Third- and fourth-degree perineal tears during childbirth

The purpose of this leaflet resource is to give information to patients about third- and fourth-degree perineal tears during childbirth.

What is a perineal tear during childbirth?

Many women experience a certain number of tears and lacerations during childbirth because the head of the child stretches the vulva and the perineum. Most tears happen in the perineal region between the vaginal opening and the anus.

Small tears affecting only the skin are called first-degree tears. These can heal without treatment. Tears which also affect the muscles of the perineum are referred to as second-degree tears. Stitches are advised in this case as torn perineal muscles do not grow back together on their own.

An episiotomy is a cut made by a midwife or a gynaecologist if the perineal region does not stretch enough to make more space for the baby’s head. During an episiotomy, the same perineal muscles are cut as would be involved in a second-degree tear. Episiotomy wounds require stitches.

What is a third- and fourth-degree perineal tear?

For some women, the tear can be deeper and extend to the muscles that control the anus, i.e. the anal sphincters. In this case the tear is referred to as a third-degree tear. If the tear is even deeper and reaches the mucous membrane of the anus or rectum, it is deemed a fourth-degree tear.

Prevalence of third- and fourth-degree perineal tears

Third- and fourth-degree tears can occur in three out of 100 births. There is usually no way to tell who will experience a third- or fourth-degree tear. Risk factors include:

first time giving birth
extended second stage of labour (the cervix is fully dilated longer than usual)
vacuum or forceps assisted birth
shoulder dystocia (one of the shoulders of the child gets stuck behind the pelvic bone)
the baby is over 4.5 kg
previous third- or fourth-degree tears

Can perineal tears during childbirth be avoided?

Most of the time, third- and fourth-degree perineal tears cannot be avoided because there is no way to predict them. In the event of vacuum and forceps assisted birth, the risk of tearing is higher and an episiotomy can be used to prevent third- and fourth-degree tears. Episiotomies are performed only when needed.

What happens when a third- or fourth-degree tear occurs during childbirth?

If the doctor diagnoses a third- or fourth-degree perineal tear, you may be taken to an operating room to be stitched up. Depending on the situation, spinal, epidural or, in rare cases, general anaesthesia will be used while the tear is repaired. After the operation, a catheter will be positioned into your bladder. This will be taken out once you are able to go to the toilet without assistance. After the operation:

you will be given pain medication;
you will be given anti-inflammatory medicinal products; and
use of laxatives is recommended to make bowel movements easier and less painful.

After the operation, you will be advised on exercises for pelvic floor muscles.

Is breastfeeding permitted?

Yes. All treatments and medicinal products used are suitable for breastfeeding.

What sensations may occur?

After experiencing a tear or having a perineal cut, it is normal to feel pain and tenderness around the perineum for 2-3 weeks, especially when sitting down or walking. You may feel a stinging sensation when urinating. It is a good idea to continue with pain relief at home, e.g. by taking paracetamol with a recommended dose of up to two pills at a time, (i.e. one gram), up to four times a day.

Dissolvable threads are used for stitching tears. These usually disappear within a couple of weeks, by which time the wound will have healed. Sometimes the ends of the threads are visible for longer. You may also observe knots coming off. All of this is normal.

You may experience involuntary passing of wind from the anus or feel a sudden urge to empty your bowels immediately after tearing. If the tear is detected and stitched up immediately after childbirth, most women heal up without any issues.

What will help with the healing process?

To prevent infections, the area of the tear must be kept clean. This means showering at least once per day or using a hand shower and changing your sanitary pads regularly. You should drink at least 1.5 l of liquids every day and eat food that is rich in fibre (fruits, vegetables, whole grain products) to prevent constipation. Laxatives (e.g. lactulose) may be necessary for an extended period of time. Exercises for pelvic floor muscles support the healing process and help restore muscle function. You should start with the exercises as soon as you can. Try not to support your weight on the torn area (i.e. sit) for the first two weeks after being stitched.

When to seek medical advice?

You should turn to your gynaecologist or midwife if:

the torn area becomes swollen and smelly discharge is leaking from the wound – this could be indicative of an infection;
the stitches unravel;
the wound starts bleeding; or
you are unable to control when you pass wind or have bowel movements.

When can you start having sex again?

You can start having sex again when the tears have healed and the bleeding has stopped, provided that you feel ready. It usually takes 6-8 weeks. A small number of women may experience persistent pain during intercourse and sex may be uncomfortable. If this is the case, turn to your doctor.

When to come for a follow-up check-up?

A postpartum check-up is advised two months after birth. The check-up will cover the healing progress of the tear and include questions about any difficulties you may have experienced with bowel or wind control.

Will you be capable of vaginal childbirth in the future?

Most women who have had a third- or fourth-degree tear will have a vaginal (natural) birth in the future. There is a somewhat higher risk of a recurring tear during subsequent births (5-7% of women have another tear). Birth plans are prepared individually.

ITK1058

Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 10.11.2021 (protocol no. 16-21)