DabbourPhysio@gmail.com
Severe tears after birth

Hi all,

As part of my work for Babycentre, I was recently asked to discuss severe tears. As chance would have it, I also had this question in clinic recently so I thought it might be something worth doing a blogpost about.

Tears:

Firstly, tears range from first to fourth degree tears. This assessment is done based on how large the tear is and what parts of your body that are affected. First-degree tears are typically small and will heal by themselves, although they can give discomfort. Second-degree tears will have impacted your skin as well as the muscle of your perineum – they are usually stitched and often heal without complication. However, if they are causing discomfort or not healing properly, it could be worth seeing your GP or Women’s Health physiotherapist.

Now, severe tears are often referred to as the third and fourth degree tears. Third-degree tears go from your vagina and perineum to your anal sphincter. There are three different gradings of third degree tears (a, b and c) although this assessment can vary. Fourth degree tears will have affected your anal sphincter, including the lining and/or the rectum.

Now, at your birth, you should be checked for tears and informed accordingly, but sometimes it is missed or a lower grade tear is causing more problem than expected, in which case you shouldn’t suffer in silence but rather seek help and aftercare. This will allow you to get back on track and get the help you need, be it physiotherapy or in the case of severe tears, surgery.

Secondly, most tears will get better in a few weeks or months, scaling upwards with the severity of the tear. Now, if you have had a complex tear, it can take up to a year to return to normal – this is quite uncommon, but not unheard of and again there is a lot that can be done to help.

Healing:

Bruising, swelling and soreness are undoubtedly present regardless of your tear. Antibiotics are prescribed to decrease the risk for infection and be sure to wash the tear daily as well as change sanitary pads regularly. Some women find hot water uncomfortable but cold or luke-warm water is fine – be gentle and slow. It will get better and sensation will return gradually.

If you have had a severe tear or are in a lot of discomfort, avoid standing for long periods or walking a lot – both have been found to increase pressure on the healing tear and it can make the swelling take longer to settle. If possible, also rest lying down rather than sitting if it is more comfortable for you. If the tear aches, feels heavy or itchy you have typically been upright for too long and it is time for a rest.

One tip is to cool your pads/sanitary towels in the fridge or freezer – many of my patients reports this is quite helpful. Another option is to use a frozen pack (peas!) between your legs as you lie down.

Painkillers may be required, so don’t be afraid to use them if you need to – just check with your GP first. Some painkillers adversely impact breastmilk and can cause constipation which is less than ideal if you have a tear in your sphincter. But, there are plenty of painkillers that are suitable to use so please don’t be fearful of using them. They will help with healing and make the situation better.

 

With regards to constipation, this is something to be aware off – midwives often prescribe laxatives or stool softeners for this reason. Both help with bowel movements and to minimise pain around your tear. Similarly, check with your GP/Midwife/Pharmacist if you are breastfeeding as there are options for this. It is also worth to be sure to drink sufficient fluids and eat fibres to keep on top of this.

All of this will also help the first time you need to use the bathroom as there will be minimum strain involved – try to relax and don’t push down. It is also common to suddenly feel an urgent need to pass urine or have bowel movements, or passing wind. As the healing progress, all will improve and it will get easier and easier, but if it doesn’t, you can discuss this with your medical professionals without fear, it is very common and there is much that can be done to help. Definitely seek help if you suffer from urine or faecal incontinence – the earlier intervention the better.

It is also quite common to not feel much in the area the first few times. Nerves are usually numb for a while after birth and it can take a while to recover – this is often different for every woman and even between births, so don’t stress about it unless it has gone on for an unusual long amount of time (months).

Aftercare:

This is where Women’s Health Physiotherapists come in. With a severe tear or a minor one that is causing discomfort that is affecting your quality of life, it is well worth to see a physiotherapist. Your Doctor or midwife can refer you.

The typical assessment will include checking your pelvic floor muscles to check that they are functioning correct and that they have sufficient strength to help control bladder and bowels. This also helps with healing and minimise strain on the tear.

We will also often discuss pelvic floor exercises as they help with your pelvic floor muscles but also as they improve blood circulation which is good for all healing.

Next is regarding the scar – it often feels tight and sensitive in the early days but should then improve slowly but surely. Your physiotherapist will often assess your scar and determine whether this is or will be likely to cause any problems. While pelvic floor exercises will help the scar stay flexible and minimise the risk of it causing an issue, scar tissue massage can also be helpful and your physiotherapist can help you with this. Massaging is generally good and can also help you avoid the area around your tear to become over-sensitive which is a common problem that we often see in clinic.

 

Scars often start to feel better after around 6 weeks, but it depends on the healing process as a whole. Sometimes it takes longer, sometimes it will heal quickly. It can be worth to book in to see a doctor or Women’s Health physiotherapist just to have it checked, especially if it has remained uncomfortable. In a worst case scenario, a minor surgery could be required to adjust the scar.

 

Sex:

Well. Often when people talk about recovery from tears this is the hidden question that they are afraid to ask. Please don’t be.

Let me repeat that. Please don’t be afraid to ask about when you can have sex again and how we can help and how you can help yourself.

 

Sex is an important measure for quality of life and something we as healthcare professionals take into great consideration. And most importantly, we can help.

There are numerous issues that can have impacted your sex-life in relation to a tear:

  • Fear and anxiety is up there. How it looks, how it will feel, you and your partner’s expectations.
  • Scars and numbness might have changed how you feel ‘down there’.
  • Sensations might have changed, up or down.
  • Hormone changes can have multiple effects.
  • Sometimes a tear can cause dryness or itchiness.

So, what can I say immediately about this?

Firstly, a vibrator massager is a great way to help massage the scar tissue. This will help the tissue stay flexible and to let you understand and improve how you perceive sensations.

Secondly, lubrication. Use as much as you need. Due to hormones among other things, it might take a while for your natural lubrication to get back up to speed.

Thirdly, be slow and gentle. It is a readjustment period and pacing is useful – build up to where you where before. However don’t be afraid to start – every little helps and moves you back towards normal.

Finally, vaginal sex is fine as soon as you feel comfortable. Typically it takes up to around six months for severe tears but I’ve seen shorter and longer. Another word of advice is that if you have a tear on your sphincter (third or fourth degree), avoid anal sex for up to nine months to give it extra time to heal.

 

If you have any problems, please talk to us!
Hope this helps with some of the most common questions regarding tears.

 

Hanna

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