous third or fourth degree tear
Could anything have been done to prevent it?
A third or fourth degree tear cannot be prevented in most situations because it cannot be predicted. Research has shown that although an episiotomy makes more space for the baby to be born, it does not prevent a third or fourth degree tear from occurring.
What happens if you have a third or fourth degree tear?
If your obstetrician or midwife suspects you have sustained a third or fourth degree tear, they will closely examine your perineum and anus. This will involve inserting a finger into the back passage to allow closer inspection of the anal sphincter (the muscle that controls the anus). The obstetrician will confirm the extent of the tear and provide you with information about the repair. You will need an anaesthetic for the repair; this is usually an epidural or a spinal but occasionally may be a general anaesthetic (where you are put to sleep). The obstetrician will then suture (stitch) the damaged anal sphincter and tear in the operating theatre. We can provide a rectal pain-relieving suppository at the end of the repair.
What treatment will I be offered after surgery?
A drip in your arm will provide fluids until you feel able to eat and drink. A catheter (tube) in your bladder will drain urine until you feel able to walk to the toilet.
You should be able to go home after 24-48 hours. It is safe to breastfeed whilst taking all the medications we prescribe you following the repair.
We will provide:
- Antibiotics
- You will be advised to take a five day course of antibiotics to reduce the risk of infection because the stitches are very close to the anus.
- Pain-relieving drugs
- You will be offered pain-relieving drugs such as paracetamol, ibuprofen or diclofenac to relieve pain.
- Laxatives
- You will be advised to take laxatives to make it easier and more comfortable to open your bowels.
- Physiotherapy
We will arrange for you to see a physiotherapist to help you start pelvic floor exercises.
What can I do to speed up healing of the tear?
- Keep the area clean. Have a bath or a shower at least once a day and change your sanitary pads regularly (wash your hands both before and after you do so). This will reduce the risk of infection.
- Drink at least two to three litres of water every day and eat a healthy balanced diet (fruit, vegetables, cereals, wholemeal bread and pasta). This will ensure that your bowels open regularly and help prevent you from becoming constipated.
- Do pelvic floor exercises as soon as you can after birth. You should be offered physiotherapy advice about pelvic floor exercises to do after surgery. Continuing pelvic floor exercises regularly reduces the risk of pelvic floor prolapse in the future.
What can I expect after a third or fourth degree tear?
Most women make a good recovery, particularly if the tear is recognised and repaired at the time.
During healing, some women may have:
- pain or soreness around the area of the repair
- a feeling that they need to rush to the toilet to open their bowels urgently
- apprehension about having sex; many women worry about this even if they have not had a third or fourth degree tear. You should wait until the bleeding stops and the repair has healed to have sex, which may take several weeks. After that you can have sex when you feel ready to do so. Some women find sex continues to be painful. If this is the case, see your doctor for advice.
- fear about future pregnancy and birth.
Very rarely, you may have a fistula (hole) between your anus and vagina after the tear has healed. This can be repaired by further surgery.
Contact your midwife or GP if:
- your stitches become more painful or smell offensive – these may be signs of an infection
- you cannot control your bowels or control when you pass wind
- you have any other worries or concerns. You can be referred back to hospital earlier than your follow-up appointment if you wish.
Your follow-up appointment
You will be offered a follow-up appointment with your consultant at the Women’s Health Clinic 12 weeks after you have given birth. You will be asked questions about your urine and bowel functions. If there are any complications, you may be referred to a specialist.
This appointment offers you the opportunity to discuss any concerns that you may have, such as sexual intercourse.
Can I have a vaginal birth in the future?
This depends on a number of factors. Your obstetrician will discuss these with you at your follow-up appointment or early in your next pregnancy and will take into account your circumstances and preferences.
If you continue to experience symptoms from the third or fourth degree tear, you may want to consider a caesarean delivery next time.
If your tear has healed completely and you do not have any symptoms, then you should be able to have a vaginal birth. Between 5 and 7 out of 100 women who had a third degree tear previously will have a similar tear in a future vaginal birth.
How can I find out more information?
Please discuss any queries or concerns with your midwife or consultant during your appointment.
If you need information or advice at any other time, please do not hesitate to contact the Pregnancy Assessment Unit to speak to a midwife.
Other information:
- National Childbirth Trust
- Royal College of Obstetricians and Gynecologists
- National Institute of Clinical Excellence
Data Protection
Any personal information is kept confidential. There may be occasions where your information needs to be shared with other care professionals to ensure you receive the best care possible.
In order to assist us to improve the services available, your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews and Statistics.
Further information is available via Gateshead Health NHS Foundation Trust website or by contacting the Data Protection Officer by telephone on 0191 445 8418 or by email [email protected].