Third or fourth degree tear - advice to improve postnatal recovery

Patient information factsheet

What are third and fourth degree tears?

• Third and fourth degree tears are injuries to the perineum, the area between the vagina and the anus.
• They affect the pelvic floor muscles and the ring of muscles around the back passage, including the internal and external anal sphincter muscles.
• Classification is based on the depth of tear:
  • 3a - less than 50% of EAS thickness
  • 3b - more than 50% of EAS thickness
  • 3c - both EAS and IAS injured
  • 4 - injury to sphincter complex (IAS and EAS) and lining of the anus

The Female Perineum

What might cause a third or fourth degree tear?

• First vaginal birth
• Assisted birth (forceps or ventouse)
• After an episiotomy (a cut made during birth)
• If the baby is over 4kg
• Long pushing stage or very quick birth
• Baby’s position during labour.

What are the symptoms of third and fourth degree tears?

• The pelvic floor and anal sphincter muscles help keep your anus closed until you are ready to go to the toilet.
• After a severe tear during childbirth (a third or fourth degree tear), some women may have weaker muscles or sometimes minor nerve damage.
• This can make it harder to control bowel movements.
• Common problems include:
  • Trouble holding in gas (wind)
  • A sudden strong need to go to the toilet
  • Leaking faeces (poo) before reaching the toilet
  • Weak pelvic floor muscles can also sometimes cause urine (wee) leaks.
• These problems are often small and may get better over time, but sometimes they can last longer.
• Some women only notice them many years later. This is because the muscles in that area can get weaker as you get older.
• Doing pelvic floor exercises after having a baby can help lower the chance of problems in the future.
• It is strongly recommended that you go to a Postpartum Pelvic Floor Clinic or see a specialist pelvic health Physiotherapist.
• They will check you properly and give you the right help.

Initial medical treatment

• After your baby is born, a Midwife or Doctor will check your vagina and back passage to see how bad the tear is.
• An experienced Doctor will repair the tear in an operating room.
• You will be given strong pain relief, like an epidural or spinal anaesthetic, so you don’t feel pain during the repair.
• After the repair, you will be given antibiotics to help prevent infection.
• You will also be given laxatives (medicine that helps you poo more easily) so your poo stays soft.
• This helps the area heal and stops you from straining your muscles and stitches.

Pain relief

• While you are in hospital, you will be given medicine to help with pain. When you go home, you can take pain medicine when you need it.
• Ice can help reduce swelling and pain in your perineum.
• Use an ice pack, like a bag of frozen peas or a frozen water-filled condom.
• Wrap it in a towel first, then place it on the area between your vagina and back passage (the perineum) for 10 minutes.
• Make sure the ice is covered in a towel to avoid burning the skin.
• Repeat several times a day, for as many days as you feel necessary.
• Sitting in a cool, shallow bath can also help. It can reduce swelling and keep the area between your vagina and back passage clean, which helps it heal.
• For the first 2 days after your baby is born, don’t do too much and rest when you feel tired.
• Try lying on your back with your knees bent and a pillow under your hips. This helps lift the area and can reduce swelling.

Resting position

Positioning

• It is important to find a comfortable position for feeding your baby, resting, and sleeping.
• You may find it more comfortable to lie on your side with a pillow between your knees.
• Try sitting on a rolled towel in an upside down “U” shape on the chair.

Bladder and bowel

• Pouring water over your perineum when you pass urine (pee) can help stop a stinging feeling.
• Try not to get constipated.
• Drink 1.5 to 2 litres of drinks each day that don’t have caffeine, like water, herbal tea, or squash.
• If you are breastfeeding, try to drink 2.5 to 3 litres a day.
• Eat lots of fruit and vegetables - about 5 to 10 portions a day.
• When using the toilet, put your feet on a small stool so your knees are higher than your hips, and lean forward with your elbows on your knees.
• You may also feel more comfortable holding a pad or tissue against the sore area when you poo.

Pelvic floor exercises

• Start pelvic floor exercises as soon as possible after giving birth.
• Exercises can promote healing and reduce perineal pain.
• Exercises are extremely important for rebuilding strength.
• Read a Pelvic Floor Exercise leaflet for full instructions.

How to do pelvic floor exercises

• Tighten and lift the muscles inside your bottom, vagina, and wee passage.

• It should feel like you are trying to stop wind, squeeze your vagina, and stop wee at the same time.

• The muscles should lift up and forward.

• In the first week after birth, do this gently and only as much as feels comfortable.

• After one week, you can try to squeeze harder.

  Slow squeezes:

  • Tighten the muscles and hold for up to 10 seconds.
  • Then relax for 10 seconds. Repeat 10 times.

  Quick squeezes:

  • Tighten the muscles quickly, then relax straight away.
  • Repeat 10 times.

• Try to do these exercises 5–6 times a day for the first 3 months after birth.

• After that, do them 3 times a day.

Sexual intercourse

• Wait until you feel ready. Everyone is different.
• Many women wait about 3 months after having a baby before starting again.
• Wait until:
  • Bleeding has stopped
  • The tear or scar has healed
  • o You do not feel pain or discomfort in your vagina
• You may need to use lubricant to make it more comfortable.
• Try different positions if it hurts.
• Some women find it easier and less painful when they are on top because they have more control.

What happens next?

• A check-up with your GP or hospital doctor about 6 weeks after your baby is born will be arranged.
• An appointment between 6 and 12 weeks in a Postnatal Pelvic Floor Clinic or with a specialist pelvic health Physiotherapist will be arranged.
• They will check how your bladder, bowel, and muscles are working.
• We strongly recommend going to this appointment, even if you feel fine and have no symptoms.
• This is a chance for you to ask questions about your tear, your recovery, and what it might mean for the future.
• You may be offered tests, like an ultrasound scan of the tear or other checks to see how strong and sensitive the muscles are.
• The pelvic floor team may include different specialists, such as a Doctor, Physiotherapist, Midwife, or Nurse who helps with bladder and bowel problems.
• You can be referred by your GP to this clinic for up to one year after your baby is born.
• If you have not been given an appointment, contact your hospital postnatal ward or pelvic health Physiotherapy team.
• You may benefit from physiotherapy treatment to help recover your muscle strength.
• If you have poor control of bowel movements or have difficulty doing pelvic floor muscle exercises, please contact your local Pelvic Health Physiotherapy team.

Labour debriefing appointment

• You can ask for a special appointment to talk about your labour experience in detail with a Doctor and Midwife. This is called a labour debriefing appointment.
• You can arrange this by asking for a referral at any of your postnatal hospital appointments.
• You can also ask for it yourself at any time, even up to a year later, through the hospital Patient Advice and Liaison Service (PALS).
• If you feel that you would like to be referred to a women’s health counselling service, please request a referral at one of your postnatal hospital appointments or through the hospital Patient Advisory Liaison Service.

Resources

International Urogynecological Association (IUGA)

Provides evidence-based patient information translated into several languages.
Website: https://www.yourpelvicfloor.org/conditions/

Pelvic, Obstetric & Gynaecological Physiotherapy (POGP)

Provides evidence-based patient information which may be recited (audio) in many languages.
Website: https://www.thepogp.co.uk/patient_information/default.aspx

Royal College of Obstetricians and Gynaecologists (RCOG)

For patient information and leaflets on many topics including exercise.
Website: https://www.rcog.org.uk

Contact our service

Whittington Bladder and Bowel Care Service
Email: whh-tr.bladderandbowel@nhs.net
Webpage: https://www.whittington.nhs.uk/?c=33288

Whittington Pelvic Health Physiotherapy
Email: whh-tr.outpatienttherapy@nhs.net
Webpage: https://www.whittington.nhs.uk/?c=42977

North central London perinatal pelvic health service - Royal Free London
Email: rf-tr.nclpphs@nhs.net
Webpage: https://www.royalfree.nhs.uk/services/maternity-services/maternity-support/north-central-london-perinatal-pelvic-health-service