Perineal Tears

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Overview

A perineal tear refers to damage that can occur in the area between the vagina and anus during childbirth.

During birth, it is common to experience tearing of the tissue between the vaginal opening and the anus known as the perineum. This area contains many muscles. These obstetrical tears are categorized into four groups:

First degree tears: These are small, skin-deep tears.
Second degree tears: Deeper tears that affect both the muscles of the perineum as well as the skin.
Third degree tears: These tears extend from the vagina and perineum to the anal sphincter, the muscle that controls the anus.
Fourth degree tears: These tears extend into the anal canal as well as the rectum, reaching further into the anus.

An episiotomy is different from a tear. An episiotomy is a deliberate cut made by the doctor or midwife through the vaginal wall and perineum to make more space for delivering the baby. A tear happens as the baby stretches the vagina during birth. A tear may occur with or without an episiotomy.

Visit our Mount Sinai Perineal (OASIS) Clinic for information about our clinic-based care.

Our care

Learn more about the specialized care provided at Mount Sinai Hospital for Gynaecology.

This content is intended for informational purposes only and is not intended to be used or relied upon for any diagnostic or treatment purposes. It does not replace the need for consultation with a health-care professional. Please speak with your health-care professional for questions about your health.

Symptoms

Third or fourth-degree tears happen in about four to six per cent of vaginal births worldwide. Factors that can increase the risk of a tear include the following:

First vaginal birth
A large baby (more than four kilograms or nine pounds)
Assisted deliveries (using forceps or vacuum)
Labour was induced
One of your baby’s shoulders becomes stuck behind the pubic bone
Pushing for a longer amount of time than expected

Diagnosis

If a third or fourth-degree tear is suspected, your midwife or physician will examine your perineum and anus. They will explain how the tear will be repaired. This is usually performed as soon as possible after your baby is born, and it is done under epidural or spinal anesthesia. In some cases, a general anesthetic may be necessary.

An obstetrician will then stitch the tear, including any damage to the anal sphincter, either in the labour room or an operating room.

Treatment

Most patients recover without complications, particularly if the tear is recognized and repaired at the time of birth. As they heal, some people may experience the following:

Pain or soreness in the perineum
Fears and apprehension about having sexual intercourse
A sense of urgency to use the toilet for a bowel movement, or difficulty controlling gas from the back passage
Stitches usually dissolve within four to six weeks, although deeper stitches around the anus can take longer to fully dissolve.

Short-term treatment

After your tear has been stitched, a single intravenous dose of antibiotics is given to help reduce the risk of infection, since the stitches are close to the anus. You may also be given oral antibiotics to continue for a period of time.

The following measures may also help with your recovery:

Pain relief medications such as acetaminophen or ibuprofen
A gentle laxative to make bowel movements more comfortable
A temporary catheter to collect urine until you feel able to walk to the toilet
Daily showers, baths and sitz baths to keep the area clean
Change maternity pads regularly to keep the area clean
An ice pack applied to the perineum outside of clothing for up to 10 minutes to help with swelling
Sitting on an air donut pillow or two rolled-up towels to ease pressure

Diet and exercise

Pelvic floor exercises (PDF) can be started as soon as your catheter has been removed. These exercises help increase blood circulation in the area and help the healing process. They also strengthen the muscles of the perineum and pelvic floor to prevent possible problems with bowel control.

Your health-care provider will teach you how to do pelvic floor muscle exercises and may recommend an appointment with a pelvic physiotherapist for extra support.

Eat a balanced, high-fiber diet to make sure that your bowels move regularly and prevent constipation. Continue to use the gentle laxatives prescribed for at least two weeks.

During the healing period, avoid heavy lifting, pushing or pulling to allow the perineum to heal. Provide manual support to your perineum during activities that increase pressure in your abdomen and on your pelvic floor such as sneezing, coughing or vomiting.

Infant feeding

Treatments for perineal tears will not affect your ability to breast/chestfeed. However, sitting for long periods of time may be difficult. To make feeding more comfortable, try different positions other than sitting. Using ice packs outside of your clothing on your perineum, may also provide relief.

Bowel movements

A bowel movement should not affect your stitches, although you may have less control for the first few days after childbirth. Eat well, drink plenty of water to avoid constipation and continue taking the prescribed laxative for 10 days after birth. A sitting position with your feet on a stool to elevate the knees above your hips can also help ease bowel movements. Move slowly and try not to strain.

Sex

Most people wait close to six weeks before having sex. Once your stitches have healed and pain and bleeding have subsided, you can have sex when both you and your partner feel ready. Ensure you have a suitable method of contraception, as pregnancy can occur soon after giving birth.

While sex may be uncomfortable or feel different at first, lasting discomfort should be discussed with your physician. You and your partner may be anxious, so talking about these feelings may help as it is important that you both feel ready and relaxed.

Future births

The possibility of a future vaginal birth depends on several factors. Your obstetrician will discuss these with you at your follow-up appointment or in your next pregnancy. If the anal muscles have completely healed, a future vaginal birth is considered safe. The risk of having another third or fourth-degree tear is approximately five to seven per cent. Some people may choose a Caesarean section to minimize potential pelvic floor damage in future deliveries.