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Third and Fourth Degree Perineal Tears

In this Health Topic

This is a type of tear sustained during vaginal childbirth which involves the tissue of the vagina, the perineum (the area between the vagina and the anus), 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.

Approximately 1-3% of women who deliver vaginally will experience third and fourth degree tears. Factors such as having a ventouse or forceps delivery, having a baby weighing more than 4 kg 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.

Perineal tear

Third and fourth degree tears are repaired in the operating theatre, usually under a spinal/epidural anesthetic. You will be given antibiotics in the operating theatre and the layers of the tear will be stitched back together. The stitches will dissolve by themselves. A catheter will be left in your bladder until the anesthetic has worn off.

You will remain in the hospital for 1-2 days following the repair operation. After sustaining a third/fourth degree tear, antibiotic treatment for a week is recommended. Stool softeners and laxatives are recommended for two weeks to make bowel movements easier. You will also be given pain medication to take home. All of the medications that you will be given are safe to take while breastfeeding. You will be seen by a physiotherapist. Regular pelvic floor exercises are recommended throughout the post-natal period.

You will be offered an appointment with a doctor 8 to 10 weeks following your delivery. At this appointment you will be asked 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 specialized internal scan of the entrance to the anus. This allows your doctor to confirm that the anal muscles have healed together adequately. The scan may feel slightly uncomfortable but is not painful.

Studies have shown the majority of women (80%) recover well and have no problems at the 3-year follow up after repair surgery. A small number of women may have problems at follow up such as urgency (being unable to hang on and having to rush to the toiled to open the bowels) or incontinence (being unable to control bowel movements or gas). 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.

The overall risk of having another third/fourth degree tear with future deliveries is 5%. Aiming for a normal delivery in any future pregnancies is generally recommended if you do not have any bowel symptoms and the muscle appears to be well healed. However, any woman who has had a third/fourth degree tear ideally should be seen by a doctor in the antenatal clinic in subsequent pregnancies to discuss options.