Recovering from a perineal tear
Congratulations on having welcomed your baby to the world!
Childbirth is a beautiful thing, although sometimes it can result in a few ongoing issues, especially for the mum. One of those can be perineal tearing.
What is perineal tearing?
At the very end of your labour the skin and muscle layers in and around your vagina thin and stretch to allow your baby to be born and it is quite common for women to have some form of perineal or vaginal tearing at this time.
Midwives and doctors have developed a system of describing the types of tears according to the size of the tear and type of tissue involved; from a first degree tear to a fourth degree tear.
First degree tear
A first degree tear is a thin tear or graze of the perineal skin. No muscles are involved. It is possible that a small number of stitches may be required.
Second degree tear
A second degree tear includes skin and muscle tissue. Stitches are usually needed and it can take around two months or so to feel completely comfortable again.
An episiotomy is a cut made into your perineum to enlarge your vaginal opening. This is done to help your baby be born. An episiotomy involves the same muscle and tissue as a second degree tear. However some episiotomies can extend further, and when this happens they might be described as a third or even a fourth degree tear depending on their severity.
Third degree tear
A third degree tear is a tear or laceration through the perineal muscles and the muscle layer that surrounds the anal canal. This requires stitches and can take a similar time to a second degree tear (two months or so), if not longer, before the wound is healed and the area comfortable.
Fourth degree tear
A fourth degree tear goes through the anal sphincter all the way into the anal canal or rectum. Most women with this condition will have no ongoing problems, with the appropriate management (including good personal hygiene by you, diet, physiotherapy, pain medication and laxatives). However a small group of women may have ongoing problems with controlling the passing of urine, wind or faeces. This is called incontinence and will require ongoing clinical review or medical consultation.
Also, although more uncommon than a tear, a recto-vaginal fistula may develop. This is when a tubelike passage links the vagina and rectum. Symptoms of this include the passing of flatus and/or faeces through the vagina. It is very important that you tell your doctor if you have either of these symptoms as infection can result.
Third and fourth degree tears are an uncommon complication of child birth, which can affect a woman’s normal bowel, bladder and sexual functions short term and in some cases, permanently. Following the recommendations below is important to try and prevent any long term problems. The time span for recovery varies in accordance with individual circumstances.
Remember to relax and give yourself time to heal.
Can a third or fourth degree tear be prevented?
It is not possible to predict, or even prevent, these types of tears. There are some factors that may make a third or fourth degree tear more likely.
This is when:
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one of your baby’s shoulders becomes stuck behind your pubic bone
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the second stage of labour is long (the time from when the cervix is fully dilated to birth)
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this is your first vaginal birth
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you have a large baby
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labour needs to be started (induced)
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you have an assisted birth (forceps or ventouse)
Taking care of your perineum
Keep it clean and free from infection
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Personal hygiene is very important. We recommend that you have at least one full shower and wash your perineal area three to four times each day
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Change sanitary pads at least every four to six hours to keep the wound as clean as possible
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Always pat the perineal area dry from the front to the back after washing to avoid introducing germs from the rectum into the vaginal area. It is also very important to wash the perineum after a bowel motion.
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Do not use a hair dryer to dry your perineum. This may delay healing or cause burning to the genital area.
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Antibiotics may be prescribed to help prevent wound infection and wound breakdown.
Keep comfortable
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Apply ice packs to the perineal area every couple of hours for the first 12–24 hours after birth. Your midwife will advise you on this while you are in the hospital. You may find the ice packs helpful for pain relief for a longer period (i.e. 24–48 hours)
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Take regular pain relieving medications. These will be prescribed by your doctor
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Try to only stand and sit for short periods of time as this places strain on your perineum. When feeding your baby shift your sitting position and lie down occasionally to reduce the pain
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Lie down to rest for between 20–40 minutes every hour for the first two to four days as this will help the stitches to heal
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Avoid double leg movements, “sit up” actions and lifting heavy weights (including picking up other children) as this places extra strain on your perineum
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Get in and out of bed over on your side as this reduces the strain on your perineum
Emptying your bowels
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For the first few days after repair, a low fibre diet is recommended to prevent any further damage due to straining to pass a stool. After the 3rd day, a high fibre diet is commenced. This will produce a stool which is easier to expel
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Keep the stools soft and ask for help if the bowels have not opened within 48 hours
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Try not to strain when using your bowels and use the recommended defecation position that is taught to you by the physiotherapist (see diagram included). The passage of hard stools can disrupt repair and delay healing
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Support the perineum with your hand while emptying your bowels, laughing, coughing, sneezing, etc.
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To assist with emptying of the bowel, bulking and softening agents such as Fybogel or Metamucil and Agarol or Lactulose are usually recommended for several days after repair. Make sure you drink a lot of water with these medications, because this will assist to reduce the likelihood of constipation occurring
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If you are prone to constipation, use bulking or softening agents up to six weeks after repair. Again, discuss this with your doctor first.
Exercises to help you recover
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We recommend you avoid pelvic floor strengthening exercises for six weeks after the birth of your baby. This is because exercise of this type can strain the wound and cause wound breakdown
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Your physiotherapist will teach you how to activate your muscles prior to moving. This will help protect your perineum as it heals
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Your physio will also teach you how to do gentle pelvic floor pulses, to improve circulation and decrease swelling and pain
These are not strengthening exercises, but are important for early recovery and functional protection of sutures.
One to two weeks after you go home the Mater physiotherapist will contact you to see how you are recovering. They will also usually talk to you about coming to see a physiotherapist specialising in pelvic floor function, to check your progress and review your longer term strengthening program.
If you require further physiotherapy you will be referred to the Mater Health and Wellness Clinic at Sourh Brisbane, or be visited on the ward by Mater's allied health team. Follow up consultants can also be made at your local phsyiotherapist, but it is best to check with your obstetrician first.
Going home
It is important to continue to look after yourself when you go home. We recommend that you don’t go home until your bowels have opened sufficiently and you are feeling well again. Your midwife/doctor will be able to advise you when you are ready and your doctor will prescribe any medication you will need upon discharge.
The importance of follow-up appointments
You will need to see your obstetrician six weeks after the birth of your baby for a check-up. This may include a vaginal examination. If you have any concerns about your recovery please see your obstetrician earlier.
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If you are uncomfortable take regular pain relief medication as prescribed. However if you are taking pain killers which have codeine in them it is important to note that it can cause constipation. Talk to your pharmacist if you are unsure
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If you notice signs of infection such as a fever, wound breakdown or discharge in the perineal region, it is important you see your doctor that day
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If you have difficulty controlling the passing of urine, please discuss this with your obstetrician. If necessary they will refer you to a gynaecologist and/or urologist or to a continence advisor.
If you have any concerns about your perineal tear, or your condition including persistent pain, please bring them to the attention of your midwife/doctor straight away.
Frequently asked questions
Always remember, relax and give yourself time to heal.