Document 6481365

Queensland Maternity and Neonatal Clinical Guidelines Program
Parent information sheet
Version 3.1 last updated: 17/12/2012
Caring for 3rd and 4th degree perineal tears after birth
This information sheet aims to answer some questions you might have about
experiencing a third and fourth degree perineal tear. A perineal tear is a tear that
occurs in the perineum (the area between the vagina and the anus).
IMPORTANT: The information contained in this information sheet is general
information only. It is not intended to be treated by you as professional advice for a
particular factual situation and is no substitute for seeking professional advice from
your health care provider. In all procedures your health care provider will explain what
will happen, the risks and benefits and will ask for your informed consent.
What is a 3rd or 4th degree
perineal tear?
A 3rd or 4th degree perineal tear
involves a separation of the skin and
muscles from the vagina through to
the anus. If the tear goes part of the
way through the anus it is considered
a 3rd degree tear. If the tear goes
all the way through the anus it is
considered a 4th degree tear.
What is involved in recovery
from these tears?
Recovery time is different for all
women, with most experiencing
no symptoms a year after birth [1].
Women who have these tears usually
have specialist treatment to help them
understand their injury, care for it and
assist with their recovery.
What makes a 3rd or 4th degree
tear more likely?
Studies have shown that 3rd and
4th degree perineal tears are more
common in women having a vaginal
birth:
›› F
or the first time [2-4]
›› With a baby weighing more than
4kg [2-5]
›› With the assistance of forceps or a
vacuum [2-4]
›› With a midline episiotomy [2]
›› Where the baby’s shoulder becomes
stuck at birth [3,5]
›› With an induced labour [2]
›› Who did not use a warm compress
on their perineum during labour [6]
How is a 3rd or 4th degree tear
repaired?
Women who have a 3rd or 4th degree
tear will normally go to an operating
theatre after birth to have their tear
repaired. Women with these tears
have either an epidural/spinal block
or a general anaesthetic. An epidural
and a spinal block are treatments that
numb the lower half of the body, while
a general anaesthetic is a treatment
that is used to put the entire body to
sleep for a short time.
Your health care provider will provide
you with information about the
benefits and risks, ask you if you have
any questions, and then ask whether
or not you consent.
What can I do to help a tear
heal?
There are a number of things you can
do to help a tear heal. These include:
›› Avoiding positions and activities
that place pressure on your affected
muscles or restrict blood flow to the
affected area for 6-12 weeks after
birth (e.g., avoid sitting up, lifting,
and high impact exercise [8])
›› Lying on your side to breastfeed
in order to avoid pressure on the
affected area [8]
›› Keeping the tear as clean and dry as
possible in order to prevent infection
(e.g., change pads frequently and
shower at least daily) [8]
›› Do pelvic floor exercises
Some women find that experiencing a
tear is very difficult both physically and
emotionally. You may want to discuss
your feelings with your care provider
or ask for contact details for a service
that specialises in helping women
with this kind of injury (see below for
some support organisations).
What is the easiest way to
use the toilet while the tear is
healing?
The following steps outline the easiest
way to use the toilet while your tear is
healing [9]:
›› S
it on the toilet and lean forward
with your elbows slightly bent and
hands resting on your knees
›› Use a foot stool or lift your heels up
so that your knees are above your
hips
›› Relax your stomach and breathe
normally
›› Take your time to empty your
bladder and bowel, and avoid
straining. You can support your
perineal area with your hand and a
pad to avoid it from stretching and
causing you pain [8]
›› To prevent infection, wipe front to
back with soft toilet paper or baby
wipes, and wash and pat dry the
perineal area after using the toilet
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How can I reduce the pain of
the tear after birth?
The following are ways to reduce pain
and swelling of tearing after having a
baby:
›› A
pply ice wrapped in a cloth to
your perineum as often as required
for 10-20 minutes, then remove
and dry the area. Applying ice can
reduce the pain and swelling related
to the tear [8,10]
›› If you need to cough, sneeze, blow
your nose or empty your bowels,
you can support your perineal area
with your hand or a cushion to
avoid it from stretching [8]
›› Keep bowel motions soft by
drinking at least 2 litres of fluid a
day, eating fruits and vegetables
often, and taking laxatives as
prescribed [8]
›› Start gentle pelvic floor muscle
exercises 2 to 3 days after you have
your baby to help with recovery by
reducing swelling and pain
›› Take pain relief medication such as
paracetamol or ibuprofen. Try to
avoid those with codeine as they
can cause constipation and make
it more painful for you to have a
bowel movement [8]
›› Lie down and rest as much as
possible
What are some signs that the
area might be infected?
Your care provider will give you
antibiotics to help prevent infections.
However, you may still develop
an infection. Look out for signs of
possible infection such as:
›› Feeling unwell (e.g., flu-like feeling,
temperature over 37.5˚) [11]
›› Abnormal pain or discomfort in the
affected area
›› Smelly discharge from the affected
area [11] or a hot feeling in the
affected area
When will I be able to resume
sexual activity?
It is usually best to wait until the tear
has healed before you resume normal
sexual activity. You may want to take
it slow and use a lubricant the first
few times. Sexual intercourse should
not cause any pain in the perineal
area after your tear has healed. You
can discuss with your care provider
any concerns that you may have
about resuming sexual intercourse.
What are pelvic floor exercises?
Women who do pelvic floor exercises
are more likely to recover quicker
from childbirth and surgery, are less
likely to have a prolapse (‘sagging’ of
the internal organs), and have better
control over their bladder and bowel,
compared to women who do not
do them [12]. They also help 3rd and
4th degree tears to heal by reducing
swelling and increasing blood supply
to the affected area [8].
A physiotherapist should visit you
prior to leaving the hospital to show
you the correct technique for pelvic
floor exercises. It is important to know
the correct technique to avoid further
damage to the skin and muscle.
What is the chance that I will
have a repeat tear in a future
birth?
Your chance of having a repeat
severe tear in a future vaginal birth
is no more than that of all women
having their first babies [14], which is
approximately 4% for Queensland
mothers [15]. Evidence does
not support the use of a routine
episiotomy (a cut made in the
perineum) in future births in order to
prevent repeat tearing [8,16]. In future
births your care provider may offer
you a caesarean section if you are
uncomfortable with having a vaginal
birth [8].
What are the long-term
consequences of having a 3rd
or 4th degree tear?
Little is known about the long-term
consequences of having a 3rd or
4th degree tear. Following the first
surgical repair approximately 60-80%
of women will no longer experience
symptoms a year after repair [1]. For
women whose symptoms persist
after their first perineal repair, research
suggests that secondary repair (a
second surgery to repair the tear) is
successful in eliminating symptoms
for approximately 88% of women [17].
Who can I see for help with my
recovery?
A number of health professionals
can help with your recovery. These
include:
›› Y
our GP – you will normally see
your GP at 6 weeks for a post birth
check-up where you can discuss
any concerns that you may have
›› An obstetrician – you will usually
be referred to an obstetrician for a
check-up which may be between 6
to 12 weeks post birth
›› A specialist physiotherapist – you
will usually be referred to a specialist
physiotherapist to assist in pelvic
floor exercises, and for tips on going
to the toilet and safe exercising (see
previous sections)
›› A continence nurse advisor (a
registered nurse with extensive
training in continence care)
›› A gynaecologist, uro-gynaecologist
or colorectal surgeon – you may be
referred to one of these if you are
experiencing poor bowel control
›› A dietician – you may want
assistance in creating a diet that
will maximise healing and reduce
constipation
If you have comments about the
content of this parent information sheet
please email info@qcmb.org.au
Comfort, support & information
13 HEALTH (13 432584) is a phone line that provides health information, referral and services to the public.
Pregnancy, Birth & Baby Helpline 1800 882 436 (free call) offers free, confidential, professional information and
counselling for women, their partners and families relating to issues of conception, pregnancy, birthing and postnatal
care.
Lifeline 13 11 14 Lifeline offers a telephone crisis support service to anyone.
Bladderbowel.gov.au (1800 330 066) information to assist with the prevention and management of bladder and bowel
problems
Continence.org.au information to assist with the management of bladder and bowel continence problems
womhealth.org.au (1800 017 676) is the website for Women’s Health Queensland Wide, a health service where nurses
and midwives can answer questions from women about their health via telephone or email.
References: Available from www.qcmb.org.au/media/pdf/References Tears2.pdf