If you have a tear to your perineum during birth, it will be classified into a ‘degree’. This degree is a measurement of the depth of the tear, and different degrees of tearing need different management.
First degree tears
These tears are to the perineal skin and vaginal mucosa only, and may not be sutured if they sit well together and are not bleeding. Tears up toward the urethra and clitoris or labial tears may be included in this classification, although technically they should be classified into their own type as degrees of tear are talking about perineal damage.
If a first-degree tear is not sitting together well or bleeding, your midwife may suture it to help it heal well.
Second degree tears
These tears affect the perineal skin, vaginal mucosa, and the superficial perineal muscles. These should be sutured in layers as the muscle will very rarely sit together and heal well on its own. These are generally sutured in the room you give birth in, and your midwife can usually do the repair. They will numb you up with local anaesthetic before they begin the repair. Local anaesthetic can sting when it goes in, but will take away sensation in the area it is injected into.
After suturing a second degree tear, your midwife will offer you a rectal examination to make sure that she has not placed any sutures through to your rectum by accident, and to check for any damage to your rectum. This is a safety measure to lessen the chances of infection and check for further damage. Like all interventions in birth, you do not have to agree to this, but if you do decline then you should keep an eye out for signs of infection or leakage of faeces or wind.
After repair, second degree tears can be uncomfortable, but if the sutures are causing significant pain, please let your midwife know.
Third degree tears
These tears affect the perineal skin, vaginal mucosa, superficial perineal muscles, and the anal sphincter muscle. This degree of tearing is divided into three sub-degrees:
3a – involving less than 50% of the external anal sphincter muscle
3b – more than 50% of the external anal sphincter torn, but internal anal sphincter not involved
3c – involve both the external and internal anal sphincter
These tears are a significant injury, and should be repaired by an obstetric doctor. Most people with third degree tears will be transferred to theatre for their repair, so that the doctor can have good lighting and space to complete the repair well. They are usually repaired under spinal or general anaesthetic, so that you are comfortable and not moving around while the repair is undertaken.
Fourth degree tears
These tears affect the perineal skin, vaginal mucosa, superficial perineal muscles, anal sphincters, and the rectal mucosa. They are a significant injury, and will be repaired in theatre by an obstetric doctor under spinal or general anaesthetic.
Third and fourth degree tears are uncommon, affecting about 3% of birthing people.
Buttonhole tears
These are a rare type of tear, in which the anal sphincter is intact, but there is a hole between the vagina and the rectum. They may coexist with first or second degree tearing, or the perineum may appear intact. These tears can cause leakage of gas and faeces from them vagina.
The chance of these rare tears is why it is recommended that all birthing people have a rectal exam after birth. Like all interventions in pregnancy, birth, and postpartum, it is your choice whether you agree to this. If you do decline this intervention, and you find that you are leaking faces or wind in any way, please tell your midwife.