You are here: Home / Services and Specialities / Perineal Trauma after Childbirth: Mount Sinai Perineal Clinic / Frequently Asked Questions: Mount Sinai Perineal Clinic

Frequently Asked Questions: Mount Sinai Perineal Clinic

Here are some of the most frequently asked questions about managing obstetric anal sphincter injuries (OASIS).

The tissue between the vaginal opening and the anus is called the perineum, and is the intersection of many muscles. More than 90 per cent of people tear to some extent during birth as the baby stretches the vagina and perineum. These obstetrical tears are categorized into four groups:

  1. First degree tears are small skin-deep tears which usually heal naturally.
  2. Second degree tears are deeper tears aff­ecting the muscles of the perineum as well as the skin. These usually require stitches.
  3. Third degree tears extend downwards from the vagina and perineum to the anal sphincter, the muscle that controls the anus.
  4. Fourth degree tears extend to the anal canal as well as the rectum (further into the anus).

An episiotomy is a cut made by the doctor or midwife through the vaginal wall and perineum to make more space to deliver the baby. A tear happens as the baby stretches the vagina during birth. A tear may occur with an episiotomy.

Third- or fourth-degree tears can happen to anyone. These occur in four to six per cent of vaginal births worldwide. There are some factors that can increase the risk of a tear:

  • First vaginal birth
  • A large baby (>4000 grams)
  • Assisted deliveries (forceps or vacuum)
  • Labour was induced (started)
  • One of your baby’s shoulders becomes stuck behind the pubic bone
  • Pushing for a longer amount of time than expected

If a tear is suspected, your midwife or doctor will perform a detailed examination of your perineum and anus. The doctor will explain how the tear will be repaired. This is usually performed as soon as possible after your baby is born, under epidural or spinal anaesthesia (occasionally a general anaesthetic may be necessary). The obstetrician will then stitch the tear including the damaged anal sphincter in the labour room or an operating room.

A single dose of antibiotics will help decrease the risk of infection because the stitches are very close to the anus.

  • You will be given pain-relieving drugs such as acetaminophen and anti-inflammatory medicine.
  • You will be prescribed a gentle laxative to make it easier and more comfortable to move your bowels.
  • You may have a catheter in your bladder to collect urine until you feel able to walk to the toilet.
  • You will need to strengthen the muscles of the perineum and pelvic floor to prevent possible problems with bowel control.
  • Your health care provider will advise you on how to do pelvic floor muscle exercises correctly and can offer an appointment with a pelvic physiotherapist.
  • Keep the area clean. Shower or bathe daily and change your maternity pads regularly.
  • Take a 10-minute sitz bath with warm water several times throughout the day.
  • Eat a balanced high-fiber diet. This will ensure that your bowels move regularly and prevent constipation. Use the gentle laxatives prescribed for at least two weeks.
  • Avoid heavy lifting, pushing or pulling while allowing the perineum to heal. Manually support your perineum during activities that increase the pressure in your abdomen and on your pelvic floor such as sneezing, coughing or vomiting.
  • An ice pack may be helpful if your perineum is bruised and/or swollen. Do not apply ice directly to the skin or leave on too long (max 10 minutes) as this may cause an ice burn.
  • Sitting on an air-donut pillow or two rolled up towels placed parallel to each other under your sit bones can alleviate pressure on your perineum. Lying with a wedge pillow under the low back can also help raise the perineum and decrease swelling.
  • Pelvic floor exercises can be started as soon as your catheter has been removed. These exercises help increase the circulation of blood to the area and aid the healing process.
  • The stitches usually dissolve within six to eight weeks but deeper stitches around the anus can take longer.

Yes. None of the treatments will prevent you from breastfeeding. However, it may be difficult to sit down for long periods of time. Breastfeeding in positions other than sitting, or using ice packs on your perineum, may be helpful.

A bowel movement should not affect your stitches. You may have less control for the first few days after having your baby. It’s important to eat well and drink plenty of water to avoid constipation and to continue the laxative for 10 days after birth. The best position to sit in is with your feet on a stool to raise your knees above your hips. Go slowly and try not to strain.

Most people wait close to six weeks before having sex. Once your stitches have healed and the pain and bleeding has subsided, you can have sex whenever it feels right for you and your partner. Ensure you have a suitable method of contraception as you can get pregnant very soon after giving birth.

Sex may be uncomfortable and feel different at first but the discomfort should not persist. You and your partner may be anxious, so talking about these feelings may help as it is important that you both feel ready and relaxed. If you continue to experience pain or discomfort, you should raise these concerns with your health care professional.

Most women make a good recovery, particularly if the tear is recognized and repaired at the time of birth. During recovery, some women may have:

  • Pain or soreness in the perineum
  • Fears and apprehension about having sexual intercourse.
  • A feeling that they have to rush to the toilet to make a bowel movement urgently, or poor control of wind from the back passage.

The majority of patients (80 per cent) will recover without any problems or complications.

One to two weeks after birth, you will be offered an early assessment appointment with the Mount Sinai Perineal Clinic (or with your obstetrical care provider) to ensure that the area is healing and there are no signs of infection. You will also be asked about any bowel or bladder symptoms and have an opportunity to discuss your birth and ask any questions you may have. You will then have a routine postpartum follow up appointment at six weeks.

At three to four months after birth, you will have a late assessment appointment at the Mount Sinai Perineal Clinic to have an endo-anal ultrasound (a specialized ultrasound of the anal muscles). It may be uncomfortable but will not be painful and the information from the ultrasound will help to ensure the muscles have healed together well. This can help with planning for your next pregnancy and birth, as well as to investigate any symptoms you may be experiencing.

You may arrange an appointment with a physiotherapist who specializes in the pelvic floor. This can be done at two to three weeks after the birth and again at six to eight weeks post birth. This care is delivered fee-for-service but is covered by many insurance policies. It is important to make sure that your pelvic floor muscles are working correctly in order to prevent bladder and/or bowel problems (visit Pelvic Health Solutions to find a provider near you).

Having a future vaginal delivery depends on a number of factors. Your obstetrician will discuss these with you at your follow-up appointment or in your next pregnancy. If the anal muscles have healed completely, you should be safe to have a vaginal delivery in the future. The risk of having another third or fourth degree tear is approximately five to seven per cent.