Third and fourth degree tears following childbirth

What are third and fourth degree tears?

A tear that involves the muscle that controls the anus (the anal sphincter) is known as a third-degree tear. If the tear extends further into the lining of the anus or rectum it is known as a fourth degree tear.

Who is at risk from third and fourth degree tears?

These types of tears usually happen unexpectedly during birth and it is not possible to predict when it will happen. However, you are more likely to have a third or fourth-degree tear if:

• this is your first vaginal birth, about 3 in every 100 women
• you are of South Asian origin
• your second stage of labour (the time from when the cervix is fully dilated to birth) is longer than expected
• you needed forceps or a ventouse, also known as vacuum-assisted vaginal delivery or Vacuum Extraction, to help the delivery of your baby
• one of the baby’s shoulders becomes stuck behind your pubic bone, delaying the birth of the baby’s body, which is known as shoulder dystocia
• you have a large baby (over 4 kg)
• you have had a third or fourth degree tear before

What will happen if I have a third or fourth degree tear?

If a third or fourth degree tear is confirmed, it is strongly recommended that you have it repaired (stitched). The tear will usually be repaired in the operating theatre. You will need an epidural or a spinal anaesthetic, although sometimes a general anaesthetic may be necessary. Your doctor will explain the procedure to you before asking you to sign a consent form.

You may have a thin tube inserted into a vein in your arm (cannula). You will be given fluids through this tube until you are able to eat and drink.

You are likely to need a catheter (tube) inserted into your bladder to drain any urine. The catheter is usually kept in until you are able to walk to the toilet.

Your tear will be repaired by an experienced doctor using dissolvable stitches (sutures). Some of the stitches can take more than 3 months to dissolve.

What will happen after the repair?

You will be:

• offered pain-relieving medication such as paracetamol, ibuprofen or diclofenac (Voltarol®) to help relieve any pain.
• advised to take laxatives. This will make it easier and more comfortable to open your bowels.
• seen by a physiotherapist who will advise you on pelvic floor exercises. Pelvic floor exercises are believed to help restore muscle tone, stimulate circulation of blood, and speed up the healing process.

Will I be able to breastfeed?

Yes. None of the treatments offered will stop you from breastfeeding.

What can I expect after the repair?

After having any tear, it is normal to feel pain or soreness around the area for 2 to 3 weeks, particularly when walking or sitting.

Passing urine can also cause stinging. Continue to take your pain relief when you go home.

All stitches are dissolvable and the tear should heal within a few weeks, although it can take several months. Stitches can irritate and become itchy as healing takes place but this is normal. You may notice some stitch material fall out; this is also normal.

Possible complications of this third or fourth tear?

Following a third or fourth degree tear, some women feel that they pass wind more easily or need to rush to the toilet to open their bowels.

Most women make a good recovery, particularly if the tear is recognised and repaired at the time. About 7 in 10 women will have no symptoms by 12 months after birth. If you decide not to have your third or fourth degree tear repaired you will almost certainly have incontinence issues, possible infection and pain.

What can help me to recover?

Personal hygiene is very important. Keep the area of your stitches clean. Have a bath or a shower, at least once a day and change your sanitary pads regularly (wash your hands both before and after you do so). This will reduce the risk of any infection.

You should drink at least 2 to 3 litres of water every day and eat a healthy balanced diet such as fruit, vegetables, cereals, wholemeal bread and pasta. This will make sure that your bowels open regularly and will stop you from becoming constipated.

You can strengthen the muscles around the vagina and anus by completing the pelvic floor exercises already shown. You should start the pelvic floor exercises as soon as you can after birth.

Looking after a newborn baby and recovering from an operation for a third or fourth degree tear can be hard. Support from family and friends can help.

When can I have sex?

In the weeks after having a vaginal birth, many women feel sore, whether they have had a tear or not. If you have had a tear, sex can be uncomfortable. You should wait to have sex until the bleeding has stopped and the tear has healed. This may take several weeks. After that you can have sex when you feel ready to do so.A small number of women have difficulty having sex and continue to find it painful. Talk to your GP if this is the case so that you can get the help and support you need.

It is possible to conceive a few weeks after your baby is born, even before you have a period. You may wish to talk with your GP or midwife about contraception or visit your local family planning clinic.

What follow up will I receive?

You will be offered a follow-up appointment about 10 to 12 weeks after giving birth. This will be in the Specialist Midwife and Pelvic Health Physiotherapist Clinic. The clinic runs alongside a consultant clinic should there be any issues that need medical input.

At the clinic your stitches will be checked and we will make sure that the wound has healed properly.

You will be asked if you have had any problems controlling your bowels following the birth of your child. If you have had problems, you may be referred to a specialist doctor. You will also have the opportunity to discuss the birth and any concerns that you may have.

For more information, please see our webpages:

https://www.gloshospitals.nhs.uk/our-services/services-we-offer/maternity/after-your-baby-is-born/perineal-clinic/

Can I have a vaginal birth in the future?

Most women go on to have a straightforward birth after a third or fourth degree tear. However, about 6 in 100 women who have had a third or fourth degree tear will have a similar tear in a future birth.

Sometimes, women continue to experience on-going problems from the third or fourth degree tear. If this is the case you may wish to consider a planned caesarean section for a future birth.

You will be able to discuss your options for future births at your follow-up appointment or early in your next pregnancy. Your individual circumstances and preferences will be taken into account.

When should I seek medical advice after I go home?

You should contact your midwife or GP if:

• your vagina become more painful or smelly – this may be a sign of an infection around the stitches
• you have a fever
• you cannot control your bowels or flatus (passing wind)

Please talk to your GP if you have any other worries or concerns.

You can also contact the physiotherapists directly for further support; the details are listed at the end of this page.

Contact information

For more information following the repair of a third or fourth degree tear, please contact your GP or community midwife or visit www.gloshospitals.nhs.uk/our-services/services-we-offer/maternity/after-your-baby-is-born/perineal-clinic/

For further help with pelvic floor exercises please contact the:

Physiotherapist Team https://www.gloshospitals.nhs.uk/our-services/services-we-offer/physiotherapy/how-can-i-see-physiotherapist/

Email: ghn-tr.womenshealth.physio@nhs.net

Further information

Bladder and Bowel Foundation

Website: www.bladderandbowelfoundation.org

RCOG patient information

Assisted vaginal birth (ventouse or forceps)

Website: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-an-assisted-vaginal-birth-ventouse-or-forceps.pdf

Shoulder dystocia

Website: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-shoulder-dystocia.pdf