Perineal Tears

Woman's Physiotherapy Advice

Congratulations on the birth of your baby! It is common for the perineum (area between the vagina and back passage) to tear during vaginal delivery. Most often the tear will require stitches and heal well. 3rd or 4th degree tears are considered more severe and will require more care and healing time.

What is a 3rd or 4th degree tear?

If a woman tears during a vaginal delivery it commonly involves the posterior vaginal wall, extending towards the anus or back passage. The tears are classified according to what structures are damaged. Your Obstetrician and/or Midwife will explain the classification of your tear.

Healing of the tissue can take up to 6 months. The first 6 weeks are particularly important for muscle and soft tissue recovery. Your Doctor and Midwife will recommend medication to help with pain management and constipation. In addition there are many things you can do and avoid to improve your recovery and reduce complications.

Grades of taering

1st degree: injury to the perineal skin 2nd degree: injury to the perineal skin and muscles 3rd degree: injury to the skin, muscles and anal sphincter complex

3a: less than 50% of the external anal sphincter torn

3b: more than 50% of the external anal sphincter torn

3c: injury to the external and internal anal sphincter 4th degree: injury to the external and internal anal sphincter and anal mucosa

Rest - lie down regularly (rather than rest in a seated position) for the first 2 weeks after the birth. This will elevate your pelvis and abdominal area. Elevation will reduce swelling and improve healing. Do your best to get as much sleep as possible as this is the best way to promote healing for your whole body. Learn to feed lying on your side to reduce the time you spend sitting. If you feel pain, pressure of discomfort in your perineum lie down and rest!
For the first 3 days aim for 30 minutes of rest every 2 hours. From 3 days - 6 weeks gradually reduce to approximately 1-2 hours of rest lying down per day.

Getting up from bed - roll onto your side rather than use a sit up motion:

Ice - apply an ice pack (or condom filled to 1/3rd with frozen water) to the perineum on the day you give birth. Place the ice pack under the maternity pad. Do not apply ice directly to the skin. Apply the ice for 20mins every 2 hours whilst you are awake for a minimum of the first 3 days. Continue to apply ice if you experience pain, pressure or discomfort for the next 2 weeks. If you continue to experience pain and swelling, consult your healthcare professional.

Compression - wear firm compression, i.e. shapewear to provide additional perineal and abdominal support whilst you are awake for at least 8 weeks. See the DRAM Recovery handout

Exercise - your pelvic floor muscles have been damaged if you have sustained a 3rd or 4th degree tear. See the Pelvic Floor Muscle Exercises handout for instructions on how to do pelvic floor exercises.

Heavy lifting - if the movement or activity causes you to hold your breath, it is TOO hard! Post birth, you shouldn’t lift anything heavier than your baby. Avoid tasks such as vacuuming, making beds, lifting toddlers, washing baskets and shopping bags) and prolonged standing or sitting. Ask for help with these tasks whenever possible.

Sexual intercourse - should be avoided at least until your 6 week appointment with your doctor. Even if your doctor gives you the all clear, you may still need more time to recover. Working with your Women's Health Physiotherapist can help you return to enjoying intimacy.

Constipation and straining on the toilet- refer to Healthy Bladder and Bowel handout

High load exercise - sit ups, crunches, planks, running, standing weight lifting and jumping movements. If the exercise causes you to hold your breath, it is TOO hard!

Activities and movements that cause lower back, pelvic, vaginal pain and/ or bulging - see your Women's Health Physiotherapist for treatment.

What problems can occur with 3rd & 4th degree tears?

Although long term problems can occur, women should be reassured that 60-80% of women have no symptoms 12 months after a 3rd or 4th degree tear.

Problems include

• Bowel urgency, flatal (gas) and bowel incontinence
• Pain during sex and perineal pain
• Urinary incontinence
• Pelvic floor muscle weakness It is important to note that symptoms can arise in the fifth and sixth decade of a woman’s life due to the cumulative effects of menopause and ageing.

When to return to exercise

The safest way to return to movement and exercise is to consult a women’s health physiotherapist for a 4 week post childbirth review. Refer to the Returning to Exercise After Birth Handout for general information about returning to exercise post birth.

When to return to exercise intercourse

Even though your doctor may have given you the 'all clear' at 6 weeks postnatal, intercourse may be uncomfortable, or even painful.

Refer to the Returning to Intimacy After Birth Handout

Well done!

Knowing your own body, and giving it the time to heal is a big step towards empowerment and taking control of your recovery.

Disclaimer

Women are encouraged to discuss their health needs with a health practitioner. If you have concerns about your health, you should seek advice from your health care provider or if you require urgent care you should go to the nearest hospital Emergency Department.

Remember your 4 week review with your physiotherapist to asses & monitor your:

• Pelvic floor recovery

• C – section incision

• Exercises to close the abdominal separation

• Returning to exercise after birth