Why and where might you suffer a tear?

Many women are understandably concerned about the possibility of tearing during childbirth, and advice about how to prevent it seems to be constantly changing. This article will explain the different kinds of tear that can happen, current practice in UK hospitals and what the evidence says.

First, let’s learn some terms that will help us understand the body parts affected:

Perineum – the skin and underlying muscles between your vulva (the female external genitals) and anus (the opening of the back passage). Birth injuries affecting this area are called “perineal tears”.

Pelvic floor – different to the perineal muscles; these muscles form a bowl-like structure that sits deep within your pelvic bones and support the organs inside, like your bladder and bowel. You can visualise these muscles by cupping your hands together, leaving a small opening at the bottom. Although they are not solely responsible for continence, they are the muscles you engage when you “pull in” to stop yourself urinating. The baby’s head will need to pass through this area as it moves down through your pelvis.

Anal sphincters – These are muscles that surround your anus. They consist of a thin inner muscle, the internal anal sphincter, and a thicker, outer ring of muscle, the external anal sphincter. Squeezing these muscles stops the passage of faeces and flatus (wind).

The four categories of tear

Tears sustained during childbirth are divided into four categories, or “degrees”, starting with the least severe. A first-degree tear is skin deep, often hidden inside the vagina, and will generally heal very well on its own. If it is bleeding, your midwife may suggest she insert a stitch (suture) to close it. Another of the less severe tears that can occur are labial lacerations (also called “grazes”), in which the labia minora (the inner labia) split. Although these are also skin-deep and rarely cause any lasting problems, they can be very sore while they heal and may alter the appearance of your vulva.

A second-degree tear affects the perineum, including the muscles. While this is still likely to heal well on its own and small ones may be left to heal naturally, it is also likely to bleed more and could leave the opening of the vagina without much structure. For this reason, the majority of second-degree tears are repaired. If you birth your baby at home or in a labour room, this is most commonly done using a local anaesthetic and performed minutes after your delivery. The cut made during an episiotomy (see below) is equivalent to a second-degree tear.

Third and Fourth-Degree Tears

Third and fourth-degree tears are more severe perineal injuries and are also called “obstetric anal sphincter injuries”, abbreviated to OASI. As the term implies, this is when the tear gets close enough to the anus to affect the muscles surrounding it. Third-degree tears are broken down into three further categories:

3a – When less than half of the external anal sphincter has torn

3b – When more than half of the external anal sphincter has torn (including if it has torn all the way through).

3c – When all of the external anal sphincter has torn and the internal anal sphincter has also torn.

A fourth degree tear has occurred if both sphincter muscles are completely divided and the thin wall of the end of the bowel (called the rectal mucosa) has been torn too so that there is nothing separating the opening of the vagina with the opening of the rectum (back passage).

If no doctor was present during your birth but a third or fourth-degree tear is suspected by your midwife, she will ask a doctor to come and examine you. This involves separating the skin at the point of the tear so that any torn muscles can be seen and putting a finger into your back passage to assess the thickness of the muscles and any damage that may have occurred. It doesn’t take long but can be very uncomfortable, and you should be offered the use of Entonox (gas and air) if you wish.

If a third or fourth-degree tear is confirmed, your doctor will explain this to you and describe how it will be treated. It’s very important that, once such an injury is suspected, it is thoroughly assessed and repaired, because if it is not mended properly, you are much more likely to experience unpleasant symptoms such as an inability to control your bowels (incontinence of stool and wind). For this reason, these tears are repaired in an operating theatre so that the lighting, bed position and equipment that the doctor needs are all available and to ensure that you are made fully comfortable with an anaesthetic (usually a spinal injection, or extra painkillers through your epidural if you have one). Once in theatre, the repair takes approximately half an hour.

After the repair, the doctor will often give you more detail about precisely how bad the injury was now they have had a chance to perform a full examination; if not, do ask if you would like to know. You will be prescribed some antibiotics to reduce the risk of developing an infection in the area and some stool-softening medication to make it as comfortable as possible to open your bowels over the following weeks as it heals. You should also be referred to a physiotherapist who will advise you on how to help the torn muscles recover, and 2-3 months later you will be offered a clinic appointment to discuss how well you’ve recovered and whether any further treatment is needed.

Preventing severe tears

How to prevent significant perineal tears is still poorly understood. We know you’re somewhat more likely to sustain a serious tear if you’ve had one before, if you have an instrumental delivery, if your baby is particularly big or if this is your first vaginal birth.¹

Various ways to stop these tears from happening have been suggested and tried with very mixed results. Often, one study will suggest a technique works, but another study will seem to disprove it. One suggestion has been to massage your perineum in the week before the birth or use a balloon device (Epi-No) to steadily stretch the opening of the vagina in preparation. However, the best studies we have on these techniques don’t show any benefit.

What position you birth in may have a role to play; women in upright positions or lying on their sides may be less at risk than those in the stereotypical hospital birthing position, lying on their back with their legs in supports.²Having a midwife use a warm compress on your perineum during delivery seems like it might reduce the risk.³

Episiotomy

An episiotomy is a cut made by a midwife or doctors to enlarge the opening of the vagina and make more space for your baby’s head. In other countries the cut may be made straight downwards from the opening of the vagina, but in the UK, if it is performed at all, the cut should be made diagonally downwards, in an 8’o’clock position with respect to the opening of the vagina (a mediolateral episiotomy). You should always be asked for your permission before this happens, and you should be given a local anaesthetic to numb the area beforehand.

Episiotomies have had a stormy history: as more and more women started to give birth in hospitals, they were often performed routinely or for many different invented reasons, almost all of which have now been disproved. However, most studies compare routine episiotomy (performed on everyone) with “selective” or “restricted” episiotomy (performed only if the birth attendant thinks it is necessary). These studies show it is better not to perform episiotomies routinely⁴, but it does not automatically follow that never performing an episiotomy is better still.

Most midwives and obstetricians will use their clinical judgement to decide whether you would benefit from an episiotomy at the point of delivery. If you feel strongly about it, speak to your midwife early in your labour. Because instrumental deliveries come with a higher risk of severe tears, episiotomies are routinely performed when forceps are used and often performed during a vacuum cup delivery. This is to make space for the additional width the instruments add to the baby’s head and to direct any tears away from the anal sphincter muscles.

Recent developments

Although more studies are needed, there are some promising results from attempts to prevent severe tears in Scandinavia.⁵ These consist of several techniques performed together: A slow, steady delivery, a specific form of “hands-on” perineal support from the birth attendant, and an episiotomy, if necessary, once the midwife or doctor has received special training. Using this method, the hospitals involved seem to have halved the number of third and fourth-degree tears they report.

In the UK, these techniques have been adapted and branded the “OASI Care Bundle” and are being piloted at several different hospitals.

Perineal tears FAQs

How often do these tears happen?

The majority of women delivering vaginally for the first time will sustain either a first or second-degree tear. Thankfully, the more serious tears (third and fourth-degree tears) are much less common – somewhere around 6 in 100 and even less (2 in 100) if you’ve had a vaginal delivery without a serious tear before. If you need a forceps delivery, the risk goes up to between 8-12%.

Although it might appear that rates of third and fourth-degree tears are going up nationally, this is likely due to better efforts to recognise and repair them.¹

How many stitches will I have?

First-degree tears and labial lacerations are rarely repaired, and if they are, it may be just one or two small stitches. Second-degree tears are repaired in three stages – first the vaginal tear, then the perineal muscles, then the perineal skin – but using one continuous stitch, so it isn’t really possible to answer the question “how many stitches”!

All the suture material (thread) used to repair perineal trauma dissolves on its own; it doesn’t need to be removed later. The stitches used for third degree tears are still absorbed, but they take longer to give time for the muscles to knit together. It can take 90 days for this type of thread to dissolve, compared to the 7-10 days it takes the material used for smaller tears. These repairs are more complicated; the muscles affected are put back together individually first, and the remaining tear is repaired just like a second-degree tear. Rarely, some of the longer lasting stitches seem to take too long to dissolve and become prickly under the skin; if this happens, they can often be removed by a doctor in a clinic.

Will it hurt?

You should always be offered pain relief while a tear is being repaired. For second-degree tears, this is usually a local anaesthetic into the surrounding area. This means a moment’s sharpness during the injection, but the area should then be numb to pain, although you may still feel some tugging. You can also use Entonox. As the local anaesthetic wears off, you may want some painkillers like paracetamol or ibuprofen.

More severe tears are repaired under spinal anaesthesia in an operating theatre. The doctors will ensure you cannot feel any sharp sensations before starting the repair.

How long will it take to recover?

Most women’s tears will have healed over within 2-3 weeks, although some take longer and some may still feel pain in the area even if it appears to have healed. Any wound first forms a thick red scar, which can be itchy, and over the course of months this will steadily be replaced by a thin silver scar.

It is common to see loose threads falling away from the area during a bath or shower after a week; this does not mean it is coming undone or was not repaired properly. Unfortunately, some women find their tear or cut does come apart and it will then take longer to heal – up to 6 weeks – but the result is usually still good.

How should I care for my perineum after a tear?

Keeping the area clean is important, but this does not mean scrubbing or using soaps. Traditional remedies like lavender oil are sometimes suggested, but these have the potential to irritate the fragile skin. The best bet is a bath or shower with plain water, at least once a day, followed by patting dry with a clean towel. You should wear loose-fitting cotton underwear and change your sanitary pads regularly.

In the first fortnight, many women find it helpful to moisten a maternity pad and put it in the freezer to act as a cold compress while there is still swelling and inflammation. Using a hairdryer on a cool setting is also a good way to ensure the area is dry and encourage any raw areas to heal over.

In the first few days after delivery, even a small tear may really sting when you go to the loo. If available, directing a gentle stream of warm water with a shower head or cup over your vulva as you urinate can make this more comfortable.

If your tear seems to have become unusually painful, bleed heavily or produce green or smelly discharge, it may be infected and you should see a doctor or midwife.

When can I have sex again?

You should wait until your cut or tear has healed and the bleeding has stopped before having sex, although sex can be painful for a while even after this time. Scar tissue is not as stretchy as uninjured skin or muscle, and some steady massage of the area can help to soften this up and help sex to become comfortable again. Only have sex when you feel ready, but if it is still painful at 6-8 weeks after delivery, speak to your doctor. Occasionally, small bridges of skin can form at the bottom of the vaginal opening during the healing process which may need a minor surgical procedure (a Fenton’s procedure) to divide.

Can I give birth vaginally again if I have a severe tear?

The majority of women who suffer third and fourth-degree tears have no symptoms of their tear after one year post-delivery. For those who are still experiencing difficulty with their bowel habit and control, and perhaps need longer courses of physiotherapy, extra tests or rarely even further operations, another vaginal delivery risks repeating the tear and worsening their symptoms again. Unfortunately, recovery is often worse the second time around. It will always be your choice as to how you birth in the future, but these women are likely to be recommended for caesarean section.

Most women who have no symptoms and recover quickly choose to aim for a vaginal delivery in future. This is generally supported by doctors, although it should be noted that if a severe tear occurs again, they too may find recovery takes longer after a second repair and that this time they do experience symptoms.

Main points

• The perineum is the skin and underlying muscles between your vulva and anus. Birth injuries affecting this area are called perineal tears.
• Tears to the perineal area are divided into four degrees of severity.
• First-degree tears are skin deep and often heal on their own, but they may require stitches and can be very sore while they heal.
• Second-degree tears affect the muscles of the perineum and are more likely to bleed and need repairing, which is often done minutes after your delivery.
• Third- and fourth-degree tears are the most severe and also called obstetric anal sphincter injuries (OASI). This is where the tear gets close to the anus and affects the muscles (sphincter) around it.
• A fourth-degree tear is where the sphincter muscles are completely torn and the thin wall of the bowel has been torn too.
• If a tear is suspected, a doctor will come to examine you. The examination can be uncomfortable, and you should be offered pain relief.
• If a third- or fourth-degree tear is not properly repaired, it can lead to incontinence.
• A doctor will need to repair more serious perineal injuries in an operating theatre, where you will be given pain relief. The procedure takes roughly half an hour.
• After the repair, you will likely be prescribed some antibiotics to reduce the risk of infection and some stool-softener so that it’s not too uncomfortable to have a bowel movement during recovery.
• You’re more likely to sustain a severe tear if you’ve had one before, if you have an instrumental delivery, if your baby is particularly big, or if it is your first vaginal birth.
• There tends to be conflicting research on how to prevent perineal tears. Giving birth in an upright position or on your side is thought to help prevent them as well as applying a warm compress to your perineum during delivery.
• An episiotomy is a cut made by a midwife or doctors to enlarge the opening of the vagina and make more space for your baby’s head. This will always be discussed with you before being performed.
• In the UK, the cut is made diagonally downwards. The cut made during an episiotomy is equivalent to a second-degree tear.
• Midwives and obstetricians will use their judgement to decide whether you would benefit from an episiotomy during delivery.
• Episiotomies are often needed during assisted deliveries to make additional space for the instruments.
• Recent developments have pointed to several effective methods of preventing third- and fourth-degree tears. These methods, named the “OASI Care Bundle” are now being piloted at different hospitals in the UK.
• The majority of women delivering for the first time will suffer a first or second-degree tear, but third and fourth-degree tears are far less common.
• The stitches used for more severe tears take longer to dissolve than those used for first and second-degree tears.
• Most women’s tears will heal within 2-3 weeks, although some will take longer.
• During recovery, it’s vital to keep the perineum clean. A bath or shower with plain water is all that’s needed.
• If your tear seems to have become unusually painful, bleed heavily or produce green or smelly discharge, it may be infected and you should see a doctor or midwife.
• If the symptoms of a third or fourth-degree tear have persisted after a year, another vaginal delivery comes with a high risk of worsening those symptoms and a Caesarean section will be offered.

References and further reading

1- I Gurol-Urganci et al. (2013) Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG

2 Elvander et al. (2015) Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births BMC Pregnancy and Childbirth (2015) 15:252

3 – Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672

4 – Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub3

5 – Laine K et al. (2012) Incidence of obstetric anal sphincter injuries after training to protect the perineum. BMJ Open
Royal College of Obstetricians and Gynaecologists (2015) Third and Fourth Degree Tears, Patient Information Leaflet, available via: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-third–or-fourth-degree-tear-during-birth.pdf