• Reference Number: HEY-490/2018
• Departments: Maternity Services
• Last Updated: 31 May 2018

Introduction

This leaflet has been produced to give you information about 3^rd and 4^th degree tears. It is not intended to replace the discussion between you and your doctor or midwife, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with the doctor or midwife who is caring for you.

What is a tear?

As your baby is being delivered a tear can occur. A tear involves the skin and muscle of the perineum which is the area between your vagina and back passage (anus). A tear can also occur inside your vagina and in the labia (lips of the vagina).

What are the types of tear during childbirth?

Most women, nine in ten (90%), tear to some extent during childbirth.

Most tears occur in the perineum, the area between the vagina opening and the anus (back passage). They may be:

• 1st degree tears – Small, skin deep tear which usually heal naturally.
• 2nd degree tears – Deeper tears affecting the muscle of the perineum as well as the skin. These will require stitches.

Up to nine in 100 (9%) the tear may be more extensive. This may be:

• 3rd degree tear – Extending downwards from the vagina through the perineum to the anal sphincter (muscle around your back passage).
• 4th degree tear – Extending to the anal canal (into your back passage).

What happens after the birth?

Your obstetrician or midwife will examine your perineum and identify if any tears have developed. If they suspect a  third or fourth degree tear, or if you had an episiotomy (a cut), a detailed examination of your perineum and anus will occur, by the obstetrician, who will confirm the extent of the tear and provide information about surgery and treatment options available to you.

What happens next?

You will need an anesthetic before any treatment can be given. This is usually an epidural or a spinal but occasionally it may have to be a general anesthetic (were you are put to sleep). A midwife will be with you at all times to offer support and answer any questions you may have.

Once you have your anaesthetic the obstetrician will start to suture (stitch) the damaged tear and this usually happens in the operating theatre, depending on the type of tear . This procedure will take place in the operating theatre.

What treatment will I be offered after surgery?

Below are the treatments you will be offered following your surgery:

• Antibiotics – You will be given a single dose of antibiotic to reduce the risk of infection because the stitches are very close to the anus.
• Pain-relieving drugs – You will be offered one or more pain-relieving drugs such as paracetamol, ibuprofen or diclofenac to relieve any pain.
• Laxatives – You will be advised to take lactulose to make it easier and more comfortable to open your bowels.
• A drip – Fluids will be given in your arm until you feel able to eat and drink.
• You may have a catheter – A (tube) in your bladder, for 12 – 24 hours to help you pass urine.

Breastfeeding

None of the treatments offered will prevent you from breastfeeding.

Going to the toilet

It is preferred but not essential that you have opened your bowels before you leave hospital.

Caring for your wound or painful perineum

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Your midwife will review your perineum when you get home and we would strongly advise you to consent to this review as they will look for signs healing or infection.

Below are some important points to remember:

• Avoid standing or sitting for long periods.
• Wear breathable materials, like cotton and disposable briefs, and avoid tight clothing.
• Begin doing your pelvic floor exercises as soon as you can after the birth this will increase the blood supply and help with healing.
• Drink plenty of water at least eight glasses a day, to dilute your urine.
• Ensure you are comfortable when sitting to feed your baby, you may find it more comfortable feeding on your side.

To help with discomfort:

• You can use cold/ice packs. Do not apply directly onto the skin always wrap in a cloth/flannel and apply for 30 minutes every so often throughout the first few days.
• Take regular pain relief for the first two to three days if required. Paracetamol and ibuprofen are both safe while breast feeding but make sure you read and understand the label.
• You may find it helpful to pour body temperature warm water over your perineum during and after passing urine, to help reduce the stinging or use a shower head or bidet.

It is important to keep this area clean:

• Wash your hands before as well as after using the toilet.
• Wash your perineum after every visit to the toilet.
• Just pat/wipe the area dry with toilet paper. Always wipe, front to back to avoid contamination from your back passage.
• Change your sanitary towel regularly, at least every four hours. Ensure it is secured in place so it does not move around and cause further irritation.
• Use plain water to clean this area, you can have a bath or shower as usual and you may find this soothing. You do not need to add anything special to your bath to help with healing.

Having your bowels open:

• When having your bowels open hold a clean sanitary towel against your perineum/stitches to protect them and to stop you feeling that your stitches will split.
• To avoid putting strain on your wound, eat a high fibre diet (fruit, vegetables and brown bread) and remember to drink plenty of water.
• If you are unable to open your bowels obtain some medicine to soften your stools.

When can I have sex?

Many women worry, and are apprehensive about this even if they have not had a 3rd or 4th degree tear.

It is best to resume sex after your stiches have healed and your bleeding has stopped but there is no right or wrong time. For some people it is within a few weeks but for others it can be when they feel ready.

Things to think about:

• Do not forget you can become pregnant the first time you have sex after the birth of your baby, so think about some form of contraception.
• Make sure you talk to your partner about resuming sex and when you start, start gently.
• You may find it helpful to use a lubricating jelly.
• You may feel some discomfort for the first few times whether you had stitches or not.
• It will feel different following the birth of a baby.
• Different positions may make it more comfortable.
• If the pain continues discuss this with your doctor.

What are the immediate and long term effects of 3rd and 4th degree tears?

Most women make a good recovery, particularly if the tear is recognised and repaired as early as possible. However during recovery some women may experience:

• Pain or soreness in the perineum.
• A feeling that they need to rush to the toilet to open their bowels urgently.
• 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 and will be fully explained to you.

Contact your midwife or general practitioner if:

• You start to feel unwell or have a temperature
• Your stitches become more painful, or smell offensive – these may be signs of an infection
• The area starts to throb or starts to swell
• Your stiches are coming apart and the tear is not healing.
• You have problems controlling your urine or you can not control your bowels or flatus (passing wind).
• You continue to rush to the toilet to open your bowels.
• You have any other worries or concerns.

Your follow up appointment

You may be offered a follow up appointment at the clinic 6 – 12 weeks after you gave birth to check that your stitches have healed properly. You will be asked if you have any bowel problems: such as leakage of stool (faeces) or wind, urgency (rushing to the toilet), constipation, diarrhoea or pain when opening your bowels.

Women with certain types of 3rd degree and all 4th degree tears will be offered an endoanal scan (anal muscle scan) and perineal nerve function test (to ensure that nerves damaged during birth are recovering). You will be informed about these tests by your obstetrician, usually through a letter. If there are any complications such as your pelvic floor muscles not being as strong as expected, you may be referred to the appropriate specialist doctor for advice and possibly treatment.

This follow up appointment also offers you the opportunity to discuss any concerns that you may have, such as sexual intercourse.

What about having another baby?

There is no reason to suggest having a vaginal birth next time is not possible. An obstetrician will discuss all your options for future pregnancies with you.

Contact numbers and further information

Further information about 3rd and 4th degree tears can be found at www.rcog.org.uk.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Community Midwives on telephone number: (01482) 382758.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.