Third and fourth degree tear

For some women, less than 3 in 100 (3%), 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).

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. Factors associated with an increased chance of a third degree tear include adopting a lithotomy position of the delivery, forceps delivery and delivery on a birth stool. 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.

You could consider perineal massage during pregnancy in order to reduce the possibility/severity of a perineal tear. Please click here for more information.

What happens after birth?

If your obstetrician or midwife suspects a third or fourth degree tear 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 surgical repair and treatment. You will need an anaesthetic. This is usually an epidural or a spinal on rare occasions this may be a general anaesthetic. The obstetrician will then suture (stitch) the damaged anal sphincter and the tear in an operating theatre. This will be performed soon after the birth of your baby.

What treatment will I be offered after surgical repair?

Antibiotics - You will be advised to take a seven 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 recommended to take pain-relieving drugs such as paracetamol and ibuprofen to relieve any pain.
Laxatives - You will be advised to take laxatives to make it easier and more comfortable to open your bowels.

When you leave theatre you will have a drip in your arm and a catheter (tube) in your bladder. The drip will give you fluids until you are able to eat and drink and the catheter in your bladder will collect urine until you feel able to walk to the toilet.

None of the treatments offered will prevent you from breastfeeding.

What can I do to speed up healing of the tear?

your stitches should dissolve in 2 to 6 weeks – you may find parts of them on your sanitary pad.
keep the area clean: shower at least once a day (a short bath on occasion is not contraindicated), a separate hand towel to dry the perineum should be used and change your sanitary pads regularly (every 2 to 3 hours).
wash your hands both before and after you go to the toilet and wipe yourself from to back. This will reduce the risk of infection.
drink at least 1.5 to 2 litres of water every day and eat a healthy balanced diet with increased fibre (fruit, vegetables, cereals, wholemeal bread and pasta). This will ensure that your bowels open regularly and prevent you from becoming constipated.
start 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.
avoid wearing tight clothing and try to ‘air’ the area whenever possible

Signs of infection – what to look out for

The following can all be signs of an infection. Be aware of your perineum and if you start to experience any of the following, let your midwife of GP know so that appropriate treatment can be given:

any offensive smelling discharge.
increasing pain in the area – you will have some discomfort as the area heals, but this should diminish. If it is worsening, get the wound checked.
increase in bleeding, particularly when not associated with an increase of activity.

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 the first month some women may experience all of the below:

pain or soreness in the perineum
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
questions about future pregnancy and birth.

Very rarely, you may develop a fistula (hole) between your anus and vagina after the tear has healed. This can be repaired by further surgery.

Contact your midwife or GP if:

you have any signs of infection (see above)
you cannot control your bowels
you feel a need to rush to the toilet to open your bowels
You cannot open your bowels
you have any other worries or concerns.

Follow-up care

A follow-up appointment at the hospital (3 months after you have given birth) is automatically arranged for all women who have experienced a 3a, 3b, 3c or 4th degree tear, in addition to this if you are experiencing problems with your bowel function following any type of tear please inform your GP who will arrange a referral to be made.

At the appointment you will see a uro-gynaecologist. You will be asked questions specifically about your bladder and bowel function, and an endoanal ultrasound may be required. If there are any complications, you may be referred to the physiotherapist or the colorectal surgeons.

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?

Most women will be recommened to plan a vaginal delivery after a previous third- or fourth- degree tear. This advice will be based on a number of factors which your obstetrician will discuss with you at your follow-up appointment or early in your next pregnancy.

If your tear has healed completely and you do not have any symptoms, then you should be able to have a vaginal birth. However, if you continue to experience symptoms from the third- or fourth-degree tear, you may want to consider a caesarean delivery.

I am experiencing pain and problems with my bowels, what should i do?

If you find you are suffering from perineal pain or bowel problems (such as bowel incontinence, bleeding/pain when opening your bowels) please discuss this with your community midwife. If they have discharged you from their care, you will need to see your GP.

What is normal bowel function?

Please complete a short questionnaire at 3 months postnatal (from the birth) to understand when symptoms may be outside of the normal.

CLICK HERE FOR QUESTIONNAIRE