Postpartum Care Advice

This information has been compiled with the help of the Facebook support group members of 4th Degree Tear Support Group. Although we have all received various medical advice, this information is not designed to replace it but to support it with additional information collated from members who have lived day to day with a tear.  Always refer to your medical health care team if specific advice is needed. Ask as many questions as you can and keep in contact with your medical advisors. 

Keep in mind that everyone heals differently! There is hope that you could be one of the lucky ones who feels back to normal in a few weeks or months. But there are some who develop complications such as infections or breaking down of stitches, so please speak up and seek care if you feel something is not right. And if you seek help and are ignored or your concerns are not taken seriously, get a second opinion! Things can return back to normal, but it is better to get problems addressed sooner to prevent short term issues into becoming long term problems.

degrees of tearingThe diagram above is just an example and every woman tears differently and in different ways, but it can be used to help you and your family understand what a tear means. A 4th degree tear is the most severe tear and means the area between your vagina and rectum has torn all the way. The skin, muscles, and fascia  of your perineum are torn, as well as the external and internal anal sphincter muscles, and the rectum.

It is essential at this point to be aware that in order for your tear to heal properly you need to look after the area.  It is very easy to focus on your new child at this point, you have created life and should celebrate these first few days with your child.  However, you must be aware that the instinctual drive to provide for your new child should not override the needs of your body in order to heal.

What can I expect immediately after the tear?

You will be very sore and in a great deal of discomfort.  This is normal and will ease with time.  You will have a heavy period as a result of childbirth and will experience the odd cramp, especially if breastfeeding.  As your anesthetic wears off you may experience the following, all of which will dull in time:

·         Muscle pain

·         Itching or burning around your vagina and anus

·         A tugging sensation where your stitches are

·         General nausea from medication given

What should I do immediately after the tear?

You must make sure you keep the area clean and dry and keep your stools soft.  As with any wound, a clean area will aid recovery.  This is especially difficult in the vagina and anus area.  To aid this carefully clean yourself with fragrance free wet wipes, sitz baths (described in more detail later), showers, travel bidets (described in more detail later) and anything that is to hand that can aid cleanliness.  Be careful not to drag dry paper items such as toilet roll over the area.  Moist paper will allow the paper to move over the area freely and avoid pulling stitches.  Additionally, to help the area to heal inside the rectum it is important to keep your stools soft and to not strain when emptying your bowels.  You know your body better than anyone, make sure you keep your meals light and easy to pass.  Medications such as stool softeners will be given to aid looser bowel movements.  It is very important that you take these regularly and maintain a soft, easy to pass bowel movement in order to aid healing.  If you are constipated, deal with it immediately with the appropriate medication, do not strain on the toilet.

What can I do after leaving the delivery unit to aid healing?

You must try to rest as much as possible for at least 2 weeks – rest similar to a cesarean is advisable.  No heavy lifting at all and long walks are discouraged.  Try to protect the area as best you can and don’t strain the stitches with excessive movement.  Although the majority of tears heal brilliantly, it can take a good deal of time to heal properly and to avoid complications you must take your healing seriously and make allowances for your own needs.  It can take up to 6 months to heal properly, you will have a new ‘normal’ when you feel downstairs.  It is impossible to go back to your pre-baby perineum but you can get it normal functioning in due time.  Without scaremongering, it is essential that you take care of yourself as if you do not then complications may result in further surgeries and faecal incontinence. 

Positions

You may find it difficult to sit upright without pain.  This is your bodies way of warning you that you are straining your stitches.  Try to keep your weight on your sides or lay down.  Please see below for breastfeeding positions that aid this.  Often if a woman struggles breastfeeding then the support team will have you sit upright and help you into positions.  Please insist that you cannot do these and feed as much as possible without putting weight onto your stitches.  It is advisable that you have someone with you as much as possible to move your child into the needed positions.  This may require your partner to take more time off work or a family member or friend to step in and help.  Limited movement cannot be stressed enough and will pay off in the future.

Wound management

Keep it clean!  Using methods mentioned above and whatever you feel comfortable with.  Do not pull stitches, fiddle with them or explore the area too much with your hands.  Touch it as minimally as possible whilst also keeping it as clean as possible.  The best way to do this is by using water.

Sitz bath

Can be as simple as a bowl in your toilet but there is a huge range of products available as pictured.  The main aim is to provide a warm bath for your downstairs whilst seated.  The water will keep the area clean and the warmth will help with the pain.  Additionally, our members have been advised that you can alternate the temperatures in order to increase blood flow and therefore healing, but you should use whatever temperature feels best for your wound.  You can take these baths as often as you wish but it is advisable to do it at least 3 times a day but if you prefer other methods to keep clean then you need not do them at all. 

squirt bottle

Travel Bidets

These are simply squirty bottles with a moveable nozzle.  You can fashion a bottle from a used water bottle or use a household jug or buy one like the picture above.  The aim is to squirt water to the area in order to aid cleanliness.  Obviously do not put boiling water or ice-cold water into the bottle, body temperature or a little above is the most soothing.  If you have a bidet plumbed into your home, this is ideal but not available to most.

Squatty Potty – or a footstool can aid elimination of bowels and decrease straining which is essential for wound healing

squatty potty

Gel Ice packs

Ice packs can alleviate pain experienced when recovering and reduce swelling.  The gel packs are the most comfortable and are easily available.  Other types of iced items can be used but may not be as comfortable.  Please pay attention to infection and cross contamination.  Be careful to keep the iced item clean using anti-bacterial products and never use food products.

Medications

This booklet is designed to be a guide and not to replace medical advice.  Please take, in full, whichever medication you are prescribed.  It is common to take a stool softener and a laxative in order to help you pass stools and to avoid straining.  It is also usual to be given pain medication and antibiotics to aid healing and avoid infection.  These come in many forms and if you are worried then contact your medical team.

Things to watch out for:

  • It is quite common to pass flatus (wind) from your vagina or elsewhere until the wound fully heals. However, passing wind from somewhere other than your anus is one of the first indicators that your surgery may not be healing as it should so be careful to monitor it.  If you pass wind but not faeces from somewhere other than your anus for quite some time, it may mean that your surgery has mostly healed and there are very small hole/s that need to be dealt with.  Consult with your medical support team with regard to this.
  • Faeces passing from anywhere other than your anus. At first it may be difficult to see where faeces are coming from, particularly when you are bleeding after giving birth.  Keeping yourself clean will help you do figure out where the faeces is coming from.  If it is coming from anywhere other than your anus then it is a sign that your surgery has not worked.  Contact your medical team immediately.  This is a sign that your surgery has not healed.  However, do not expect to be rushed into hospital.  They will examine you and advise on the best way forward.  This is usually testing such as scans to ascertain the extent of your healing and medication to help the area to further heal.  Bear in mind it can take a very long time to heal properly but passing faeces from a place other than your anus can lead to infection so it must be controlled effectively.
  • Infection. Discharge from the vagina is normal.  Be aware of discharge that is discoloured and foul smelling.  Infection will generally lead to you feeling unwell, raise your temperature and give you pain such as the full feeling experienced in pregnancy.  If worried at all contact the medical team.  Controlling infection early is more important than wasted medical trips.  Trust your body and your instincts and be sure to take it seriously.  Do not ignore symptoms, especially when you are thinking about caring for your new baby over caring for your own needs.

Sex

Most women find it uncomfortable to have sex for many weeks after having a child.  After suffering a fourth-degree tear this is heightened and it is advisable to avoid penetrative sex for a good deal of time in order to let the area heal as well as possible.  However, some women have described that their health care professionals have advised that penetrative sex can help reduce scar tissue around the wound.  It is best at this time to refer to the guidance of your health care professional.  Most of the women surveyed explained that they were given the go ahead after 6 weeks but did not feel ready to have sex both physically and mentally for up to a year afterward.  Let your doctors and your own body be your guide on this.

It may seem difficult as a couple to imagine not having sex for months but allowing your body to heal properly will allow you to have a full sex life later on whereas rushing it can lead to complications and painful experiences.  Some women find even the idea of penetrative sex after a tear a very scary prospect and this is also completely normal.  What has happened to your vagina is not to be taken lightly and patience is key.  Try to avoid penetrative sex for as long as possible in order to aid healing.  When trying to have penetrative sex after your health care team have given you the all clear, try to use plenty of lubrication, take it very slow and stop if you feel any pain at all.  Your sex life need not end without the capacity to have penetrative sex and there are many other ways that you can feel satisfied as a couple.

Mental Health

Nearly all women who experience a tear experience heightened emotion and mental health issues as a result.  It is a traumatic experience and you are doing yourself no favors by trying to shrug off your experiences or your worries.  Talking about it will alleviate many of your issues.  You may feel that due to the nature of the area that has been affected that it is too embarrassing to mention to a friend/relative/partner but the relief that can be found by explaining to someone what you have gone through and are going through can make you feel incredibly better about your journey.  You are not alone, there are thousands of women worldwide who know what you are going through and would welcome you to contact them via the methods listed at the end.  It can be a very lonely time and women often feel that focus is shifted to their wonderful new baby and away from the pain and heartache of a bad tear.  Having a child is a wonderful experience and can be kept that way by sharing asking for help when you need it and treating your mental health just as seriously as your physical health. Many of us have found professional mental help to be beneficial, especially therapy that is specific to trauma such as CBT or EMDR. Please reach out to a professional if you are suffering!

Other helpful tips:

  • Cotton underwear to aid air circulation
  • Witch hazel and arnica can aid healing
  • Doughnut or waffle cushions if attempting to sit upright

Breastfeeding positions

breastfeeding positions

Pelvic floor exercises

As a result of your tear your pelvic muscles have been damaged.  It is normal to experience anal incontinence as the sphincter has been damaged.  This is usually repaired on the day of delivery but can take a while to heal and longer to gain full use of the muscle so that you can hold in faeces properly.  It is highly recommended to see a pelvic floor therapist early in the recovery to help with incontinence, scar tissue, return to sex, and return to exercise. Take these exercises seriously as they will definitely improve your quality of life.  But take it easy and develop your exercise routine over time.

Partners

This section is dedicated to partners of those who have suffered from a fourth-degree tear.

First of all, well done, you now have an amazing new baby and you have done amazing job supporting your partner as you both brought them into the world.  Your partner is grateful for that and may struggle to communicate their appreciation during this very stressful time.  Your help is incredibly valuable and essential in order to help your partner heal properly.  She needs to have at least 2 weeks bed rest, encourage this as much as you can but do not demand it.  She is excited about her new child and wants to show her off.  But catering to the needs of visitors is the last thing she should be doing and minimal movement is encouraged.

Please do not down play the importance of your physical and mental needs during this difficult period.  The majority of partners of tear sufferers describe being left out of important decisions and not being advised on what is happening.  In the delivery suite this is usually because time is an important factor but it is perfectly acceptable for you to insist upon updates and information.  Your partner will likely be incapable of taking in information given to her by health care professionals in the first few days after delivery as it is a stressful time.  Please take in all of the information for her.  No doubt you are the one reading the document, do not be worried about asking questions, taking notes and chasing doctors who can provide what your partner needs.  It may be helpful to take more time off to support her than originally thought.  She will need as much support as you can provide, and that she will allow.  She will need to discuss with you things that may previously been taboo, such as bowel movements or vaginal issues.  Please help her feel comfortable to do this as it is important to have someone to share with during this difficult time.  Be aware of anything that she mentions that may be a signal that her health is deteriorating and push her to seek help even if it feels trivial.  Putting in the hard work now will pay off dividends later on.  Penetrative sex is off limits for a good deal of time, usually 6 months or more.  But this does not limit your sexual satisfaction and she will likely welcome other activities that will satisfy you both.  Talk about it, be open, being silent will not help either of you but then neither will pressuring her for penetrative sex.  Her vagina has changed, and you both will have to adapt.  Do not in any way down play the trauma of the situation on the day of delivery for you and your partner.  It is heart-breaking to see your partner suffer in this way and take time to discuss your feelings and experiences.  It will help you both to heal.

Original document created by Sarah Hammal

Edited by Laura Fry of Life After 4th Degree Tears