A third- or fourth-degree tear during childbirth

Rujukan: http://www.rcog.org.uk/

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 (see RCOG patient information A difficult birth: what is shoulder dystocia? [3])
  
• 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 8 pounds 13 ounces or 4 kg)
  
• labour needs to be started (induced)
  
• you have an assisted birth (forceps or ventouse; see RCOG patient information Assisted birth [operative vaginal delivery]: information for you [4]).
  

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 surgery and treatment. 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?

• Antibiotics
  You will be advised to take a 5-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.
  
• Laxatives
  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.

None of the treatments offered will prevent you from breastfeeding.

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 2–3 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 recovery, 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 at the hospital 6–12 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.

If your tear has healed completely and you do not have any symptoms, then you should be able to have a vaginal birth.

A glossary of all medical terms [6] is available on the RCOG website.