Queensland Maternity and Neonatal Clinical Guidelines Program Parent information sheet Version 3.1 last updated: 17/12/2012 Caring for 3rd and 4th degree perineal tears after birth This information sheet aims to answer some questions you might have about experiencing a third and fourth degree perineal tear. A perineal tear is a tear that occurs in the perineum (the area between the vagina and the anus). IMPORTANT: The information contained in this information sheet is general information only. It is not intended to be treated by you as professional advice for a particular factual situation and is no substitute for seeking professional advice from your health care provider. In all procedures your health care provider will explain what will happen, the risks and benefits and will ask for your informed consent. What is a 3rd or 4th degree perineal tear? A 3rd or 4th degree perineal tear involves a separation of the skin and muscles from the vagina through to the anus. If the tear goes part of the way through the anus it is considered a 3rd degree tear. If the tear goes all the way through the anus it is considered a 4th degree tear. What is involved in recovery from these tears? Recovery time is different for all women, with most experiencing no symptoms a year after birth [1]. Women who have these tears usually have specialist treatment to help them understand their injury, care for it and assist with their recovery. What makes a 3rd or 4th degree tear more likely? Studies have shown that 3rd and 4th degree perineal tears are more common in women having a vaginal birth: ›› F or the first time [2-4] ›› With a baby weighing more than 4kg [2-5] ›› With the assistance of forceps or a vacuum [2-4] ›› With a midline episiotomy [2] ›› Where the baby’s shoulder becomes stuck at birth [3,5] ›› With an induced labour [2] ›› Who did not use a warm compress on their perineum during labour [6] How is a 3rd or 4th degree tear repaired? Women who have a 3rd or 4th degree tear will normally go to an operating theatre after birth to have their tear repaired. Women with these tears have either an epidural/spinal block or a general anaesthetic. An epidural and a spinal block are treatments that numb the lower half of the body, while a general anaesthetic is a treatment that is used to put the entire body to sleep for a short time. Your health care provider will provide you with information about the benefits and risks, ask you if you have any questions, and then ask whether or not you consent. What can I do to help a tear heal? There are a number of things you can do to help a tear heal. These include: ›› Avoiding positions and activities that place pressure on your affected muscles or restrict blood flow to the affected area for 6-12 weeks after birth (e.g., avoid sitting up, lifting, and high impact exercise [8]) ›› Lying on your side to breastfeed in order to avoid pressure on the affected area [8] ›› Keeping the tear as clean and dry as possible in order to prevent infection (e.g., change pads frequently and shower at least daily) [8] ›› Do pelvic floor exercises Some women find that experiencing a tear is very difficult both physically and emotionally. You may want to discuss your feelings with your care provider or ask for contact details for a service that specialises in helping women with this kind of injury (see below for some support organisations). What is the easiest way to use the toilet while the tear is healing? The following steps outline the easiest way to use the toilet while your tear is healing [9]: ›› S it on the toilet and lean forward with your elbows slightly bent and hands resting on your knees ›› Use a foot stool or lift your heels up so that your knees are above your hips ›› Relax your stomach and breathe normally ›› Take your time to empty your bladder and bowel, and avoid straining. You can support your perineal area with your hand and a pad to avoid it from stretching and causing you pain [8] ›› To prevent infection, wipe front to back with soft toilet paper or baby wipes, and wash and pat dry the perineal area after using the toilet www.health.qld.gov.au/qcg www.qcmb.org.au © 2012 The University of Queensland, Brisbane Australia. ABN 63942912 684, CRICOS Provider No. 00025B How can I reduce the pain of the tear after birth? The following are ways to reduce pain and swelling of tearing after having a baby: ›› A pply ice wrapped in a cloth to your perineum as often as required for 10-20 minutes, then remove and dry the area. Applying ice can reduce the pain and swelling related to the tear [8,10] ›› If you need to cough, sneeze, blow your nose or empty your bowels, you can support your perineal area with your hand or a cushion to avoid it from stretching [8] ›› Keep bowel motions soft by drinking at least 2 litres of fluid a day, eating fruits and vegetables often, and taking laxatives as prescribed [8] ›› Start gentle pelvic floor muscle exercises 2 to 3 days after you have your baby to help with recovery by reducing swelling and pain ›› Take pain relief medication such as paracetamol or ibuprofen. Try to avoid those with codeine as they can cause constipation and make it more painful for you to have a bowel movement [8] ›› Lie down and rest as much as possible What are some signs that the area might be infected? Your care provider will give you antibiotics to help prevent infections. However, you may still develop an infection. Look out for signs of possible infection such as: ›› Feeling unwell (e.g., flu-like feeling, temperature over 37.5˚) [11] ›› Abnormal pain or discomfort in the affected area ›› Smelly discharge from the affected area [11] or a hot feeling in the affected area When will I be able to resume sexual activity? It is usually best to wait until the tear has healed before you resume normal sexual activity. You may want to take it slow and use a lubricant the first few times. Sexual intercourse should not cause any pain in the perineal area after your tear has healed. You can discuss with your care provider any concerns that you may have about resuming sexual intercourse. What are pelvic floor exercises? Women who do pelvic floor exercises are more likely to recover quicker from childbirth and surgery, are less likely to have a prolapse (‘sagging’ of the internal organs), and have better control over their bladder and bowel, compared to women who do not do them [12]. They also help 3rd and 4th degree tears to heal by reducing swelling and increasing blood supply to the affected area [8]. A physiotherapist should visit you prior to leaving the hospital to show you the correct technique for pelvic floor exercises. It is important to know the correct technique to avoid further damage to the skin and muscle. What is the chance that I will have a repeat tear in a future birth? Your chance of having a repeat severe tear in a future vaginal birth is no more than that of all women having their first babies [14], which is approximately 4% for Queensland mothers [15]. Evidence does not support the use of a routine episiotomy (a cut made in the perineum) in future births in order to prevent repeat tearing [8,16]. In future births your care provider may offer you a caesarean section if you are uncomfortable with having a vaginal birth [8]. What are the long-term consequences of having a 3rd or 4th degree tear? Little is known about the long-term consequences of having a 3rd or 4th degree tear. Following the first surgical repair approximately 60-80% of women will no longer experience symptoms a year after repair [1]. For women whose symptoms persist after their first perineal repair, research suggests that secondary repair (a second surgery to repair the tear) is successful in eliminating symptoms for approximately 88% of women [17]. Who can I see for help with my recovery? A number of health professionals can help with your recovery. These include: ›› Y our GP – you will normally see your GP at 6 weeks for a post birth check-up where you can discuss any concerns that you may have ›› An obstetrician – you will usually be referred to an obstetrician for a check-up which may be between 6 to 12 weeks post birth ›› A specialist physiotherapist – you will usually be referred to a specialist physiotherapist to assist in pelvic floor exercises, and for tips on going to the toilet and safe exercising (see previous sections) ›› A continence nurse advisor (a registered nurse with extensive training in continence care) ›› A gynaecologist, uro-gynaecologist or colorectal surgeon – you may be referred to one of these if you are experiencing poor bowel control ›› A dietician – you may want assistance in creating a diet that will maximise healing and reduce constipation If you have comments about the content of this parent information sheet please email [email protected] Comfort, support & information 13 HEALTH (13 432584) is a phone line that provides health information, referral and services to the public. Pregnancy, Birth & Baby Helpline 1800 882 436 (free call) offers free, confidential, professional information and counselling for women, their partners and families relating to issues of conception, pregnancy, birthing and postnatal care. Lifeline 13 11 14 Lifeline offers a telephone crisis support service to anyone. Bladderbowel.gov.au (1800 330 066) information to assist with the prevention and management of bladder and bowel problems Continence.org.au information to assist with the management of bladder and bowel continence problems womhealth.org.au (1800 017 676) is the website for Women’s Health Queensland Wide, a health service where nurses and midwives can answer questions from women about their health via telephone or email. References: Available from www.qcmb.org.au/media/pdf/References Tears2.pdf