This leaflet has been produced by the Maternity Unit at the Queen Elizabeth Hospital in Gateshead, to provide you with information if you have experienced a third or fourth degree tear during childbirth.
What are the types of tears during childbirth?
Most women, up to nine in ten (90%), tear to some extent during childbirth.
Most tears occur in the perineum, the area between the vaginal opening and the anus (back
passage). They may be:
- first degree tears – small, skin-deep tears which usually heal naturally
- second degree tears – deeper tears affecting the muscle of the perineum as well as the skin. These usually require stitches.
For some women with a tear, up to nine in 100 (9%), the tear may be more extensive. This may be:
- a third-degree tear extending downwards from the vaginal wall and perineum to the anal sphincter, the muscle that controls the anus.
- a fourth-degree tear extending to the anal canal as well as the rectum (further into the anus).
What is the difference between an episiotomy and a tear?
An episiotomy is a cut made by a doctor or midwife through the vaginal wall and perineum to make more space to deliver the baby. A tear happens as the baby stretches the vagina during birth.
Third and fourth degree tears
Can a third or fourth degree tear be predicted?
It is not possible to predict or prevent these types of tears. There are some factors that may indicate when a third or fourth degree tear is more likely. This is when:
- one of your baby’s shoulders becomes stuck behind your pubic bone
- the second stage of labour is longer than expected (the time from when the cervix is fully
dilated to birth)
- this is your first vaginal birth
- you have a large baby (over eight pounds thirteen ounces or four kg)
- labour needs to be started (induced)
- you have an assisted birth (e.g. forceps)
Could anything have been done to prevent it?
A third or fourth degree tear cannot be prevented in most situations because it cannot be
anticipated. Research has shown that, although an episiotomy makes more space for the baby to be born, it does not prevent a third or fourth degree tear from occurring.
What happens after birth?
If your obstetrician or midwife suspects a third- or fourth-degree tear, or if you had an episiotomy, you will have a detailed examination of your perineum and anus. The obstetrician will confirm the extent of the tear and provide you with information about the repair. You will need an anaesthetic.
This is usually an epidural or a spinal but occasionally may be a general anaesthetic. The obstetrician will then suture (stitch) the damaged anal sphincter and the tear in an operating theatre.
What treatment will I be offered after surgery?
You will be advised to take a five day course of antibiotics to reduce the risk of infection because the stitches are very close to the anus.
- Pain-relieving drugs
You will be offered pain-relieving drugs such as paracetamol, ibuprofen or diclofenac to relieve any pain.
You will be advised to take laxatives to make it easier and more comfortable to open your bowels.
A drip in your arm will give you fluids until you feel able to eat and drink. A catheter (tube) in your bladder will collect urine until you feel able to walk to the toilet.
Once you have opened your bowels and your stitches have been checked to see that they are healing properly, you should be able to go home.
What can I do to speed up healing of the tear?
Keep the area 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 infection.
- Drink at least two to three litres of water every day and eat a healthy balanced diet (fruit, vegetables, cereals, wholemeal bread and pasta). This will ensure that your bowels open regularly and prevent you from becoming constipated.
- Do pelvic floor exercises as soon as you can after birth. This will increase the circulation of blood to the area and aid the healing process. You should be offered physiotherapy advice about pelvic floor exercises to do after surgery.
What are the long-term effects of a third or fourth degree tear?
Most women make a good recovery, particularly if the tear is recognised and repaired at the time.
During healing, some women may have:
- pain or soreness in the perineum
- fears and apprehension about having sex – many women worry about this even if they have not had a third or fourth degree tear
- a feeling that they need to rush to the toilet to open their bowels urgently
- fear about future pregnancy and birth.
Very rarely, you may have a fistula (hole) between your anus and vagina after the tear has healed. This can be repaired by further surgery.
Contact your midwife or general practitioner if:
- your stitches become more painful or smell offensive – these may be signs of an infection
- you cannot control your bowels or flatus (passing wind)
- you feel a need to rush to the toilet to open your bowels
- you have any other worries or concerns.
Your follow-up appointment
You may be offered a follow-up appointment with your consultant at the Women’s Health Clinic six weeks after you have given birth to check that your stitches have healed properly. You will be asked questions specifically about your urine and bowel functions. If there are any complications, you may be referred to a specialist.
This appointment offers you the opportunity to discuss any concerns that you may have, such as sexual intercourse.
Can I have a vaginal birth in the future?
This depends on a number of factors. Your obstetrician will discuss these with you at your follow-up appointment or early in your next pregnancy. If you continue to experience symptoms from the third or fourth degree tear, you may want to consider a caesarean delivery next time.
If your tear has healed completely and you do not have any symptoms, then you should be able to have a vaginal birth.
How can I find out more information?
Please discuss any queries or concerns with your midwife or consultant during your appointment; alternatively if you need any more information please do not hesitate to contact the Maternity Pregnancy Assessment Unit to speak to a midwife.
Any personal information is kept confidential. There may be occasions where your information needs to shared with other care professionals to ensure you receive the best care possible.
In order to assist us improve the services available your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews. Further information is available in the leaflet Disclosure of Confidential Information IL137, via Gateshead Health NHS Foundation Trust website or the PALS Service.
This leaflet can be made available in other languages and formats upon request.