Different types of perineum tearing

What is perineum tear
    perineum tear is a spontaneous (unintended) lacerationof the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tears mainly occur in women as a result of vaginal childbirth, which strains the perineum.

Different types of tears

At the very end of your labour the skin and muscle layers in and around your vagina thin and stretch to allow your baby to be born. It is quite common for women to have some form of perineal or vaginal tearing.

Midwives and doctors have developed a system of describing the types of tears according to the size of the tear and type of tissue involved. These range from a 1st degree tear to a 4th degree tear.

The following diagram may be helpful for you to understand some of the terms used to describe the different degrees of tears that occur during child birth.

A 1st degree tear is a thin tear or graze of the perineal skin. No muscles are involved. It is possible that a small number of stitches may be required.

A 2nd degree tear includes skin and muscle tissue. Stitches are usually needed and it can take around two months or so to feel completely comfortable again.

An episiotomy is a cut made into your perineum to enlarge your vaginal opening. This is done to help your baby be born. An episiotomy involves the same muscle and tissue as a 2nd degree tear. However some episiotomies can extend further, and when this happens they might be described as a 3rd or even a 4th degree tear depending on their severity.

A 3rd degree tear is a tear or laceration through the perineal muscles and the muscle layer that surrounds the anal canal. This requires stitches and can take a similar time to a 2nd degree tear (two months or so), if not longer, before the wound is healed and the area comfortable.

A 4th degree tear goes through the anal sphincter all the way into the anal canal or rectum. Most women with this condition will have no ongoing problems, with the appropriate management (including good personal hygiene by you, diet, physiotherapy, pain medication and laxatives). However a small group of women may have ongoing problems with controlling the passing of urine, wind or faeces. This is called incontinence and will require ongoing clinical review or medical consultation.

Also, although more uncommon than a tear, a recto-vaginal fistula may develop. This is when a tubelike passage links the vagina and rectum. Symptoms of this include the passing of flatus and/or faeces through the vagina. It is very important that you tell your doctor if you have either of these symptoms as infection can result.

3rd and 4th degree tears are an uncommon complication of child birth, which can affect a woman’s normal bowel, bladder and sexual functions short term and in some cases, permanently. Following the recommendations in this booklet is important to try and prevent any long term problems. The time span for recovery varies in accordance with individual circumstances. Relax and give yourself time to heal. This guide will assist your recovery.

Can a third or fourth degree tear be prevented?

It is not possible to predict, or even prevent, these types of tears. There are some factors that may make a third or fourth degree tear more likely.

This is when:

one of your baby’s shoulders becomes stuck behind your pubic bonethe second stage of labour is long (the time from when the cervix is fully dilated to birth)this is your first vaginal birthyou have a large babylabour needs to be started (induced)you have an assisted birth (forceps or ventouse)

Taking care of your perineum

Keep it clean and free from infection

Personal hygiene is very important. We recommend that you have at least one full shower and wash your perineal area three to four times each dayChange sanitary pads at least every four to six hours to keep the wound as clean as possibleAlways pat the perineal area dry from the front to the back after washing to avoid introducing germs from the rectum into the vaginal area. It is also very important to wash the perineum after a bowel motion.Do not use a hair dryer to dry your perineum. This may delay healing or cause burning to the genital area.Antibiotics may be prescribed to help prevent wound infection and wound breakdown.

Keep comfortable

Apply ice packs to the perineal area every couple of hours for the first 12–24 hours after birth. Your midwife will advise you on this while you are in the hospital. You may find the ice packs helpful for pain relief for a longer period (i.e. 24–48 hours)Take regular pain relieving medications. These will be prescribed by your doctorTry to only stand and sit for short periods of time as this places strain on your perineum. When feeding your baby shift your sitting position and lie down occasionally to reduce the painLie down to rest for between 20–40 minutes every hour for the first two to four days as this will help the stitches to healAvoid double leg movements, “sit up” actions and lifting heavy weights (including picking up other children) as this places extra strain on your perineumGet in and out of bed over on your side as this reduces the strain on your perineum

Emptying your bowels

For the first few days after repair, a low fibre diet is recommended to prevent any further damage due to straining to pass a stool. After the 3rd day, a high fibre diet is commenced. This will produce a stool which is easier to expelKeep the stools soft and ask for help if the bowels have not opened within 48 hoursTry not to strain when using your bowels and use the recommended defecation position that is taught to you by the physiotherapist  (see diagram included). The passage of hard stools can disrupt repair and delay healingSupport the perineum with your hand while emptying your bowels, laughing, coughing, sneezing, etc.To assist with emptying of the bowel, bulking and softening agents such as Fybogel or Metamucil and Agarol or Lactulose are usually recommended for several days after repair. Make sure you drink a lot of water with these medications, because this will assist to reduce the likelihood of constipation occurringIf you are prone to constipation, use bulking or softening agents up to six weeks after repair. Again, discuss this with your doctor first.

Exercises to help you recover

We recommend you avoid pelvic floor strengthening exercises for six weeks after the birth of your baby. This is because exercise of this type can strain the wound and cause wound breakdownYour physiotherapist will teach you how to activate your muscles prior to moving. This will help protect your perineum as it healsYour physio will also teach you how to do gentle pelvic floor pulses, to improve circulation and decrease swelling and pain

These are not strengthening exercises, but are important for early recovery and functional protection of sutures.

One to two weeks after you go home the Mater physiotherapist will contact you to see how you are recovering. They will also usually talk to you about coming to see a physiotherapist specialising in pelvic floor function, to check your progress and review your longer term strengthening program.

If you require further physiotherapy you will be referred to the Mater Health and Wellness Clinic which is located on level 2 of the Mater Private Clinic, 550 Stanley Street, South Brisbane. Further information can be obtained from www.wellnessclinic.mater.org.au or you can telephone directly on 07 3163 6000.

Going home

It is important to continue to look after yourself when you go home. We recommend that you don’t go home until your bowels have opened sufficiently and you are feeling well again. Your midwife/doctor will be able to advise you when you are ready and your doctor will prescribe any medication you will need upon discharge.

The importance of follow-up appointments

You will need to see your obstetrician six weeks after the birth of your baby for a check-up. This may include a vaginal examination. If you have any concerns about your recovery please see your obstetrician earlier.

If you are uncomfortable take regular pain relief medication as prescribed. However if you are taking pain killers which have codeine in them it is important to note that it can cause constipation. Talk to your pharmacist if you are unsureIf you notice signs of infection such as a fever, wound breakdown or discharge in the perineal region, it is important you see your doctor that dayIf you have difficulty controlling the passing of urine, please discuss this with your obstetrician. If necessary they will refer you to a gynaecologist and/or urologist or to a continence advisor.

If you have any concerns about your perineal tear, or your condition including persistent pain, please bring them to the attention of your midwife/doctor straight away.

Frequently asked questions

Why is my perineum sore?

The primary cause of perineal pain is an episiotomy or extensive tearing during the birthEven if you didn’t have a 3rd or 4th degree tear, your perineum would still be bruised and tender after the birth of your babyBecause your perineum is a very tender site for a cut or stitches, recovery can take longer than elsewhere in your body.

Exactly how much longer varies from person to person and also depends on how deep the tear is. With a 3rd or 4th degree tear there may be pain/discomfort for three months or longer while your body heals.

What can I do to relieve the pain?

Apply ice packs intermittently for first 24–48 hoursWash your perineum and keep it dryTake pain relieving medication, as prescribedLie down as much as possible, rather than standing or sittingDo gentle pelvic floor "pulses"Move smoothly without straining at allTalk to your midwife/doctor/physiotherapist to see if they have any further suggestions and consider whether you need to be reviewed.

What about my diet?

For the first few days, usually a low fibre diet and plenty of fluids is recommended to prevent any further damage caused from straining to pass a stool. Foods include white bread, refined pasta, rice and cornflakes, rice bubbles, egg, fish, cheese, meat and chicken (no skin), small amounts of soft, ripe skinless fruits and vegetables. After three days, eat a high fibre diet to assist passage of soft, easily expelled stool. We recommend wholemeal breads and cereals, brown pasta and rice and at least four serves of fruit and five serves of vegetables daily. Drink at least eight glasses of water daily, to decrease the risk of constipation.

When can I resume sexual relations?

Comfortable sexual activity can begin after your body has completely healed. This may happen as early as six weeks after the birth of your baby, however it may also take more than three months. A small number of women may experience ongoing discomfort during sexual intercourse. If this is the case it is important that you discuss this with your doctor, as sexual intercourse should not cause any discomfort in the perineal area once it has completely healed.

When can I go swimming?

When the bleeding has stopped and your stitches have completely healed.

What to do if I continue to have bowel symptoms and/or urinary incontinence?

Contact your physiotherapist and your obstetricianWhere needed, your obstetrician will refer you to a gynaecologist and/or urologist as required.

Is there any other planned follow-up I should know about?

Yes. All women should be offered a planned follow-up at three months with their obstetrician. You will be offered further assessment and referred to a colorectal surgeon if needed.

What about future pregnancies and births?

Advice about future births will depend on how well you recover after the birth of this baby. If you are fully recovered there is no evidence to suggest the best way for your baby to be born.However if you have some ongoing incontinence problems, especially with controlling your bowel motions, vaginal birth may make this problem worse. All women will have the opportunity to talk to their doctor/midwife about how they wish their baby to be born and receive information about the possible benefits and risks associated with vaginal and caesarean births.

If I have difficulties coping, who do I contact?

Talk with your obstetrician about any concerns you may haveContact a midwife at Mater Mothers’ Private Hospital on 07 3163 7000.Contact a physiotherapist at Mater Mothers’ Private Hospital on 07 3163 8787 or at the Mater Health and Wellness Clinic on 07 3010 5744.

Final advice

Avoid constipationAim for soft easy-to-pass stoolsRemember the physiotherapist’s advice regarding defecation positioningAlways ensure that you have good pain reliefDo not take any medications or suppositories via your anus, as you can aggravate the tear or cause an infectionStart exercises as advised by your physiotherapistKeep your wound clean and dryIf you think your wound is becoming infected see your doctorRemember your follow-up appointments

Always remember: relax and give yourself time to heal