Third and Fourth Degree Perineal Tear


 What is an episiotomy?

An episiotomy is a cut made by the doctor during labour through the vaginal wall and  perineum (i.e the area between the vaginal opening and anus) to make more space to deliver the baby.
Figure 1 A normal perineum
What are the different types of perineal tear?
  • First degree tear : small tear involving only the skin-deep tears
  • Second degree tear: deeper tear affecting the muscle of the perineum and skin. An episiotomy is a second degree tear.
Approximately 9 out of 100 women experience a more extensive perineal tear.
  • Third-degree tear: a more extensive tear downwards involving the vaginal wall and perineum down to the anal sphincter which is the muscle that controls the anus.
  • Fourth-degree tear: a more extensive tear involving to anal canal as well as the rectum.
Figure 2 Fourth Degree tear
What are the risk factors for developing third or fourth-degree tear?
  • When you have a difficult birth e.g your baby has shoulder dystocia
  • Your first vaginal birth
  • Large baby
  • Assisted vaginal birth e.g with forceps or ventouse.
Why did I have a third or fourth degree tear? Could it have been prevented?
You may have the above risk factors that have contributed to your perineal tear. Unfortunately, it is not possible to predict and hence prevent the tear. Even an episiotomy does not prevent a third or fourth-degree tear.
What happens after birth if I have a third or fourth-degree tear?
Your doctor will need to suture the tear in the operating theatre with proper lighting and analgesia either epidural or spinal. Afterwards, you will be sent to the post natal ward. You could eat and drink as usual. You should be able to breast feed your baby. You will be given the treatments mentioned below. Once you are able to open your bowels and your sutures have been examined you may be allow to go home. A post-natal appointment will usually be given 6 weeks after delivery. This is to review you perineal sutures, any symptoms or concerns such as sexual intercourse or future delivery.
What treatment will be given?
After the tear is sutured and repaired you will be given several things to help your tear heal properly:
  • Antibiotics for about 5 days to reduce the risk of wound infection as the sutures are very close to the anus.
  • Analgesia to reduce any associated pain.
  • Laxatives to ensure that your stool is not hard.
What should I do at home ?
  • Drink at least 2 litres of water and eat a lot of fibres in your diet (e.g fruit, vegetables, wholemeal bread / pasta) to prevent constipation and regulate your bowel movements.
  • Do pelvic floor exercise as soon as you can after delivery to strengthen your pelvic muscles. In addition, this exercise will help improve blood to your pelvic area and speed up recovery.
What are the long term effects of this?
During recovery you may experience soreness in the perineal area, worried about having sex and future pregnancy. Most women will recover well with no or very minimal symptoms. However, you need to see your doctor if you have the following symptoms.
  • The sutures in your perineum become more painful and smell offensive as there may be some infection.
  • Very rarely, a fistula (a hole develops between your anus and vagina) This may require further surgery.
  • You could not control your bowels or flatus


Can I have a vaginal birth in my future pregnancy?

This issue needs to be discussed with your obstetrician as it depends on a number of factors. An elective caesarean section may be offered to you for future pregnancy if you have persistence symptoms or further operation was required to suture the tear after delivery. However, if you have no symptoms you may elect for a vaginal delivery.
1. A third or fourth-degree tear during childbirth. Royal College of Obstetricians and Gynaecologists, Nov 2008.



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