Perineal Tears Obstetrics & Gynaecology Women & Children s Group This leaflet has been designed to give you important information about your condition / procedure, and to answer some common queries that you may have.
You have been given this leaflet because you have had a tear during the birth of your baby. What is a perineal tear? Many women, 8-9 out of 10 (85%), have a tear during childbirth. Tears usually occur in the perineum, which is the area between the vagina and the anus (back passage). The tear, which is usually due to overstretching of the soft tissue of the birth canal, may vary in severity and may be identified as follows: 1st degree tears these are small, involving the skin only, which may heal naturally. Some women do not require stitches. 2nd degree tears these are slightly deeper, affecting the perineal muscles as well as the skin. All second degree tears require stitches. For some women (1-9%) the tear may be more extensive, involving the muscle around the anus (the anal sphincters) and/or the lining of the back passage. 3rd degree tears this involves the vaginal wall, and the perineum to the anal sphincter (the muscle that controls the back passage). 4th degree tears As a 3rd degree tear but with damage to the lining of the bowel. Is an episiotomy different to a tear? Yes an episiotomy is a deliberate cut made by a doctor/midwife to increase the outlet space for the delivery of the baby. The cut is made through the vaginal wall and perineum. A tear happens as the baby stretches the vagina during birth. Research has shown that although an episiotomy makes more space for the baby to be born, it does not prevent a 3rd or 4th degree tear from happening. Why did I tear? Although there are known risk factors with perineal tears, in many cases there is no clear reason. Your chance of developing a perineal tear is increased when: You have a large baby (> 4kg or 8lbs 13oz) It is your first vaginal delivery Labour is induced Second stage of labour is longer than 1 hour You have an assisted delivery (forceps or ventouse) Your baby s shoulder gets stuck behind your pubic bone Could the tear have been prevented? Sometimes perineal massage in the antenatal period may reduce your risk of tearing in labour. Unfortunately, there are no medical interventions available during childbirth to prevent a third or fourth degree tear from occurring and it is very difficult to predict when they might happen. How are tears treated? Tears especially 2nd, 3rd and 4th degree tears are treated by surgery. If your doctor/midwife suspects a tear a thorough examination will be performed and a discussion of the findings and options of treatment will be discussed with you. The usual pathway of repair is surgery (stitching).
Surgery These tears require specially trained healthcare personnel to repair them immediately after childbirth. Your midwife is the most likely person to suture a 1st or 2nd degree tear. The repair for third and fourth degree tears is carried out in theatre and will require anaesthesia; usually an epidural or spinal but occasionally a general anaesthetic may be required. 3rd or 4th degree tears are sutured by Senior Doctors. Medication Following surgery you may require certain medication, which will include: Antibiotics you will be given antibiotics to reduce the risk of infection. It is vital that you complete the course. Painkillers you will be offered painkillers to ease your discomfort, such as paracetamol, ibuprofen or diclofenac. Laxatives These should be used for at least ten days and help soften your stools. This makes it more comfortable to open your bowels which reduce the strain on the stitches. What should I be doing? Bowel Care Keep the perineum clean. Have a shower or bath daily (you do not need to add anything special to the water); wash your hands before and after changing your sanitary towels or using the toilet. It is important that you avoid constipation. In order to do so the following advice may be helpful: Drink 2-3 litres of water a day. Eat a healthy balanced diet with plenty of fibre. Empty your bowel as soon as you get the urge. Use a sanitary towel to support your perineum when going to the toilet. Passing urine Some women find that it is uncomfortable to pass urine whilst their wound is healing. Passing urine in the bath or pouring warm water over your perineum whilst trying to pass urine often eases this discomfort. If you have had a 3rd or 4th degree tear repaired, you may have a drip in your arm to give you fluids and a catheter (tube) in your bladder. The catheter is important as you may not feel the need to pass urine initially, but it stops your bladder getting over full. When your catheter is removed (usually the next day) you may be asked to keep a chart recording how much fluid you drink and how much urine you pass. Pelvic floor exercises Pelvic floor muscles wrap around the underside of your bladder and bowel. They are important for controlling bowel and bladder function. Pregnancy and tearing weaken these muscles meaning they cannot carry out their function. Doing these exercises aids the healing process by increasing the circulation of blood to the area. It is important that you perform physiotherapy and pelvic floor advice for 6-12 weeks after birth. You will be given a separate leaflet for these exercises.
Breastfeeding None of the treatments will prevent you from breastfeeding. Your follow up appointment You should be seen by the obstetric team at the hospital 6-12 weeks after giving birth. They will check your stitches and make sure your wound is healing. You will be asked about your bowel and urinary habits. You should tell the doctor about any other concerns you may have, including sexual intercourse. If there are any complications, you may be referred to a specialist. Can I have sexual intercourse? Many women experience reduced libido after giving birth this is normal. There is no right time for sex; however, it may be best to wait until your stitches have fully healed and bleeding has stopped. Make sure that you have arranged contraception before you begin to have intercourse again as you can conceive straight away. Some women find that they may need to use a vaginal lubricant initially and try different positions that may make it more comfortable. If you are worried about starting to have sex again, make sure that you talk to your partner, and start gently. Will I be able to have another vaginal delivery? This depends on a number of factors. A lot of women do go on to give birth vaginally following 3rd and 4th degree tears, however, you should receive counselling from your doctor before making any decisions. If you still have symptoms associated with your tear, you may be offered a caesarean section to reduce the risk of further problems occurring. If your tear has healed properly and you have no symptoms a vaginal birth is an appropriate option. Are there any long term effects? Most 3rd and 4th degree tears will heal in time but you might experience some of the following: Pain and soreness in the perineum Inability to control flatulence (breaking wind) Problems with your bowels including leakage, urgency and lack of control Haemorrhoids Apprehensive towards sex Concerned about future deliveries Fistula (connection) between the anus and the vagina after the repair has healed. This is uncommon and can be repaired by further surgery When should I contact a Midwife/Doctor? Contact your doctor or midwife if any of the following occur: If your pain is not well managed If you become concerned about your stitches or there is any discharge If you suspect you have a fever If you keep having to rush to the toilet to open your bowels If you cannot control your bowels or flatulence
If you have any other concerns or worries do not hesitate to contact your midwife or GP. Useful telephone numbers: Scunthorpe General Hospital Antenatal Clinic: 01724 290168 Pregnancy Assessment Centre 01724 290409 Diana Princess of Wales Hospital, Grimsby Antenatal Clinic: 01472 875248 Antenatal Day Assessment Unit: 01472 875248 Goole Midwifery Centre 01405 720720 ext 4079 01724 290021 Concerns and Queries If you have any concerns / queries about any of the services offered by the Trust, in the first instance, please speak to the person providing your care. For Diana, Princess of Wales Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01472) 875403 or at the PALS office which is situated near the main entrance. For Scunthorpe General Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01724) 290132 or at the PALS office which is situated on C Floor. Alternatively you can email: nlg-tr.pals@nhs.net Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Diana Princess of Wales Hospital Scartho Road Grimsby 01472 874111 Scunthorpe General Hospital Cliff Gardens Scunthorpe 01724 282282 Goole & District Hospital Woodland Avenue Goole 01405 720720 www.nlg.nhs.uk Date of issue: September 2013 Review Period: September 2016 Author: Ward Manager (CDS) IFP-559 v1.1 NLGHFT 2013