UK Midwifery Archives
These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
- Repairing the tear
- Why did it happen?
- What about the next birth? Elective caesarean?
- Fenton’s Procedure, and elective episiotomy?
- Links to other sources of information
- Abstracts on third-degree tears
Feeling a bit fed up tonight. Looked after a woman today, 1st baby, came in fully dilated, went on all fours, did as her urge inclined her to in the way of pushing. Head coming out steadily, then big push and head sort of a third of the way out. I said just a small push now, wham bam baby, head and body caught in one push and ? third degree tear. GUILT, GUILT.
Asked for the labour suite manager to review the tear as it looked like just the skin of the anus involved. But got a co-ordinator who seemed to think I was asking whether it needed suturing at all!! When I pointed out I was querying 3rd degree, to my horror an SHO (relatively junior doctor) was sent in. I asked her discreetly if she felt she was up to seeing if it was a 3rd degree and she looked sheepish and carried on to look. After furtling, she asked for the senior registrar. I am so cross with myself that I didn’t insist on a senior to start with, to prevent so much furtling for the woman.
Apparently it was a third degree tear, and was sutured in theatre under spinal. There is an issue and has been for a while between doctors and midwives re. third degree tears and I and others have felt it is under-reported from obstetricians and over-reported from midwives births. Sad but true.
Anyway hopefully the woman was sutured well, and that is what is important in the end, but she had to wait 3 hours to be sutured.
At the hospital I work in third degree tears are now sutured by general surgeons, not obstericians, as this apparently gives a better result in the long term. The downside is the woman is not sutured until the morning when the theatre list starts, so if she happens to have given birth at 1800 she will wait till 0900 the next day. Of course she will be nil by mouth as she is going to theatre in addition to probably having had nothing to eat all day while in labour!
I was with a woman last week who had a third degree tear. She had to wait 3 hours to go to the obstetric theatre for a spinal and suturing. She was uncomfortable, bleeding from the wound and dreading the thought of waiting 12 hours or perhaps even more if it is not given high priority (is it?) – sounds pretty grim.
You don’t often get to know long term outcomes but the women (who have such experiences) do seem to be OK postnatally on the ward. They also have a strict regime of cocodamol 4hrly for three days to “bung them up” while they heal, then lactulose for 5 days as well as antibiotic cover. They are seen by the surgeon on the postnatal ward and there is trouble if his drug regime has not been adhered to. He prefers them to stay in until they have had their bowels open to ensure there are no problems.
As for having to wait to be sutured, the few women I have cared for don’t seem to mind (or they don’t complain to me). They often sleep well in the relatively more peaceful atmosphere on labour ward as compared to the postnatal ward. If the tear is bleeding then sutures are put in to achieve haemastasis while waiting and they are given pain relief if needed. It amazes me that some women can quite happily wander along to the toilet and get up and change their babies etc with this *wound*.
It is given priority in the morning and they are placed first on the list. Depending on how busy their theatre list is, sometimes the surgeons come to labour ward, but more often the woman goes to main theatre.
I spoke to a woman who had a 4th degree tear which required revision of the repair a few months after the birth. When I asked her, she said she would not consider a c-section for a subsequent birth. However, it is important to note that she had her repair and the revision done under local anesthesia. All is well, thanks to an understanding consultant.
More women and consultants (and midwives) need to consider alternatives to general anesthesia for repair of these tears. The practice at our hospital is a pudendal block with the repair done in the birthing room. I had another client who was diagnosed with an molar pregnancy at 20 weeks. Her past history included sexual abuse. Her procedure was done under epidural and I was allowed to be with her for support.
I seem to have had a run of negative labour ward experiences – emergency CSs, induction for IUD – and *two* third degree tears…
Both with woman in all-fours position.
First instance (2 months ago): a very unyielding perineum. On reflection, I should have asked her to ‘turn over’ – since I’ve sometimes found (oddly enough) that left lateral or semi-recumbent relaxes a perineum that has been tight in all-fours. But I didn’t. Third degree tear sutured under spinal in theatre.
Second instance (this week): all lovely and normal, calm mother, second stage progressing well. Controlled birth of baby’s head – sudden gush of blood – but perineal skin stretched beautifully and stayed intact. Later, expected to find small vaginal wall tear – instead found deep tear in wall. Third degree tear sutured under spinal in theatre. (Another midwife suggested that maybe the baby’s shoulder or elbow caught in a smallish tear and enlarged it…)
First: I’ve discussed these experiences with both my supervisor and manager. Both gave me warm support and understanding. In spite of everything, I work in a good place!
Second: Although I’m aware of considerable anecdotal evidence that perineal trauma is less likely if the mother adopts an all-fours position for birth, I’m wondering if there is any research-based evidence. I seem to recall that a MIDIRS search a year or so ago drew a blank, but I’m wondering if I’ve missed anything. Anybody got any ideas?
Third: What has been the experience of other members of this list regarding birth in all-fours and trauma?
Most of our women give birth kneeling or on all-fours. I think my own observation would lead me to suggest that there is a more frequent occurrence of labial grazes and small tears, and probably no clear evidence of any difference to perineal or vaginal tears. If the perineum is intact and yet there is a vaginal tear it might well suggest the baby came hand-up.
But another important factor to take into account here (and I think it often gets overlooked in hospital, because hospital midwives do not meet the labouring woman before admission) is the woman’s nutritional status and general level of fitness and energy. The strength of surface and connective tissue layers, and the elasticity of muscle itself, is very much bound up with health, and specifically diet which promotes strong and elastic tissue, exercise which helps to keep muscles toned and responsive, and energy levels and blood biochemistry which all affects the vasculature (ain’t that a good word, I always think).
Does any of this ring a bell?
My partner-midwife and I spend quite a time talking about whether this woman or that woman might have avoided a tear. We always seem to end up saying to each other: “Some women tear, others don’t. You can’t win ’em all.”
Feeling very depressed today. Looked after a young couple yesterday having their first baby (both 17). She came in with a history of contractions 1in 15 lasting 10-20 seconds (wouldn’t be put off when she phoned) and turned out to be 7-8 cms dilated membranes bulging. She mobilised for a bit and had the odd puff on the entenox every now and then. Then she lay down on her side and went to sleep and I am ashamed to say I actually began to doubt my VE because she was so relaxed. She suddenly sat up at 1745 and said she wanted to push and at 1753 her waters went. Things progressed well and 20 mins later presenting part was advancing rapidly.
It was at this point that despite my trying to talk her through it she really lost it. She was screaming at the top of her voice and pushing like mad cos she just wanted it out. I couldn’t get her to listen to me or try the entonox.
Anyway she gave birth within 5 mins of this, girl 8lbs 12ozs. But on inspecting the perineum I found an extensive tear that extended to the anus. The Reg came to check it and pronounced a third degree tear where the external sphincter had torn through completely.
I feel that maybe if I’d got her to listen to me it might not have happened although I also know that you can’t always prevent tears from happening. Everyone at work was very supportive and regaled me with stories of their 3rd degree tears but I still felt awful.
The woman herself was sitting in bed breastfeeding and eating fish and chips 1 hour after delivery still not needing pain relief… I have promised to go and see her on New Years day when I am next in so I can see how she is.
I would like to let you know of an American anamoly that took me awhile to figure out. It has to do with perineal tears in birth. It was my experience working in the UK that third degree tears were rare things and something to be professionally embarrassed over. Not here.
Here there are not 3 degrees of tearing but 4. Why 4? I couldn’t figure it out for awhile. But eventually the penny dropped. What we would call third degree tears are so common here that they have divided them into 2 categories. And a very high percentage of these tears are following episiotomy. It is midline, not medio-lateral but I doubt the placement of the episiotomy is the culprit. OBs deliver most of the babies here and they did not have the benefit of being taught by midwives. The medical school adage here is: see one, do one, teach one. And that often isn’t far off from the truth.
So second stage is an uncontrolled explosion, as far as the perineum is concerned. All women are in lithotomy with feet in stirrups. Episiotomy is not uncommon, the mother is told to “Push hard!”. The best part is that the training on the mechanism of birth does NOT include the concept of internal rotation of head or shoulders. Therefore once the head is born, the body should come out IMMEDIATELY. And we know (here) how dangerous second stage is for the baby, so the doctor starts pulling on the head when that doesn’t happen. Which we know is most of the time. So what happens next? Well, America has the most phenomenally high incidence of shoulder dystocia accompanied by serious tears.
So as bad as things are in the UK, and I don’t minimise that for a second, just remember you could be practising in amerika.
Melody – midwife in the USA
I am currently caring for a woman who had a third degree tear at her first birth in 1999. She is now 33 weeks pregnant with her second child and has been told that she should have an elective caesarean section. She has had some faecal incontinence since her last birth, but is very scared of having a section.
Has anyone cared for a woman with these problems, and is a elective section always the only answer? I have been searching the literature, but I am not getting very far!
In my opinion the lady would be a fool to choose an elective LSCS without long and careful consideration. She may not even get a nick this time!!! Yet a LSCS will DEFINITELY cut her open with all its associated risks!!
Why did this happen the first time is always a good starting point……was she on her back? did she have an episiotomy? Both these increase the risk of third degree tears.
I have cared for women with this scenario and they need lots of psychological care but also the correct information. I do not believe there is any evidence to support the widely held view that they are more likely to tear or would be better off with episiotomies or LSCS.
Better that she labours gently and physiologically, is given the type of care that promotes belief in her body and when the time comes to get into a position she feels comfortable in…..for most women this is all fours and head down all fours will help with gentle stretching of the perineum. She could talk to women who have been in a similar situation. If that is not possible as you or she know no-one you can contact me off line for further help.
Virginia Independent Midwife
You could also advise perineal massage using wheatgerm oil (available from Boots) in the weeks leading up to the birth.
Perinal massage is very good. I also would advise to let the mother soak in the bath tub during labor – softens the tissue very much and the mother should exercise squatting (tailor position) and hold her own knees good spread while pushing.
I suggest that hands and knees or left lateral for the birth, if the woman feels comfortable in either position. I would strongly advise against dorsal or standing positions and I would do a lot of work with her about blowing and letting the baby s-l-i-d-e out s-l-ow-l-y .
Mary Cronk, Independent Midwife
I am bemused by people suggesting elective CS as a way to prevent perineal damage. They are suggesting that you go for guaranteed severe lacerations on your abdomen, cutting through skin and muscle and increasing risks of all sorts of complications (see ‘risks of caesarean sections‘) – instead of having a chance of lacerations on your perineum. Swapping the possibility of one adverse outcome, for the certainty of another.
On the other hand, not having experienced a third-degree tear, I suppose I am not in a position to guess how much risk and discomfort it is worth going through to avoid another one. It certainly seems to be thebête noir of British obstetrics; I wonder if women who have had a third degree tear and a caesarean section have any comments on comparing the two? Did your obstetrician discuss any other ways of reducing the risks of a third degree tear, such as avoiding forceful pushing in the third stage, and trying to ‘breathe’ the baby out?
The research strongly suggests that third degree tears are more likely with an episiotomy than without – as they tend to occur when an episiotomy extends. However, I suspect that this may be based on midline episiotomies, common in the USA, and not mediolateral episiotomies which are done here -which go out to the side. But mediolateral episiotomies are apparently more painful, take longer to heal, and are more prone to complications than midline. The one saving grace of mediolateral episiotomies is that they are supposedly less likely to extend into a third degree tear, as they take the damage out to the thicker muscle at the side, rather than down the ‘line of least resistance’, the midline of the perineum.
The following quote is from ‘A Guide to Effective Care in Pregnancy and Childbirth’, by Enkin, Keirse et al. It is comparing liberal versus restricted use of episiotomy, so is perhaps of limited relevance in this case – but still interesting in its conclusions regarding mediolateral versus midline episiotomy:
“There is no evidence to support the postulated benefits of liberal use of episiotomy. Controlled trials show that restricted use of episiotomy (as opposed to liberal use) results in less risk of posterior perineal trauma, less need for suturing perineal trauma, fewer healing complications, and no differences in the risk of severe vaginal or perineal trauma, postpartum perineal pain, dyspareunia, or urinary incontinence. The only disadvantage shown in the restrictive use of episiotomy is an increased risk of anterior perineal trauma. These results are similar for both mediolateral and midline episiotomy.”
“….The question of whether midwline episiotomy results in a better outcome than mediolateral episiotomy has not been satisfactorily answered. The suggested advantages of performing a midline episiotomy are: better healing with improved appearance of the scar, and better future sexual function. Thos not favoring the use of the midline method point out that it is associated with higher rates of extension of the episiotomy and consequently an increased risk of serious perineal trauma. In one trial, midline episiotomy was associated with less bruising, more third-degree perineal lacerations, and earlier resumption of sexual intercourse, but neither this nor a subsequent trial was methodologically sound enough to draw reliable conslusions.” (p295-6, 3rd Edition)
More on episiotomy and third-degree tears in Obstetric Myths Versus Research Realities, by Henci Goer – chapter on episiotomy, summarising the literature, with full refs. (http://www.cma.ca/cmaj/letonlin/1997/l970474.htm) –
Reviewing Thorp JM and Bowes WA. Episiotomy: Can its routine use be defended? Am J Obstet Gynecol 1989;160(5 Pt 1):1027-1030 she notes that “No study found that midline or mediolateral episiotomy reduced the incidence of third- or fourth-degree tears. ” 
Anther very relevant study: Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair , by AH SUltan [2, abstracts], found that
“Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy”.
I don’t know what a ‘posterolateral’ episiotomy is, but it sounds as if it is like midline – to the side and backwards?
See Links for more references on episiotomy and third-degree tears.
Can anyone give me any information on how to prevent a subseqent 3d tear? The consultant suggested I have an elective Caesarean (which I don’t want) or an elective episiotomy. I am now 37 weeks – had Hyperemesis for the first 4 months and have had SPD for the last 5 months – I have to use elbow crutches to walk…
I have a child of 7 years (born Nov 93). During labour I had a great 1st stage with no pain relief, started at 8am and got to hospital at 1pm where I was 8cm dilated. I did not dilate any more at the hospital and at around 6pm the midwife ruptured the membranes. After this I was put in Lithothmy and had overwhelming desire to push which I could not control. The head soon crowned and the baby was born quickly. I felt fine but it turned out I had a third degree tear involving the anal sphinter muscle.
.. I started getting regular contracts at 8am, went to hospital at 1.30pm where I was 8cm dilated. At around 6/7pm the midwife had me get up on the bed and lie in a semi-sitting position (more down than up) with legs apart (not 100% sure about this time but speaking to my birth partner this is what we came up with)to perform ARM. After the ARM the contractions became fast and very strong then all pain stopped (by the way I had no pain relief at all during the first stage as I found I could cope OK).
The second stage began and it felt like something had jumped into my body and was controlling it. I had absolutely no control over the pushing at all and after 2 of these sensations the head crowned. With the next sensation the head and body came out and that was it! She was 8lbs 1oz and fine.
I had no coaching in labour. It was in this semi lying/sitting position that I gave birth. No episiotomy was suggested (I had specified that I did not want one however!).
I had no problem with the tear and was sutured in the delivery room using gas and air. No one explained the possibility of future problems or even what a 3rd degree tear was. The only problem I did have was a few months after when I continued to get an offensive discharge and found that a peice of tissue from my vagina had been left out – after pointing this out to GPs etc I was able to have it repaired under a local in hospital which was fine and all healed very well – no incontinence problems at all!
The whole thing finally healed up (with no real stress incontinence) and I forgot about it until I had to see a consultant with this pregnancy at about 16 weeks (due to the previous tear and hyperemesis). This was when I learned the hospital recommended an elective caesarian after such a tear as I could become incontinent in both bladder and anus.
At the time I was just surprised and didn’t know the first thing about C-Sections – now I have more information and feel that I would not like a caesarian if I could possibily avoid it.
Can anyone help with advice, previous experience etc? My main worry is that this uncontrollable pushing will happen again but even quicker this time – any advice on how to control it (would gas and air help?) would be most appreciated.
See page on Diastasis Pubis Symphysis / Symphysis Pubis Dysfunction for more on SPD
I believe all fours is a good position for birth with SPD (although SPD sufferers need to find their own position really) and might minimise any tear that does occur.
Remember though, an elective episiotomy does NOT neccessarily reduce the chances of extension, that is to say an episiotomy can extend, just as a tear might. Also, there is a strong school of thought that tears heal better than episiotomies anyway and women have less pain and discomfort (this is backed by research).
I am so upset to hear that you have been advised to have a caesarian because seven years ago after a rapid delivery you had a third degree tear. However you have no problems with incontinence of either type. Why is it that obstetricians are so obsessed with urinary incontinence or anal problems if mothers are allowed to have vaginal births?
My belief is that physiologically incontinence may be more likely to occur when the head during the second stage may sit for a long time in the vagina, damaging the muscles. I am finding this quite difficult to describe, I hope you can understand what I mean.
The perineum prior to birth is thick, and during a controlled descent it will stretch and enlarge until it is almost paper-thin and at this point it should allow the babies head to slip through. A small tear is not a problem and normally will heal well without intervention. The important thing is to try and control the descent of the head, as I always said, gentle pushes.
The importance of preparing the perineum during the antenatal period and preparing the mother may well help. Previous scar tissue and the whole perineum should also be massaged with a suitable oil and gently stretched. This cannot guarantee that you will not tear but it should help. The state of your perineum needs to be assessed antenatally. If you have rather friable tissue or a very rigid perineum this could be a contraindication to a normal delivery.
I do so hope you have the birth you want and please enjoy your pregnancy and don’t let this take away any of the joys of getting ready for your birth.
The suggestion of an elective Caesarean to prevent a third degree tear is, I feel, totally outrageous. Why does your consultant think that this major abdominal operation will be less risky to you or your baby? Perhaps you could ask her/him?
I don’t think there is any need for an elective episiotomy either – my practice with women who have had a previous third degree tear is to observe and plan my management of the situation as it occurs – ie, keep a watchful eye on the perineum during second stage. I do not doom women into having unnecessary cuts and I’m sure midwives on this list will nod in agreement. I have not had a bad outcome yet and often have intact perineums. At worst, a second degree tear requiring minimal or no sutures.
Speak to your midwife – surely if you are left to labour and birth in the place and position of your choice, you will birth your baby beautifully with no surgical interference.
Sorry – I’m not great with any research references but I would like to see your consultant’s research which advocates abdominal surgery or perineal mutilation to prevent a tear!!
No wonder there was such damage pushing in such a way. Following ARM there was rapid descent of the head, not allowing for physiological stretching and up in lithotomy – she was pushing through her perineum!!!
There is no evidence that there will be a repetition and the likelihood is that she will not tear at all.
I had a client with the same story a while back and I had various professionals offering advice about what I “should” do ranging from section to elective episiotomy.
What the woman decided was she would push with her head down whilst on all fours if the baby was in a hurry…………. as it turned out she was standing and the perineum stretched nicely with no damage!!!!
Read the story of Alison on my website www.babyscoming.co.uk.
I would ask for evidence that section is the best way forward before making her decision.
Virginia Howes, Independent Midwife
I would just suggest a confident, experienced midwife! Also, an exaggerated knee chest position for second stage.
I looked into this with a woman in the same circumstances several years ago. She had some incontinence of flatus and occasional leeking/staining from a bowel movement and was told that another third-degree tear would make it worse. She did have nerve studies done and was told that the amount of posible damage following another third degree tear could depend on the skill of the repairer.
So the advice was a bit if and but… We discussed all the gentle birthing options and my client ummed and ahhed about a home water birth but in the end opted for another Caesarean Operation, as there was no way I (or anyone) could guantee not needing forceps or Ventouse nect time. 5-6 years on she is still uncertain if she made the right decision. You can only go with your feelings after finding out as much as you can. All the best.
It may depend upon the thickness of the muscle layer between the rectum and the vagina. I have a woman on my caseload at the moment having a c/section because the muscle is paper thin.
Good luck. As well as trying to breathe the baby out s-l-o-w-l-y try to think “saggy baggy softy fanny”. (you can get it back to nice firm bum after) My other suggestion is staying off your back. In the second stage left-lateral or hands and knees, whichever feels right for you, and don’t be afraid to change if your body wants to. Lots and lots of positive thoughts.
Have you thought about birth positions related to slowing the birth? Knee-to-chest or left lateral with a pillow under the hips? Trying to reverse gravity and focussing on breathing, not pushing, so it is just the uterus doing the pushing. Try a yoga tape for breath awareness.
Chris, midwife and yoga for pregnancy teacher.
A friend of mine had a third degree tear with her first baby – she felt she had been asked to push when she had no urge to, had the midwife from hell, etc etc.
Having decided what went wrong, she determined to have a home birth the second time.
Her allocated consultant washed his hands of her – “Well, if you want to end up incontinent of faeces, that’s your problem”…
The labour was progressing well; the midwife asked if she could examine my friend – particularly as she was concerned about her perineum. My friend did not want to push, but wanted to breathe the baby out slowly (just as Mary recommended). Her partner was stood at the side of the bed – saying “breathe, breathe”, and hyperventilating. The midwife was asking my friend to put her bottom on the bed so she could actually examine her. The partner passes out and his head hits the floor. My friend is distracted by this event and relaxes her tail end – the baby crowns and is born oh so smoothly – a girl to follow a boy. No tear, no episiotomy. A story I’ve always cherished.
Update from Jane:
Hi – My initial query was about a vaginal birth after a 3rd degree tear and with PSD. I got lots of great information and I just thought I would update you about the birth.
I went 9 days overdue and after a painless sweep went into labour starting at 12.30pm on Saturday – going into hospital at 4.30 pm and delivering at 6.30pm (1/2 hour of pushing on all fours on the bed over a beanbag – I tried the left lateral but found it really uncomfortable. Delivered a baby girl (Asha) 8lbs 10oz!! she also came out with her hands by her head! – All I had was a small tear – I had 2 stitches which came out later that night. So no major abdominal surgery!!
Does anyone know of the chance of having a susequent third degree tear in a second pregnancy (in a woman who had a third degree tear the first time with a ventouse). The MIDIRS search provided little insight, quoting risk factors of having a third degree tears as primips, instrumental deliveries and episiotomies. No mention of previous third degree tears. I will advise the woman that an all fours or left lateral position may offer some protective effect. What about a waterbirth?? Any thoughts?
I attended a client who had previously had an extended episiotomy 3rd degree that had made life really horrible (understatement).
She booked at 34 weeks and began daily perineal massage and we talked about her birthing baby into her hands so she controlled her pushing and perineum stretching. (planned hospital birth)
She birthed her baby s-l-o-w-l-y holding her perineum and baby’s advancing head in the birthing pool kneeling with one leg and the other leg foot on bottom of pool. Vertex visible for about an hour FH fine scalp good colour.
She had very small second degree tear sutured with interrupted sutures (reviewed by lovely registrar).
She is ecstatic – her perineum 10 days on is comfortable and healing well.
Surrey Independent Midwives
I had a 3rd degree episiotomy with my first, 2nd degree with my second, and neither of these were seen as a barrier to giving birth in water. My m/w and I did discuss the need to push him out slowly – but in the end he came out with one involuntary push (so quickly and painlessly that I didn’t really believe Linsi when she told me I should probably pick my baby up!). I had a small tear – but nothing that warranted stitching…. doing the splits over the edge of the bath the next day did more damage – so I ended up with stitches after all!
I had one 3rd degree tear and one 4th degree tear with the hospital births of 2 of my children – my 4th degree tear was partly due to an POPP baby, but both were almost definately caused because I was in hospital, strapped to a delivery bed and flat on my back.
My following 2 babies were born at home in water and I did not tear at all as I was able to deliver them in a position that I most comfortatble in (all fours in my case).
Both my homebirths had bigger head circumferences than my hospital births and my last one was substantaly bigger (weighing in at over 9lbs) than either of my hospital births (over 2 lbs in one case). My other 3 babies were emergency C/S for various reasons.
But from someone who has experienced both 3 C/S and 2 very bad tears I can honestly state that the recovery from 3rd or 4th degree tear was far less painful, and is far quicker than that of a C/S. Even having 2 very bad tears in the past I am still opting for a homebirth in water next March. (update: she had her homebirth in March, with an intace perineum yet again!)
Linda Hinchliffe – mother and VBAC supporter.
And from someone who had 1 CS and 1 3rd degree tear, I can say that so far, at least (8 days later), c-section recovery is far easier, quicker, and less painful – not least because I’m still in pain from the tear, over two years ago, not to mention the continence problems.
I think the variation in recovery from 3rd degree tears is so great that generalisations aren’t all that useful. Some women are fine after surgery, some require no surgery, some find that surgery can’t help much at all. After my third degree tear, I couldn’t walk unaided for over a week; after the section I could walk to the shower only 24 hours after the birth itself. I could dress myself only three days after the section; after the tear I needed help (because moving my legs caused perineal pain) for weeks.
Even laughing hurts less after my section than it did after the tear, and I need far fewer painkillers, much less often.
All the research my midwife was able to find showed that the main factors are ongoing symptoms. A 3rd degree tear that healed up fairly well is quite a different affair from one that healed badly and left multiple serious symptoms, even if the extent of the two tears was the same to begin with – and 3rd degree tears can vary hugely in extent anyway.
A 3rd degree tear that healed up fairly well is quite a different affair from one that healed badly and left multiple serious symptoms, even if the extent of the two tears was the same to begin with
I agree: I think the key here is how well the original repair was done rather than the extent of the tearing. As I had had a near- phobia of pelvic-floor damage before my first birth, I had read everything research-wise I could get my hands on about the subject prior to birth; from what I remember, the key factor with regard to the time required for and success of recovery was whether or not the initial repair was well done (i.e. done properly, extensively (under anaesthetic by a surgeon knowledgeable in this type of repair) etc.
This knowledge gave me the courage to decline the services of an obstetrician whom I felt was unsympathetic and insensitive when I transferred into hospital post-homebirth #1 for a repair: he was downright rude, suggested that it was my fault for having had a homebirth, and told me that I would not be “allowed” to leave hospital for several days. I dismissed him from the room with a wonderfully useful phrase (from the Mary Cronk lexicon which should be a book; I like to imagine it will be called “Don’t diss Mama, Mr Doctor Man”) “allowed is not appropriate language to use when addressing a mentally competent adult” — with the full support and backing of my independent midwife, who was horrified by his manner. The Sr. Consultant on duty that night was called in; she spent several hours in surgery doing a skilful and extensive repair that has served me well.
I am eternally glad for the strength that allowed me at that vulnerable time to avoid being repaired by a doctor who made it clear that he had neither sympathy nor empathy for my situation: would I really want to entrust my continence, future sexual health and possibility of childbirth to such a man? Absolutely not. Interestingly he initially assumed that he’d be doing the repair under local anaesthetic. When the repair was done (by the lovely Consultant), it was done in theatre, with a full team, under spinal anaesthesia. I do not see how it could have been done properly otherwise — certainly not under local anaesthetic (the thought fills me with absolute dread). I wonder how many women’s *ongoing* problems are the result of botched initial repairs. IIRC, subsequent follow-up surgery can be successful, but the overall long-term outcome is largely determined by the initial repair and healing thereof…
I wonder how many Obs are truly skilled in this type of repair? How many take hours rather than minutes to do such repairs? How many women suffer lifelong problems as a result of their lack of knowledge? At my local NHS trust hospital there is an interest in perineal health following childbirth: a perineal clinic staffed by Obstetricians and midwives, at least one of whom is doing ongoing research into perineal healing post-partum for a Masters degree was established about 3 years ago — is this unique, or is awareness growing?
Antonia (mother of three children, all born at home)
The Royal College of Obst. and Gynaecologists has produced recommendations which really ALL obstetricians should be sticking to in the case of third- and fourth-degree tears. Briefly:
1) They should be repaired in theatre with good lighting, under appropriate anaesthesia – preferably a spinal block.
2) The doctor carrying out the repair should be experienced or under the supervision of an experienced consultant.
3) Aparients (laxatives) should be prescribed to prevent constipation and straining post repair. Together with dietary advice.
4) Physiotherapy referrals for strengthening pelvic floor.
5) Careful explanation about signs of possible incontinence and observation to ensure everything is in in working order. Which in the Trust I work ats case means having to have a bowel movement prior to discharge.
6) Offering caesarean delivery for future pregnancies as a recommendation – an offer not an order.
Any obstetrician who doesn’t follow the RCOG guidelines is risking professional suicide; they do appear well researched and reasonable.
I am pleased to say the Trust I work at sticks to these guidelines pretty rigidly.
My first child is now 2 and a half and was born in hospital. Labour was over in 4 hrs and came on quickly and very strongly – I skipped ‘early labour’ and went straight to transition!!!
I was not encouraged or supported in the use of upright positions and was encouraged to actively ‘purple face’ push for the whole of the second stage. An anterior lip was removed and when it came to crowning, there was so much stretch and no more so that an episiotomy was suggested and, along with the inevitable Type II dips that were now occurring, I agreed in order to get Thomas born as quickly as possible.
In addition to the episiotomy there were labial and vaginal tears and the whole thing took a good while to stitch up again. I have no beef with the nice lady who stitched me up – I reckon she did nothing but that and did a very good job of what must have been a very messy presentation. However, there was so much bruising and swelling and no care offered to try and alleviate same post delivery, that the most massive amount of scar tissue formed in the perineum.
Following various consultations it was decided that the best option was to have a modified Fenton’s procedure performed. Looking back I cannot understand why I went for this since it was clearly meant to deal with a vagina that was too tight (I never complained of this once) as opposed to scar tissue. I have since spoken to a lady who suffered similarly with excessive scar tissue who had surgery to remove the scar tissue, which sounds like that I should have had done, if anything.
Having not been too upset about the appearance of my nether regions following the episiotomy, I am horrified by how they look and feel following this surgery. There is no perineum to speak of. The distance between the base of the vagina and the anus is about half what it was before. There is no soft, stretchy perineal tissue and in fact the tissue here is paper thin.
In my opinion the chances of having an unpleasant third degree tear involving the anus/rectum seem very high to me based on the new anatomy I have now got.
I am wanting to have a home birth this time so I can be free to do what feels right, but an considering requesting an elective episiotomy figuring that a planned incision without lots of tearing might be better all round.
What is everyone’s opinion of this idea????
I have picked up your email and wanted to share my thoughts with you.
a) I do not think an elective episiotomy would help you at all. In fact it might just lead to a repeat of the first experience because it might extend and the midwife knowing your history might want to transfer you to hospital for suturing.
b) If there is very little perineal body It would be difficult to know where to cut an episiotomy If the paper thin tissue does tear a little that will be easily dealt with with a couple of little stitches or even left to heal unstitched depending on the midwife’s opinion at the time.
c) I would suggest you discuss with your midwife giving birth on all fours or lying on your left side with your knees bent but not too far apart, so that the head is not bouncing on the perineum (or whats left of it).
I would also suggest that you do not actively push, but just do as your body wants you to, and at the time of emergence of the baby’s head that you try very very hard not to push. Sometimes making yourself blow through the contraction will help you stop actively pushing This will let the birth of the head take place S-L-O-W-L-Y almost let the head S-L-I-D-E out. Your midwife may suggest that if she thinks the head is coming quickly she apply some gentle counter pressure to control the head.
Please do not hesitate to share this email with your midwife.
Mary Cronk, midwife for over thirty years
Obstetric Myths Versus Research Realities, by Henci Goer – chapter on episiotomy, summarising the literature, with full refs. (http://www.cma.ca/cmaj/letonlin/1997/l970474.htm)
Article on midline versus mediolateral episiotomy in the BMJ (http://www.bmj.com/cgi/content/full/320/7250/1615)
Correspondence arising from it is perhaps a more entertaining read. It includes a wonderful letter from Rachel Myr, who was on this list, saying that the importance of the midwife makes a difference to perineal outcomes too – on postnatal wards, “we learn to recognize our colleagues’ ‘signatures’ by watching mothers sit down on chairs”. There is also a letter from Sheila Kitzinger, and then one from an Argentinian obstetrician which left me staggered – they are considering changing their policy of “routine” episiotomy, applied to 80% of women, to one of “selective” use, estimated appropriate for … wait for it… a mere 30% !!!!!
 Am J Obstet Gynecol 1989 May;160(5 Pt 1):1027-30
Comment in: Am J Obstet Gynecol. 1991 Mar;164(3):936
Episiotomy: can its routine use be defended?
Thorp JM Jr, Bowes WA Jr.
Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill.
Episiotomy is routinely used before delivery in the United States. The rationale for routine episiotomy is based on two foundation arguments: that episiotomy reduces perineal trauma and that it prevents subsequent pelvic relaxation. A careful review finds little evidence to support these arguments. Episiotomy may predispose the gravid woman to third- and fourth-degree lacerations. Efforts should be directed to determine whether episiotomy is beneficial.
Publication Types: Review Review, Academic
PMID: 2658595 [PubMed – indexed for MEDLINE]
 Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair , by AH SUltan full text is available on the BMJ site (http://www.bmj.com/cgi/content/abstract/308/6933/887?ijkey=FiAllVgzPAVEg)
 BMJ 1994;308:887-891 (2 April)
A H Sultan, Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London E11 1NR.,a M A Kamm, C N Hudson, C I Bartram a St Bartholomew’s (Homerton) Hospital, London E9 6SR St Mark’s Hospital, London EC1V 2PS Correspondence to: Mr
Objectives : To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. Design : (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. Setting : Antenatal clinic in teaching hospital in inner London. Subjects : (i) All women (n=8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. Main outcome measures : Obstetric risk factors, defaecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. Results – (i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P=0.00001), primiparous delivery (85% v 43%; P=0.00001), birth weight >4 kg (P=0.00002), and occipitoposterior position at delivery (P=0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%;20P=0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P=0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. Conclusions : Vacuum, extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.
Third degree obstetric tears are an uncommon but serious complication of vaginal delivery
Forceps delivery, first vaginal delivery, a large baby (>4 kg), and persistent fetal occipitoposterior position are the main risk factors
Almost half the affected women have persistent defaecatory symptoms despite a primary sphincter repair
The cause of anal incontinence is persistent anatomical sphincter disruption rather than pudendal nerve damage
AH updated 11 April 2007