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  • Deborah Thomas BPT MCSP MAPPI Chartered Physio

Perineal tears, 3rd & 4th degree tears

In this blog, I will explain about the perineum, and specifically, what happens when in / during labour, tears occur.


I will discuss how as a Pelvic Health Physio I am able to help you, and what considerations there are for future pregnancies, Bowel, Bladder & sexual function, as well as further into the future.


In the UK, a third- or fourth-degree tear (also known as obstetric anal sphincter injury – OASI) occurs in about 3 in 100 women having a vaginal birth. It is more common with a first vaginal birth.


What is the Perineum?

The Perineum is the area between the anus and the vaginal opening. It is a complex structure of soft, connective tissue, comprised of skin, fascia, and muscles. It is rich in blood and nerve supply, as well as oestrogen receptors. It is designed to be flexible, mobile, and responsive to loads like breathing, stretching, exercising, lifting. The rich blood supply helps with healing and recovery. This area is also the attachment for many of the pelvic floor muscles, and their activity, ability to work well, depends, as well as on other factors, on the structure and flexibility of the perineum. This area, during labour, may experience degrees of injury, via spontaneous tears or an episiotomy.


What is an episiotomy?

An episiotomy is a cut made by a healthcare professional through the vaginal wall and perineum. This may be done if your baby needs to be born more quickly or to make more space for your baby to be born. It is possible for an episiotomy to extend and become a deeper tear. An episiotomy is then stitched by dissolvable stitches, and a healing process starts.




What is a perineal tear?

Many women experience tears during childbirth as the baby stretches the vagina and perineum.

  • First-degree tears are small, skin deep tears and usually heal naturally and do not require stitching.

  • Second-degree tears are tears that are deeper and affect the muscle layer of the perineum. These usually require stitches.

  • A third-degree tear is a tear that extends into the muscle that controls the anus (the anal sphincter).

  • If the tear extends further into the lining of the anus or rectum (rectal mucosa) it is known as a fourth-degree tear. All these muscles that are affected, are a part of the ‘pelvic floor muscle’ group.

  • Another rarer situation, which is not a tear, a rectal buttonhole. This occurs when the anal sphincter is not torn, but there is a hole between the back passage and the vagina. This means that wind and faeces may be passed through the vagina instead of via the anus. This is not normal, and if you experience this you should see your healthcare professional urgently.

Third- & fourth-degree tears and rectal buttonholes – will all require suturing (stitching) in the operating theatre.

If you become worried about the way the tear is healing, or if you experience pain, discomfort or any signs of infection – it is important to seek advice from a health care professional like your pelvic health physio or a GP.


3rd & 4th degree tears (OASI)

The risk factors contributing to these are:

  • Forceps delivery

  • Induction of labour - Oxytocin

  • Birth weight of 4kg

  • Persistent OP (occiput posterior) position

  • Epidural

  • Nulliparity (a woman who has never borne a child)

Currently, there is no way to predict a woman experiencing these tears.



What might you experience in the first 6 weeks?

Initially, the area may be sore, especially on walking or sitting. This may affect positions of comfort for feeding your baby – A Pelvic Health Physio can help you look at a variety of solutions and positions. As the skin heals, it may become tighter, and this can cause a pulling-like sensation on the stitches, especially in the first 4-6 weeks. It is important to keep the area clean – with water only! Do not use any products, soaps, or douches on the area. Some people feel benefit from a bath with x3-4 drops of Lavendar oil – this is a natural antiseptic and may aid healing.

Bleeding is normal after labour and should gradually reduce and stop after 6 weeks. If you find that you are bleeding from the stitches, pain & discomfort are worsening – please seek help from a health care provider.


Bowel & Bladder functions:

You will be prescribed laxatives, to soften your stools. It is important to keep drinking plenty of water and eat vegetables and fibre to maintain soft stools. The aim is to avoid constipation and straining during a bowel movement, and to aid this further – your position while sitting on the toilet is important:

Use a foot stool, to elevate your knees, so the angle between your legs and trunk is closer to 45’ rather than 90’ (knees above hips)– this helps ‘lengthen’ the rectum and ease the stools out. Taking some nice, big belly breaths here, helps further – your Pelvic Health Physio can teach you how to do this.

Occasionally, passing urine may sting a little around the stitches. Wash the area with water immediately after to relieve the sting, but make sure you are not holding on to a full bladder or pushing urine out.


Pelvic Floor Muscles, should you exercise them?

As we have found out, the tears have affected the muscles, as well as connective tissue and skin. A natural healing process can take 6-12 weeks for these tissues, and you can help this.

Exercising the pelvic floor muscles will improve blood flow to the area, and this aids healing. It will also help to regain function & coordination of these muscles, as they heal from their injury. Another benefit is improving the quality of the scar tissue that forms.

Research has shown that many people do not perform their pelvic floor exercises correctly:less than one fourth could perform adequate contractions at the time of initial evaluation’ Moen M et al 2009, and ‘common errors performed during attempts to contract the pelvic floor muscles after delivery’ Neels H et al 2018 – therefor, instructions and tuition by a Pelvic Health Physiotherapist will ensure you are working these muscles correctly, and not using ‘compensatory’ strategies or mis-using other muscle groups.


What to expect when getting back to normal activities?

Every woman’s recovery will be slightly different, and what they view as normal daily activities will also differ. Especially returning to high load exercise like running, or cross-fit, will take longer and require a gradual, preparatory programme designed for your specific needs. If you have had a third- or fourth-degree tear, you should avoid strenuous activity or heavy lifting for 4–6 weeks. After 4–6 weeks, you can gradually increase your general activity. A Pelvic Health Physio will do exactly that: following an assessment and establishing goals, you will be instructed and provided with a bespoke training / rehab programme.


Sex

Once your stitches have healed and bleeding has stopped, you can have sex again when it feels right for you and your partner. Sex may be uncomfortable and feel different at first, but the discomfort should not persist. If you continue to experience pain or discomfort, you should raise these concerns with your healthcare professional.


Consequences of OASI

OASI ‘is the major cause of anal incontinence in young women… with a positive correlation with bladder, bowel and sexual dysfunction’ Hoesli J 2019.


Anal incontinence (AI)

AI is defined as ‘involuntary loss of flatus or faeces which becomes a social or hygiene problem’ ICS. It is when you have problems controlling your bowels. Symptoms include sudden, uncontrollable urges to open your bowels and not being able to control passing wind. You may also soil yourself or leak faeces. At 6 months post-natal, less than 5% will experience AI, less than 70% will experience faecal urgency, and 70% will be a-symptomatic.

Most third- or fourth-degree tears heal completely, but some women may experience these symptoms. It is important to highlight such concerns early on, to your Pelvic Health Physio as research has shown that ‘performing individually adapted PFME on a regular basis may reduce postpartum AI symptoms, and that PFME may be offered as a first-line treatment for postpartum AI’ HH Johannessen et al 2016.


Bladder symptoms

As the pelvic floor tissues and muscles support normal bladder function, OASI can lead to some bladder dysfunction, such as stress urinary incontinence, urge urinary incontinence, or mixed incontinence. Research has shown that ‘Urinary incontinence was reported “frequently” or “daily” by 17% at stress, 11% at urge, and 7% at mixed circumstances’ D.Desseauve 2016.


Perineal pain

Pain scores are higher with OASI than other tears. If you experience pain after 6 weeks post-natal – come and see a Pelvic Health Physio – to be assessed and provided with treatment, as it’s better to address this early on.


Sexual dysfunction

Sexual dysfunction can last for several years following an OASI: ‘Even 3 years after sustaining OASIS, up to half of women and many male partners meet the criteria for sexual dysfunction’.


Types of dysfunction can include:

  • Dyspareunia (Complaint of persistent or recurrent pain or discomfort associated with attempted or complete vaginal penetration.)

  • Delay in starting intercourse and reduced sexual activity at 12 months

  • Coital anal incontinence

Your Pelvic Health physio is trained to assess and treat such complaints, in a sensitive, empathic manner.


Looking after your perineum

Perineal massage, either on your own or with your partner, may help you feel more comfortable before you begin having sex again. You may notice your vagina feels drier than usual, particularly if you are breastfeeding. A water-soluble lubricant may be helpful. Your Pelvic Health Physio can teach you how to perform this massage and suggest a variety of lubricants and moisturisers. A new study has demonstrated that ‘At 12 weeks postpartum, the PFPT (pelvic floor physical therapy) group reported a significant improvement in pelvic floor symptoms and bother compared with the standard care group’ Bargen V et al 2020.


Concerns about the future?

Future pregnancies and deliveries can cause concern to women experiencing OASI. It is important to discuss this with your health care team as it’s important you understand the options available and their implications. Some of these will depend on if you are experiencing symptoms or not. The team will include a variety of professionals, including medical and non-medical staff, and you may benefit from some investigations to assess the work & strength of the pelvic tissues.


As I’ve explained, the tissues in the perineum are rich in Oestrogen receptors, and so, at times in our lives, when we have a reduction in oestrogen levels over a prolonged period (prolonged breast feeding, peri & post menopause , and during some treatments for cancer), the tissues and scar tissue that has evolved may become thinner, less flexible and more prone to re injury.


How can a Pelvic Health Physio help you?

As we have seen from all the above, Pelvic Health physiotherapy can provide you with a thorough assessment of bowel, bladder, and sexual function. Both manual therapy techniques, to work on soft tissue and muscles, as well as a bespoke structured exercise and rehab programme, and not forgetting education into all these issues – result in a complete rehab programme following perineal tears.

Whenever you feel the time is right for you – contact me, it is never too late for us to help you.

I work closely with other professionals who are able to provide further emotional and sexual counselling.


References:

  1. Hølmo Johannessen H, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 2017;124:686–694. DOI: 10.1111/1471-0528.14145

  2. Moen, M.D., Noone, M.B., Vassallo, B.J. et al. Pelvic floor muscle function in women presenting with pelvic floor disorders. Int Urogynecol J 20, 843–846 (2009). https://doi.org/10.1007/s00192-009-0853-6

  3. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. European Journal of Obstetrics & Gynecology and Reproductive Biology. Volume 220, January 2018, Pages 113-117 https://doi.org/10.1016/j.ejogrb.2017.11.019

  4. RCOG: Care of a third- or fourth-degree tear that occurred during childbirth (also known as obstetric anal sphincter injury – OASI) - October 2019

  5. ICS: INTERNATIONAL CONTINENCE SOCIETY https://www.ics.org/

  6. Von Bargen, Emily DO; Haviland, Miriam J. MSPH; Chang, Olivia H. MD, MPH; McKinney, Jessica PT, MS; Hacker, Michele R. ScD; Elkadry, Eman MD :Evaluation of Postpartum Pelvic Floor Physical Therapy on Obstetrical Anal Sphincter Injury, Female Pelvic Medicine & Reconstructive Surgery: April 9, 2020 - Volume Publish Ahead of Print - Issue - doi: 10.1097/SPV.0000000000000849

  7. Long-Term Sexual Function After Obstetric Anal Sphincter Injuries

O'Shea, Michele S. MD, MPH; Lewicky-Gaupp, Christina MD; Gossett, Dana R. MD, MSCI. Female Pelvic Medicine & Reconstructive Surgery: 3/4 2018 - Volume 24 - Issue 2 - p 82-86

doi: 10.1097/SPV.0000000000000466

  1. Joris, F., Hoesli, I., Kind, A. et al. Obstetrical and epidemiological factors influence the severity of anal incontinence after obstetric anal sphincter injury. BMC Pregnancy Childbirth 19, 94 (2019). https://doi.org/10.1186/s12884-019-2238-2

  2. D.Desseauve, S.Proust, C.Carlier-Guerin, C.Rutten, F.Pierre,X. Fritel Evaluation of long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI) at least one year after delivery: A retrospective cohort study of 159 cases. Gynécologie Obstétrique & Fertilité Volume 44, Issues 7–8, July–August 2016, Pages 385-390

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