Caring for the perineum: Third and fourth degree tears

This is a tear between the vagina and the anus (back passage) involving the muscles that surround the anus, known as the anal sphincter.

There are two portions of muscle: the inner ring (known as the internal sphincter) and the outer ring (known as the external sphincter). These muscles control the passing of stools and wind from your back passage.

In most situations, third and fourth degree tears cannot be predicted or prevented. They occur in approximately 2 per cent of vaginal deliveries.

Third and fourth degree tears are graded according to the depth of the tear:

• 3a = less than half of external sphincter is torn
• 3b = more than half of the external sphincter is torn
• 3c = both the external and internal sphincter are torn
• 4th = both sphincters and the skin lining the anal canal are torn

Most women (60-80 per cent) will make a full recovery and have no symptoms one year later. If you do have symptoms at your postnatal check you will be offered physiotherapy to reduce your symptoms and speed up your recovery.

Common symptoms experienced are:

• pain and soreness around the vagina, back passage and tailbone
• a feeling that you need to rush to the toilet to open your bowels urgently
• difficulty controlling wind
• difficulty opening your bowels and / or needing to strain
• discomfort with sexual intercourse

Antibiotics:  you will be given antibiotics for five days after giving birth to help prevent infection.

Pain relief: you will be offered regular medication to relieve any pain; these will be prescribed for you to take home.

Laxatives: for example, Fybrogel and Lactulose will be provided to help keep your bowel movement soft and regular, to help healing. It is important to try to keep your stools like a ‘toothpaste’ consistency.

None of these medications will interfere with breastfeeding and any risks or side effects will be discussed with you.

How to manage your pain?

1.    Use the painkillers prescribed.

2.    Avoid sitting or standing for long periods of time for the first two weeks. To help with sitting, place towels or pillows under the length of each thigh, to raise you up and take the pressure off of the area. We do not recommend sitting on a rubber ring.

3.    Using ice packs for the first few days can help with pain and improve the healing of the wound. To use ice over the perineum, wrap it in a clean, damp towel and place it onto the area (for no longer than 10 minutes) or dampen some sanitary towels, put them in the freezer then use these as an ice pack. You must cover the sanitary towel with a cloth or a few pieces of paper towel before using it to prevent ice burns.

4.    Get some rest and allow yourself time to heal.

Wound care

Your stitches should dissolve and disappear in a couple of weeks. Stitches in the sphincter muscle take longer to dissolve (around three months).  Sometimes these can be felt through the skin near the back passage, when wiping your bottom - this is normal.

If you are having problems with your stitches please discuss this with your community midwife or GP. If you’re still having problems after six weeks please discuss them with us at your follow-up check.

Washing

• It is normal to have bleeding and vaginal discharge. You should keep the area clean and dry by washing once a day and changing your sanitary pad regularly
• You should use warm water to wash the area - do not use salt water
• Do not soak in a bath for long periods of time
• When drying the area you may wish to use a cool setting on the hairdryer or simply pat dry with a clean towel
• After opening your bowels, wash yourself from front to the back, to avoid stool (poo) getting into the wound area or near the urinary passage. This will reduce the risk of wound or urinary tract infection.
• Always wash your hands after using the bathroom or toilet facilities to avoid spreading bacteria to the wound.

After childbirth, you may have had stitches to repair any perineal tears, or an episiotomy. Up to one-in-four women may experience wound infection /breakdown or pressure on the stitches from bleeding underneath can cause the stitches to break down, leaving an open or gaping wound. This is called perineal wound dehiscence, or breakdown.   

Episiotomy and perineal tears (NHS Choices)

You can start to bring blood flow to the area of your scar and therefore oxygen, which helps with healing. The intention is to gently break down the scar with pressure and spread out the scar tissue which has formed.

1. Gently apply moderate pressure — no more than three out of 10 in intensity — and massage along the scar in and up-and-down motion on your perineum, externally.
2. Where you feel the most pressure is where you will need to work the most.
3. If you find it difficult to touch your scar, start with a 'labial pull'. Gently pull the labia up and down and make circular motions to become comfortable with touching.
4. Place your thumb at the vaginal entrance and make a 'U'-shape to gently stretch the muscles and scar.
5. Make sure you perform this massage with clean hands. Get into a comfortable position and perform the massage every day for at least two minutes.
6. You can use an oil such as 100% rose hip oil, almond oil or extra virgin olive oil.

After delivery your midwife will give you a bowl to measure your urine in. It is important for us to know the volume of urine to ensure your bladder is working properly.

You may have a catheter post-delivery. After the catheter is removed it is important you pass urine within 6 hours. If you don’t you must tell your midwife or doctor immediately.

It is important that you report anything unusual to your midwife. Think about the following questions:

• Are you fully emptying your bladder?
• Is there any urine leaking?
• Do you have to push or strain to pass urine?

If you are having difficulty passing urine or have not had an urge to pass urine 4 hours after your catheter has been removed try:

• Going to sit on the toilet, relaxing and leaning forwards
• Turning on the taps so you can hear running water or pulling lightly on the pubic hair (both of these can help to stimulate an urge)
• Rocking forwards and backwards on the toilet
• Gently tapping over the bladder near your pubic bone for a few minutes

If you have pain when you pass urine, pour lukewarm water over the perineum as you pass urine or just after. Please tell your midwife about any pain. If you are still constipated, increase this to up to 3 litres of fluid per day.

It is important that you try not to put off opening your bowels once you have had the urge to go, as this can make you more constipated.

Use the laxatives prescribed as you need to ensure that your stools remain soft but not watery. It is important to keep your stools like a ‘toothpaste’ consistency.

To help to prevent constipation you will need to maintain a good fluid intake and healthy diet rich in fibre.

Make sure you sit in a good position on the toilet to ensure you completely empty your bowels.  

The ideal position is:

• Knees higher than your hips (to do this place your feet on a step or point your toes)
• Lean forward and put your elbows on your knees
• Bulge your abdomen outwards and straighten your spine
• if you have discomfort, hold a sanitary pad or a wad of tissues with your hand and apply pressure to the vagina and perineum

Pelvic floor exercise

Pelvic floor muscles help to control the bladder and provide support to the uterus, bladder and bowel. You should start pelvic floor exercises as soon as the catheter has been removed and you have passed urine. The exercises will help reduce swelling and pain and help prevent / treat incontinence.

You should aim to do all of the exercises 3-5 times a day.

Imagine you are trying to stop yourself passing wind and then pull forward as though you are also trying to stop your flow of urine. This closes and draws up the back passage and vagina. Start with some gentle squeeze and relax 10 times, three times a day for a few weeks then start to build up the strength, then after this start to build up the strength by doing the exercises below…

You need to exercise this muscle in two ways:

1.    Slow holds: Hold the muscle in for as long as you can upto 10 seconds. Release slowly and rest for at least five seconds between each one. Aim to do 10 in a row.

2.    Fast squeezes: Squeeze the same muscles but strong and quickly, releasing straight away. Aim to do 10 in a row.

You can do these exercises almost anywhere and anytime but not when passing urine. In the beginning you will find these exercises easier to do when lying down or sitting.

Return to exercise

For 4-6 weeks, you should avoid strain or pressure on the anus, and avoid high impact exercise or heavy lifting. Walking and pelvic floor muscle exercises are safe to start from the day one. After 6 to 8 weeks, if you are healing well, you can begin some other low impact exercises e.g. Pilates, yoga and swimming. You should wait at least 12 weeks before returning to any high impact exercise e.g. running, aerobics or any form of jumping. If you are having any symptoms of bladder or bowel incontinence, symptoms of prolapse such as heaviness in the pelvic or a sensation of dragging, or perineal pain, then we would suggest seeking an assessment from a pelvic health physiotherapist who can guide you on your return to exercises.

We recommend that you avoid sexual intercourse for at least six weeks to ensure you have healed. There is no need to delay intercourse beyond 12 weeks unless you have been advised to at your check-up.

It is natural to feel anxious and for it to feel different. Begin slowly, it is important to feel aroused as this can make sex more enjoyable. Many women do feel some discomfort during sex after both vaginal and caesarean deliveries but for most this improves with time.

You may wish to use an oil-based lubricant if you are not using condoms. If you are using condoms for contraception, a natural water based lubricant may be helpful for comfort.

If you are experiencing pain or difficulties with returning to sex, there are lots of services that you may be able to access. For further information, liaise with your midwifery team or GP.