The Management of Third- and Fourth-Degree Perineal Tears

Green-top Guideline No. 29 June 2015

Executive summary of recommendations

It is recommended that the classification outlined in this guideline be used when describing any obstetric anal sphincter injury.
If there is any doubt about the degree of third-degree tear, it is advisable to classify it to the higher degree rather than the lower degree.
Clinicians need to be aware of the risk factors for obstetric anal sphincter injuries (OASIS).
Clinicians should be aware, however, that risk factors do not allow the accurate prediction of OASIS
Clinicians should explain to women that the evidence for the protective effect of episiotomy is conflicting. [New 2015]
Mediolateral episiotomy should be considered in instrumental deliveries. [New 2015]
Where episiotomy is indicated, the mediolateral technique is recommended, with careful attention to ensure that the angle is 60 degrees away from the midline when the perineum is distended.
Perineal protection at crowning can be protective. [New 2015]
Warm compression during the second stage of labour reduces the risk of OASIS. [New 2015]
All women having a vaginal delivery are at risk of sustaining OASIS or isolated rectal buttonhole tears. They should therefore be examined systematically, including a digital rectal examination, to assess the severity of damage, particularly prior to suturing.
Repair of third- and fourth-degree tears should be conducted by an appropriately trained clinician or by a trainee under supervision.
Repair should take place in an operating theatre, under regional or general anaesthesia, with good lighting and with appropriate instruments. If there is excessive bleeding, a vaginal pack should be inserted and the woman should be taken to the theatre as soon as possible. Repair of OASIS in the delivery room may be performed in certain circumstances after discussion with a senior obstetrician. [New 2015]
Figure of eight sutures should be avoided during the repair of OASIS because they are haemostatic in nature and may cause tissue ischaemia. [New 2015]
A rectal examination should be performed after the repair to ensure that sutures have not been inadvertently inserted through the anorectal mucosa. If a suture is identified it should be removed. [New 2015]
The torn anorectal mucosa should be repaired with sutures using either the continuous or interrupted technique. [New 2015]
Where the torn internal anal sphincter (IAS) can be identified, it is advisable to repair this separately with interrupted or mattress sutures without any attempt to overlap the IAS.
For repair of a full thickness external anal sphincter (EAS) tear, either an overlapping or an end-to-end (approximation) method can be used with equivalent outcomes.
For partial thickness (all 3a and some 3b) tears, an end-to-end technique should be used. [New 2015]
3-0 polyglactin should be used to repair the anorectal mucosa as it may cause less irritation and discomfort than polydioxanone (PDS) sutures. [New 2015]
When repair of the EAS and/or IAS muscle is being performed, either monofilament sutures such as 3-0 PDS or modern braided sutures such as 2-0 polyglactin can be used with equivalent outcomes.
When obstetric anal sphincter repairs are being performed, the burying of surgical knots beneath the superficial perineal muscles is recommended to minimise the risk of knot and suture migration to the skin
Obstetric anal sphincter repair should be performed by appropriately trained practitioners.
Formal training in anal sphincter repair techniques should be an essential component of obstetric training.
The use of broad-spectrum antibiotics is recommended following repair of OASIS to reduce the risk of postoperative infections and wound dehiscence.
The use of postoperative laxatives is recommended to reduce the risk of wound dehiscence.
Bulking agents should not be given routinely with laxatives. [New 2015]
Local protocols should be implemented regarding the use of antibiotics, laxatives, examination and follow-up of women with obstetric anal sphincter repair.
Women should be advised that physiotherapy following repair of OASIS could be beneficial.
Women who have undergone obstetric anal sphincter repair should be reviewed at a convenient time (usually 6–12 weeks postpartum). Where possible, review should be by clinicians with a special interest in OASIS.
If a woman is experiencing incontinence or pain at follow-up, referral to a specialist gynaecologist or colorectal surgeon should be considered.
Women should be advised that 60–80% of women are asymptomatic 12 months following delivery and EAS repair.
All women who sustained OASIS in a previous pregnancy should be counselled about the mode of delivery and this should be clearly documented in the notes.
The role of prophylactic episiotomy in subsequent pregnancies is not known and therefore an episiotomy should only be performed if clinically indicated.
All women who have sustained OASIS in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should be counselled regarding the option of elective caesarean birth.
Units should have a clear protocol for the management of OASIS. [New 2015]
Documentation of the anatomical structures involved, the method of repair and the suture materials should be made.
The woman should be fully informed about the nature of her tear and the offer of follow-up should be made, all supported by relevant written information.

Overall risk of obstetric anal sphincter injury is 1% of all vaginal deliveries

Third degree perineal tear – partial or complete disruption of anal sphincter muscle which may involve either or both EAS and IAS muscles

Fourth degree perineal tear – disruption of anal sphincter muscles with breach of rectal mucosa

Prediction and Prevention of Ob anal sphincter injury

Risk factors: BW over 4kg (up to 2%) IOL (2%)

2^nd stage labor longer than 1 hour (4%) Shoulder dystocia (4%)

POP (3%) Midline episiotomy (3%)

Nulliparity ( 4%) Forceps delivery (7%)

Epidural anesthesia (2%)

Where episiotomy is indicated, mediolateral technique is recommended (angle cut away from the midline)

Classification and Terminology

1^st degree – injury to perineal skin only

2^nd degree – injury to perineum involving perineal muscles but not involving anal sphincter

3^rd degree – injury to perineum involving anal sphincter complex

3a : less than 50% of EAS thickness torn

3b: more than 50% of EAS thickness torn

3c : both EAS and IAS torn

If tear involves only anal mucosa with intact ASC (buttonhole tear) – document as separate entity

Identification of Obstetric anal sphincter injury

All women having vaginal delivery with evidence of genital tract trauma should be examined systematically to assess severity of damage prior to suturing
All women having operative vaginal delivery or if experienced perineal injury should be examined by experienced practitioner trained in recognition and management

Surgical Techniques

Overlapping or end-to-end approximation method
IAS is identified and repaired separately with interrupted sutures
Repair in OR under anesthesia

Suture material

EAS – use monofilament suture as Polydiaxanone (PDS) or modern braided sutures as polyglactin (Vicryl)
IAS – use 3-0 PDS or 2-0 Vicryl
Burying of surgical knots beneath the perineal muscle to prevent knot migration to skin

Surgical Competence

OAS repair should be performed by appropriately trained practitioner
Formal training in anal sphincter repair techniques is recommended

Post-operative Management

Broad-spectrum antibiotics is recommended to reduce incidence of infection and wound dehiscence (include Metronidazole to cover anaerobic contamination)
Laxatives is recommended to reduce incidence of wound dehiscence
Offer physiotherapy and pelvic floor exercises 6-12 weeks after anal sphincter repair
Review 6-12 weeks postpartum by consultant Ob
If experiencing incontinence or pain → refer to specialist Gyne or colorectal Surgeon for endoanal ultrasonography and anorectal manometry

Prognosis

60-80% are asymptomatic at 12months
Most of symptomatic women describe incontinence of flatus or fecal urgency
Use of endoanal US as part of ff-up demonstrated persistent defects in 54-88% of women after repair

Future Deliveries

Counsel about the risk of developing anal incontinence or worsening of symptoms with subsequent vaginal delivery
Advise that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies
All women who are symptomatic or have abnormal endoanal US and /or manometry should have the option of elective CS

Risk Management

When repair is performed, ensure that the anatomical structures involved, method of repair and suture materials used are clearly documented and that instruments, sharps and swabs are accounted for.
Inform woman of the nature of her injury and the benefits to her of follow-up. Include written information

Councelling station ( Information for you)

What is a perineal tear?

Many women experience tears to some extent during childbirth as the baby stretches the vagina
occur in the perineum, the area between the vaginal opening and the anus (back passage
Small, skin-deep tears are known as first-degree tears and usually heal naturally. Tears that are deeper and affect the muscle of the perineum are known as second-degree tears

What is a third- or fourth-degree tear?

deeper tear that also involves the muscle that controls the anus (the anal sphincter) is known as a third-degree tear.
If the tear extends further into the lining of the anus or rectum it is known as a fourth-degree tear.

What will happen if I have a third- or fourth-degree tear?

If a third- or fourth-degree tear is suspected or confirmed, this will usually be repaired in the operating theatre.

Your doctor will talk to you about this and you will be asked to sign a consent form.
- epidural or a spinal anaesthetic, although
- occasionally a general anaesthetic may be necessary.
You may need a drip in your arm to give you fluids until you feel able to eat and drink.
You are likely to need a catheter (tube) in your bladder to drain your urine.
This is usually kept in until you are able to walk to the toilet.

After the operation you will be:

offered pain-relieving drugs such as paracetamol, ibuprofen or diclofenac to relieve any pain advised to
take a course of antibiotics to reduce the risk of infection because the stitches are very close to the anus
advised to take laxatives to make it easier and more comfortable to open your bowels.
None of the treatments offered will prevent you from breastfeeding.

What can I expect afterwards?

it is normal to feel pain or soreness around the tear or cut for two to three weeks after giving birth, particularly when walking or sitting.
Passing urine can also cause stinging.
Continue to take your painkillers when you go home.
Most of the stitches are dissolvable and the tear or cut should heal within a few weeks, although this can take longer.
The stitches can irritate as healing takes place but this is normal.
You may notice some stitch material fall out, which is also normal.
To start with, some women feel that they pass wind more easily or need to rush to the toilet to open their bowels.
Most women make a good recovery, particularly if the tear is recognised and repaired at the time: 6–8 in 10 women will have no symptoms a year after birth.

What can help me recover?

Keep the area clean. Have a bath or a shower at least once a day and change your sanitary pads regularly (wash your hands both before and after you do so).
This will reduce the risk of infection.
You should drink at least 2–3 litres of water every day and eat a healthy balanced diet (fruit, vegetables, cereals, wholemeal bread and pasta).
This will ensure that your bowels open regularly and will prevent you from becoming constipated.
Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help healing.
It is important to do pelvic floor exercises as soon as you can after birth. You should be offered physiotherapy advice about pelvic floor exercises to do after surgery.
Looking after a newborn baby and recovering from an operation for a perineal tear can be hard. Support from family and friends can help.

When should I seek medical advice after I go home?

You should contact your midwife or general practitioner if:
- your stitches become more painful or smelly – this may be a sign of an infection
- you cannot control your bowels or flatus (passing wind).

When can I have sex?

In the weeks after having a vaginal birth, many women feel sore, whether they’ve had a tear or not. If you have had a tear, sex can be uncomfortable for longer.
You should wait to have sex until the bleeding has stopped and the tear has healed.
This may take several weeks.
After that you can have sex when you feel ready to do so.
A small number of women have difficulty having sex and continue to find it painful.
Talk to your doctor if this is the case so that you can get the help and support you need.
It is possible to conceive a few weeks after your baby is born, even before you have a period.
You may wish to talk with your GP or midwife about contraception or visit your local family planning clinic to discuss this.

Your follow-up appointment

You may be offered a follow-up appointment at the hospital 6–12 weeks after you have had your baby to check that your stitches have healed properly.
You will be asked questions about whether you have any problems controlling your bowels. You may be referred to a specialist if you do.

Can I have a vaginal birth in the future?

Most women go on to have a straightforward birth after a third- or fourth-degree tear.
However, there is an increased risk of this happening again in a future pregnancy.
Between 5 and 7 in 100 women who have had a third- or fourth-degree tear will have a similar tear in a future pregnancy.
You may wish to consider a vaginal delivery if you have recovered well and do not have any symptoms.
If you continue to experience symptoms from the third- or fourth-degree tear, you may wish to consider a planned caesarean section.
You will be able to discuss your options for future births at your follow-up appointment or early in your next pregnancy.
Your individual circumstances and preferences will be taken into account.