Long before all this, back in the hazy rose-tinted days of NCT classes I didn't really give much thought to what could happen when I gave birth. I'd done the class where we covered all the different options - being induced, sweeps, caesareans, forceps delivery etc. I kept thinking "I won't plan my labour too much as anything can happen" but in reality I didn't think things would turn out this way.
Maybe it was best that I was in the dark. Certainly my friends who don't yet have children have pulled some faces when I've explained what happened to me. I hope I haven't put them off.
It wasn't until after the birth that I learnt a lot about tears. Who knew there were different degrees of tear? Thankfully, my consultant actually gave me a handout to help explain it and for that I was very grateful. So here is the information care of that handout.
What is a third or fourth degree tear?
This is a type of tear sustained during vaginal childbirth which involves the tissues of the vagina, the perineum and the structures around the anus. If the tear involves the muscles around the anus, it is called a third degree tear; if it also involves the tissue on the inside of the anus, it is called a fourth degree tear.
Third and fourth degree tears happen to roughly 1 to 3% of women having a baby vaginally. Factors such as having a venthouse or forceps delivery, having a baby weighing more than 8lbs or having a baby that is "back to back" at delivery increase the risk that you may have a third or fourth degree tear. Often there is no particular reason identified.
How is a third or fourth degree tear treated?
Third and fourth degree tears are repaired in the operation theatre usually under a spinal/epidural anaesthetic. You will be given antibiotics in the operating theatre and the layers of the tear will be stitched back together. All of the stitches used will dissolve by themselves. A catheter tube will be left in your bladder until the anaesthetic has worn off.
What will happen afterwards?
You should not need to be in hospital for more than 1 or 2 days. After sustaining a third/fourth degree tear, we recommend treatment for a week with antibiotic tablets, plus stool softeners and laxatives for a minimum of two weeks to make it easier for you to open your bowels. You will also be given pain relief to take home. All of the medications that you will be given are safe to be taken when breastfeeding. You will be seen by a physiotherapist, and we recommend that you perform regular pelvic floor exercises during the postnatal period.
You will be offered an appointment with a doctor 8 to 10 weeks following your delivery. At this appointment, we will ask you some questions about your delivery and any bowel symptoms that you might have. You will be examined to make sure that the perineum has healed properly. You will also have the opportunity to discuss your delivery and ask any questions.
You may also be offered a specialised internal scan of the entrance to the back passage, which will allow us to confirm that the anal muscles have healed together adequately. The scan may feel slightly uncomfortable but is not painful.
What are the long term effects of a third/fourth degree tear?
The majority of women (80%) recover well and have no problems at the three year point. A small number of women may have problems at follow up with urgency (being unable to hang on and having to rush to the toilet to open the bowels) or being unable to control bowel motions or wind. Most of the time, these problems will settle with measures such as physiotherapy. A small proportion of women will need further treatment for bowel disturbances.
What will happen with future pregnancies?
The overall risk of having another third/fourth degree tear is 5%.
If you do not have any bowel symptoms and the muscle appears to be well healed, we would generally recommend aiming for a normal delivery in any future pregnancies. However, any woman who has had a third/fourth degree tear is seen by a doctor in the antenatal clinic in subsequent pregnancies to discuss options.
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