Maternity Services Care of your Perineum following 3 rd and 4 th degree tears Introduction This leaflet aims to give you information about the repair and aftercare of the third or fourth degree tear you have sustained when your baby was born. What is a perineal tear and how are they classified? The area of skin and muscle between your vagina and back passage (anus) is called the perineum. The perineum is stretched during childbirth and injury can occur. Evidence suggests that over 85% of women having a vaginal birth sustain some form of perineal injury (8 to 9 in 10 women); of which 60-70% of women need stitches (also called sutures) and around 5 in 100 women will experience a 3 rd or 4 th degree tear. This is a tear between the vagina and the anal canal (back passage) involving the muscles that surround the anus known as the anal sphincter. There are two rings of muscle surrounding the anal canal - the inner ring (known as the internal sphincter) and the outer ring (known as the external sphincter). Both these muscles are actively involved in the control of your stools and wind from your back passage. Damage to these muscles can be graded according to the depth of injury (3a = partial thickness external sphincter torn, 3b = full thickness external sphincter torn and 3c = internal sphincter torn). A 4th degree tear is a tear that also involves the skin (mucosa) lining the anal canal What is the difference between an episiotomy and a tear? An episiotomy is a cut made through the vaginal wall and the perineum to make more space to deliver the baby. It is not performed as a matter of routine and is only done when necessary. Research has shown that although episiotomy makes more space for the baby to be born, it does not prevent a 3 rd or 4 th degree tear from happening. 1
3 rd and 4 th degree tears - can they be predicted? The majority of 3 rd and 4 th degree tears can not be predicted or prevented in most situations because it cannot be anticipated. However research suggests that approximately 5% of primigravida women (first time vaginal deliveries) will sustain a rectal injury with an increased risk of 7% for the subsequent (second) vaginal deliveries. Multiparty women who have not sustained rectal injury in their first delivery are at a 1.7% risk of rectal injury. There are some risk factors which are known to increase the risk of a woman sustaining rectal injury, these are: First vaginal birth, (up to 5%) A long or short second stage of labour (the time from when the cervix is fully dilated to the birth of your baby - the pushing stage), (up to 4%) Instrumental deliveries (forceps and suction cup), (up to 7%) Babies birth weight greater than 4kg, (8lb 130z), (up to 2%) If your baby s shoulders are difficult to deliver (shoulder dystocia), (up to 4%) If your baby is lying in an unusual position (persistent back to back position), (up to 3%) Labour needs to be started for you (induction of labour) (up to 2%) Epidural pain relief, (up to 2%) Ethnicity, such as Asian What happens when / if I have a 3 rd or 4 th degree tear on examination? Following the birth of your baby your midwife or doctor present for the birth will examine your perineum and vagina to assess if there has been any trauma sustained from having your baby. If your midwife thinks that you have a 3 rd or 4 th degree tear she will ask an experienced doctor to examine you to confirm this. All 3 rd and 4 th degree tears are repaired in the obstetric operating theatre to ensure the surgeon has the best equipment and environment to repair the tear carefully with good light source, sterile conditions and experienced theatre team to assist him/her. You will be asked to sign a consent form for this surgery as you will need an anaesthetic. An Anaesthetist will come to see you to discuss the anaesthetic with you. This is usually an epidural or a spinal, which will make you numb from the waist downwards for a short while to make sure you do not feel any pain or discomfort when you are having your stitches. Occasionally you may need a general anaesthetic. What happens during surgery? You will be taken to theatre by your midwife who will ensure you are introduced to the staff assisting with your operation to repair your tear and from there the theatre team will care for you until the procedure is complete. Your birth partner and baby will stay on the labour ward until you have been stitched and are taken to the recovery room. 2
In theatre you will be monitored by the anaesthetist, ensuring your vital signs are normal. Once the operation is completed you will be transferred to the recovery room, where you will recover from the repair. This usually lasts no more than an hour. Once in the recovery room your birth partner and baby will be with you. In order for the doctor to repair your tear, your legs will be put up into leg rests (often called stirrups) and a drip will be put up, usually in your arm, which will give you fluids during the operation. A tube called a catheter may be inserted into your bladder to collect your urine in a bag to ensure your comfort following the procedure. Both the drip and catheter if used will stay in place until you have recovered from your operation and you are up and about on the postnatal ward. Depending on the extent of the tear it may take up to an hour or more to suture the tear. What treatment will you be offered after surgery? Antibiotics - You will be offered a 5-day course of antibiotics to reduce the possibility of infection due to the closeness of the tear to the back passage (anus) Pain-relieving drugs - You will be given pain-killers such as: Paracetamol 1g (up to four times a day) Ibruprofen 400mg (up to three times a day) Oramorph 10-20 mg (up to three times a day) to take yourself to relieve any pain and discomfort you may have following the operation (please ensure that you follow the instructions for administration as set out in the medication leaflet) Stool softener - You will be given laxatives which will soften your stools to make it easier and more comfortable to open your bowels and avoid constipation None of the treatments offered will prevent you from breastfeeding. After care - What can I do to speed up healing of the tear? It is important to maintain a good standard of personal hygiene by keeping the area clean, frequently changing your sanitary towel and having a bath or a shower at least once a day. Don t forget to wash your hands both before and after you do these as this will also reduce the risk of infection. Avoid constipation by drinking at least 2 to 3 litres of water every day and eat a healthy balanced diet (fruit, vegetables, cereals, wholemeal bread and pasta).. It is vital to do pelvic floor exercises as soon as you can after birth in order to tone and strengthen your pelvic muscles. This will also increase the circulation of blood to the area and aid the healing process. You will be provided with an exercise and advice leaflet to support your recovery and have access to a specialist pelvic floor physiotherapist as an out-patient. 3
Tips on getting comfortable: Take your painkillers as needed Keep the area cool o Cool packs at each feed, fridge cold water in plastic glove/sandwich bag o Keep new sanitary towels cool in the fridge Sit with a cushion under each buttock to relieve pressure from your stitches Rolling to get in/out of bed reduces friction on the wound area Start your quick squeeze pelvic floor exercises to aid circulation and swelling asap Pace activities as you need to rest the sore area little and often During your stay in hospital You will be reviewed by your Doctor the day after your procedure and before going home to ensure that your tear is clean and free from infection and starting to heal. Care at home On discharge from hospital your community midwife will check your stitches are healing well and if there are any problems she will refer you back to the hospital. At your routine 6-8 week appointment you can request that your stitches be checked. Tell your midwife if you have any of the following: If your stitches become more painful or smell offensive as these may be signs of infection. It is important that you make contact with your midwife as soon as possible in this instance. If you cannot control your bowels or flatus ( involuntary loss of bowel movement, passing wind) Having problems with urinary incontinence (loss of control of your bladder) If you have any other worries or concerns Continue to avoid constipation by drinking plenty of water and eating fibre in your diet. Ensure you complete any course of antibiotics prescribed to assist with reducing the risk of infection Your stitches should dissolve and disappear in a couple of weeks. Stitches in the sphincter muscle take longer to dissolve and sometimes can be felt as a sharp discomfort through the skin near the back passage, when wiping your bottom. This is normal. When opening your bowels supporting the perineum with a clean sanitary pad held gently in place may aid comfort. Avoid excessive straining. Occasionally, some women experience slight bleeding when opening their bowels for the first few occasions and this can be normal. 4
Avoid sexual intercourse for at least 6 weeks to ensure you have healed and bleeding stopped. Some couples may worry about starting intercourse for the first time and find intercourse slightly uncomfortable. It may be helpful to use an additional lubricant such as Sylk rather than water based lubricant and start gently to avoid any problems. Follow up care When you go home you will be sent an appointment for approximately 12 weeks postdelivery. This appointment will be to attend the postnatal perineal trauma clinic, at Broomfield Hospital, with either the specialist perineal health midwife or the specialist consultant, dependant on the degree of your trauma. At this appointment you will be asked about your recovery and any concerns, symptoms or questions you may have. Specific discussion about your bowel control will also be discussed. There is also an opportunity for your repair to be assessed (visualised), to ensure healing has happened correctly. The consultant may also ask to examine you internally (vaginally and rectally) to examine the strength of your pelvic floor and rectal muscles. This is optional and if you would prefer you can decline this part of the appointment. It may be that you have commenced your menstrual cycle (period) at the time of your appointment, please do not worry about this as it will not stop your appointment from going ahead. It is advised to still attend your appointment even if you feel you have recovered well as it is an important part of planning when it comes to your future pregnancies. If there are any concerns raised at the postnatal perineal trauma appointment a follow up appointment may be made for you to come back to the clinic after treatment. Your consultant or specialist midwife can refer you to be assessed by a specialist pelvic floor physiotherapist as an out-patient. This appointment will offer an opportunity for an examination, advice and an exercise programme to promote your long-term pelvic floor function. Additionally there is opportunity to discuss any problems or concerns regarding urinary leakage or difficulties with bowel emptying, urgency or leakage and to check on your general health and well-being. Can I have a vaginal birth in the future? Many women go on to have successful vaginal deliveries after sustaining a rectal injury. Experiencing rectal trauma alone does not make you high risk and you may still have the option of having a low risk birth, dependant on other factors in your pregnancy and health. There are occasions where it is safer for women to have a planned caesarean section because the trauma has caused damage that has left significant side effects, which a vaginal birth can further complicate. Once pregnant in a subsequent pregnancy you will be given an appointment to come back to the perineal trauma clinic, at about 28 week s gestation. At this appointment you will be seen by the specialist consultant who will discuss any symptoms or concerns you have and evaluate any on-going issues since your last delivery. From this assessment he will be able to give his recommendation for the mode of delivery that is safest for you. Once you have this recommendation you can discuss any concerns or questions you may have and make a decision regarding the mode of delivery you are happy with. 5
Should you feel that you are unhappy with the recommendation made, you will have the opportunity to discuss your choices with another consultant. Research suggests that for women who have sustained a previous rectal injury the approach of a hand s on technique for vaginal delivery is recommended. This technique works by the midwife or doctor delivering your baby using their hand in a position to slow the delivery of the presenting part (usually the head) and supporting the perineum at the same time. This approach rather than a hand s off or hands poised has been seen to be successful in reducing significant perineal and rectal trauma. This practice is usually standard for many midwives and doctors, however it is beneficial to remind your care provider at the time of your previous history and if you would like them to use this technique. Experiencing a rectal injury can cause you to feel upset about what happened at your delivery. At Mid Essex Hospital we have a service, run by an experienced midwife, known as the Birth Refection s Service which allows you the opportunity to meet and go through your experience. From this you may be able to gain clarity in what happened and why. If this is something that you feel may be beneficial to you then please ask your midwife to complete a referral. Appointments are usually made a couple of months after the delivery, to allow you time to process your experiences and prepare any questions you have. Contacts/Further Information If you would like further information regarding the evidence printed in this leaflet please refer to: www.rcog.org.uk www.nice.org.uk If you require any further support or advice please contact: Specialist Midwife for Perineal Trauma perinealhealth@meht.nhs.uk Secretary to Consultant Urogynaecologist 01245 513243 Physiotherapy Department, Broomfield Hospital: Physiotherapy Out Patient Department; Physiotherapist; Physiotherapy Aid 01245 514198 Clinical Nurse Specialist for Continence: Clinical Nurse Specialist for Continence: 01245 318518 6
If you feel that this booklet hasn t answered all of your questions, please contact your Community Midwife or GP. Please ask if you require this information in other languages, large print, easy read accessible information, audio/visual, signing, pictorial and change picture bank format via the Patient Advisory Liaison Service (PALS) on 01245 514235. Mid Essex Hospital services NHS Trust is smoke-free. You cannot smoke on site. For advice on quitting, contact your GP or the NHS smoking helpline free, 0800 169 0 169 Charitable donations can make a very real difference to the level of patient care at our Trust. As well as contributing to new facilities, donations can be used to buy specialist equipment and smaller items to make patient s stay in hospital more comfortable. For information about making a donation please contact the Charities Office on 01245 514559 or visit the website at: http://www.meht.nhs.uk/get-involved/ Document History Department Maternity Published/Review: May 2018/April 2021 File name Care of your Perineum following 3rd and 4th degree tears Version/ref no 3.1draft / MEHT120303 7