Vaginal tears

There seems to be a great deal of confusion among natural childbirth and homebirth advocates about the nature and treatment of vaginal tears.

All vaginal tears are not alike. The decision on whether they should be repaired, how they should be repaired and the consequences of not repairing them depend completely on the type of tear. Unfortunately, the need for repair is negatively correlated with the ability of a midwife to repair it. In other words, homebirth midwives know how to repair only minimal tears that would probably heal without repair. Most midwives, including certified nurse midwives, do not know how the to repair the tears that are most critical to repair. These are the tears that lead to bowel incontinence.

Most tears occur downward into the area between the vagina and rectum known as the perineum. It is more accurate, therefore, to refer to them as perineal tears. The Mayo Clinic website has an excellent series of slides detailing the normal anatomy of the perineum and the 4 degrees of perineal tears.

The illustration below portrays the normal perineal anatomy.

The perineal muscles identified in the illustration are the superficial perineal muscles; there is another deeper set that is more important for holding the pelvic organs in place. The anal sphincter is the ring of muscle that holds the anus closed. It is directly responsible for preventing bowel incontinence. If it will is torn completely apart and not properly repaired, the woman will be incontinent. Of note, this form of incontinence is different from a fistula, which is a hole inside the upper vagina that connects it directly to the bladder in front, the bowel behind or both.

Perineal tears are graded in severity from first degree to fourth degree, with first degree being minor and fourth degree most severe.

You can see a first degree tear below.

The tear is superficial and therefore minor. It’s the equivalent of a paper cut, and like a paper cut, will heal without stitches. Some people even think they heal better without stitches. First degree tears are very common.

Second degree tears are also common, but they heal better when stitched back together.

As you can see, this tear extends into the muscles that surround the vagina. The tear can be short in length or it can extend the entire distance between the bottom of the vagina and the top of the anal sphincter. A median episiotomy produces a second degree tear like this.

Putting the muscles back together makes sense if you want to preserve the natural shape and anatomy of the vagina. If it is not repaired, the opening to the vagina will gape, but there are usually no serious consequences of failing to repair it. Theoretically it is possible that the muscles will be able to heal back together on their own, but it is extremely unlikely. With the exception of very tiny tears, there are no circumstances under which a second degree heals “better” if it is not stitched.

A third degree tear MUST be repaired, and you can understand why when you look at the illustration.

The anal sphincter has been torn apart. If it is not repaired, bowel contents will be allowed to flow freely out of the rectum and there is nothing a woman can do to prevent it. Moreover, if the anal sphincter is not repaired at the time of delivery, the repair itself becomes much more complicated.

Unfortunately, though the illustrations make the difference between a second degree and third degree tear obvious, it is usually not so clear in real life. That’s because the muscle fibers of the anal sphincter tend to retract back into the surrounding tissue. If that happens, a third degree tear looks exactly like a second degree tear. If a tear extends the entire length of the perineum, the only way to tell the difference between a second degree and third degree tear is to put a finger in the anus and feel if the sphincter is still present.

A torn sphincter will not heal itself because the torn ends are usually far apart from each other after the muscle fibers retract. The superficial layers of the tear will heal and it may look like everything is normal, but the woman will not be able to control her bowel function and will definitely need an involved surgical repair under anesthesia.

Most midwives do not know how to repair a third degree tear and most homebirth midwives don’t even know how to tell the difference between a second degree tear and a third degree tear. Therefore, they often fall back on the tried and true tactic that homebirth midwives use when confronted with something they cannot do; they insist that it is unnecessary. In the case of perineal tears, this has the paradoxical effect that the more serious the tear, the more likely the homebirth midwife is to insist that it doesn’t need to be repaired.

The repair itself is not rocket science. You simply have to bring the torn ends of the sphincter out from the surrounding tissue and stitch them together. But you can only do that if you have the experience to diagnose the problem and carry the specialized clamps that will allow you to find and grasp the torn ends. Since homebirth midwives don’t have either, they often fail to repair third degree tears and the patient ends up with a surgical procedure under general anesthesia within months after the birth.

A fourth degree tear is the most serious. A fourth degree tear extends into the rectum. The result is that the vaginal and rectum form one continuous space.

The repair of a fourth degree tear starts with the repair of the rectum itself. Depending on the how far the tear extends up into the rectum, the repair can be technically challenging and can take an hour or more. Once the rectum is repaired, the rest of the tear is repaired like any other third degree tear. However, because the rectum itself has been torn, the possibility exists that the tear may heal improperly and leave a hole (fistula) between the vagina and rectum with consent leaking of feces from the vagina. Obviously, a fourth degree tear MUST be repaired in the immediate aftermath of birth.

Let’s review:

  • Perineal tears are classified by severity.
  • First degree tears do not need to be stitched.
  • Second degree tears ought to be stitched but the results are not catastrophic if they are not stitched.
  • Third and fourth degree tears MUST be stitched or the woman will be left with bowel incontinence.
  • Third and fourth degree tears can only be diagnosed by someone with experience.
  • Third and fourth degree tears will NOT heal by themselves.
  • Third and fourth degree tears must be repaired by someone with extensive experience in repairing them.

Bedrest does NOT heal tears and the only thing it does is increase the risk of a woman developing a deep vein thrombosis or pulmonary embolus. If a homebirth midwives tells you that your tear will heal if you just stay on bedrest, it is a signal to get to the hospital as soon as possible for an expert diagnosis and repair. Otherwise, the results are likely to be embarrassing, painful, and require further more extensive surgery in the future.

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  • SNM1

    Thanks for the article and clear explanation. As a student nurse-midwife I have (luckily) not seen any extreme tears yet, and I am often worried about my ability to tell the difference as it is not as easy to distinguish as illustrations make it seem! I definitely plan to get a second opinion from an experienced CNM or backup OB as a new grad to help me accurately identify the degree of any questionable tears! Thanks again!

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    Midwives are sometimes underrated, in terms of the number of conditions that they have to be able to treat.

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  • AnaC

    Thank you so much for this article. I suffered a third degree tear 2 years ago and have been looking up on the subject on the internet ever since, and I must say, this is the clearest, most straight-forward explanation for the “layman” I’ve found. I am 7 months pregnant with my second now, and I now have to decide whether to go for an elective c-section (in fact, my appointment to let them know my decision is tomorrow!). After spending most of the last 2 years considering what I would do on my second birth, I have now pretty much made up my mind of having a c-section; however, I would love to hear your professional opinion on this, since it has been extremely frustrating, throughout the whole process, the fact that doctors in the UK are very careful about telling you what they think you “should do” and remain very vague on the consequences of having another vaginal birth.

    By the way, I have not suffered incontinence, I believe my perineum has healed quite well, although I can’t say my BMs are as they were before giving birth entirely. I seem to “have to go” more often.

  • Jo Jo

    I’m sure your information was professional and accurate as to tear repait but why did you have to be so condescending – to say the least – towards midwifes? It was totally unnecessary and out of context!

    • http://gamesgirlsgods.blogspot.com/ Feminerd

      Incorrect. It’s there because midwives need to know this, and many of them don’t. Thus, they don’t repair tears properly or even diagnose them properly, leaving women with mangled genitals and rectums.

      If someone doesn’t even know the degrees of tears and how to diagnose/fix them, why is (usually) she attending a birth claiming to be a trained midwife?

      • Mishimoo

        100% this!

  • BDG

    Maybe I’m incredibly weird… but 3 non medicated vaginal deliveries (with relatively short pushing phases 12, 16 and 20 min respectively) the first on a birth stool, the rest upright in bed (kinda a modified sitting position) no vaginal lacerations at all… and IDK but for me I did my best to relax during the pushing contractions (well through all of the contractions) and keep gentle pressure when they were gone… my kids were 8.9, 8.12, and 6.7 (the little guy was the “most painful”… (my first was at a freestanding birth center with a CPM (who for tears 2nd+ would refer to her OB, they had a great relationship, and I loved that if something was beyond her realm she didn’t have a problem saying so and getting the help/resources she needed), my last two have been with CNMs in hospital, and my fourth will be too)

    My first OB during our first consult said that 90% of his FTMs needed episiotomies to deliver… :/ thank God my husband got moved across the country for the military when I was 38 weeks and I changed providers… my intact vagina will forever be indebted to the USAF (lol, but seriously, I would have “had to have” and episiotomy… when I didn’t tear AT ALL)… I guess my question is would you rather know you’re going to have a laceration (probably at least 2nd degree) or risk a small one? Most of the info I have read shows that most 3rd & 4th degree lacerations are from extensions from episiotomies… The big data collection I’ve seen from the NCB community regarding vaginal trauma/lacerations was from The Farm and their “data” from all of their deliveries… I think it was something like 4000 births with like less than 2% resulting in 4th degree lacerations and something like 60% suffering no tearing at all… I think it was like 30% 2nd and 15ish% with 3rd degree tears… I just thought it was an interesting set of statistics on what the NCB community would probably see as the “ideal” environment for “saving vaginas” lol…

    That being said… definitely times and places where they are warranted and needed… but under no circumstances without the express consent of the person you are performing the procedure on… (which is why I think the before discussion is so so so so important, there should already be a mutual understanding a respect for the “expectations” you know the if this then this convos… )

    I think its interesting how some practitioners have really high rates of lacerations and extensive vaginal trauma, and others that really don’t… I know at our hospital here there are some docs who do 2nd and 3rd degree repairs on almost all of their clients, where as others very rarely have to do them at all (including our amazing CNM practice)… I generally don’t ask about episiotomies, but rather the extent of the
    repairs the provider finds themselves doing most often… that tells me more than I only do episiotomies when I think they’re needed lol…

    I think there are a multitude of factors that come into play… some women will just tear, like stretchmarks (some midwife “anecdata” I’ve read has shown a relationship with if a mom has a lot of strechmarks (showing maybe not very good skin elasticity???) and a higher incidence of tearing)… presentation is definitely a factor… there have been some recent articles I’ve read on when the head is delivered (between contractions vs. during)… laboring down… which like some others have mentioned you can often do a lot more of with an epidural… I’m not sold on the size thing… I think it has more to do with speed… not saying a 11lb baby won’t do any damage (lol)… but a little 6lber may shoot out too fast to allow for gradual stretching… and really… I’ve always thought the shoulders were the worst!!! my first had 15″ shoulders…. and I remember thinking, I knew it was the shoulders that would be the worst…

    My “anecdata”: I know a single mom who has delivered with an epidural that didn’t have tearing (it was her second)… most ended up with 2nd or 3rd degree tears and I know 4 who had episiotomies that extended into 4th degree tears requiring surgical repair (two opted for c/s for their next children), the majority of non epidural moms I know only had 1st degree tears… (I know I know… doesn’t mean anything… but the info that I’ve been presented with in IRL, shows that there is a slight correlation between having an epidural and more extensive tearing… for whatever reason)… I’m a fan of the providers who just do perenial support with mineral oil… or warm compresses… shouldn’t a “goal” of delivery not only be a healthy baby, and mom but an intact perineum? and trying different methods to ensure that happens? I get why an episiotomy is easier to repair maybe… but I don’t know that its easier to recover from something that wouldn’t have happened at all (I can’t tell you the number of moms I’ve heard say they said no to an episiotomy much to the chagrin of their provider, to ultimately end up with no lacerations at all?) ? I guess thats my question at the end of the day… and ultimately I would want a provider that was extremely judicious in his/her use of episiotomy…

    and on a side note… we always did prenatal perineal massage… I didn’t really think of it as like “stretching” per say but more an exercise in kinda getting a feel for what it feels like… teaching yourself to kinda give into the pain and resist the urge to get it out now…

    and while I am as “crunchy” as it comes when you’re talking NCB… I
    think every woman/family should be left to make the choice for herself! I can completely see and support why a woman would prefer an elective CS over a vaginal delivery… in the same way I can completely understand why a mom would prefer to forgo an epidural, elective induction etc… it all boils down to autonomy in my book, and finding a provider who is comfortable with what you are as well… I think its incredibly rude and stupid to try to force your own “wants/expectations” on someone who’s scope of practice just doesn’t include that (and ultimately sets you up for failure… don’t go to a doc who does 100% episiotomies and then be upset that he gave you one too)… we have doctors here that run the gamut! which is amazing (and not everyone is as fortunate… especially since we live in a relatively small town 45 min from canada lol)… those that are completely fine with a 38 week C/S and those that will d0 41-42 weeks with NSTs… anyways… pardon the long long long post but I had to chime in with my .02…. oh and tearing was my biggest fear… well not really tearing but the lidocaine to do the repair… lol I know so crazy… ugh rambling…

    • toni

      A few obstetricians here have said that unanaesthetised women can’t control their pushing and tear worse as a result.. another reason why epidurals are a good thing. Have to say though that wasn’t true in my case either, it hurt to push so I was happy to stop when instructed. Never felt that irresistible urge to push you hear about.

      The doctor did the perineal stretching thing on me, it hurt like the dickens but I didn’t need any stitches so I guess it worked. No stretch marks either so maybe the two are related. Seems plausible at least! It does make me cringe to think ten years ago I would have probably been cut as a matter of course even though I wouldn’t have needed it, but the vast majority do tear some and if me getting an unnecessary small cut prevents other women getting horrible 3rd/4th degree tears I can live with that. Would be great if they could just tell who is going to tear and who isn’t so no one gets a cut they don’t need or a horrid tear that would have been avoided with a episiotomy

      • toni

        Also my baby was just 30th percentile head circumference which must have helped. I asked at my last ultrasound if the baby’s head looked big and the technician just said it looked ‘normal’. Head size must be a better indicator of difficult birth/bad tearing than anything else (like weight which they try to estimate before birth) Lisa Murakami’s first had a 95th percentile head or something and needed to be delivered with forceps. Hard to believe they couldn’t tell it was on the large side and going to be problematic

  • Sarah Wynne Fuller

    Hi Amy, thank you so much for this page. I had a 2nd degree tear with my baby 9 months ago. My stitches fell out 2 days after giving birth due to infection. My vaginal opening gapes like you described and i am in bits over it. Im not being taken seriously by the surgeon i got referred to. She denied it was even torn at first and said it had just stretched. Then she said 2nd degree tears dont even need to be stitched, so my stitches coming out was irrelevant.

    Is there anything that can be done to help me? could I send you a photo and have you tell me what you think?

    Thank you

    Sarah, Liverpool UK

    • Jocelyn

      Hi Sarah! I’m obviously not Amy, but I would recommend seeing a different doctor than your current one. Is that possible?

      • Sarah Wynne Fuller

        I am going to try to get a 2nd opinion, thank you

    • Dr Kitty

      Sarah, i’m a GP in the UK, so I am giving you advice from that perspective.

      See your GP.
      Explain that you are unhappy at the advice you have received.
      You have a right to a second opinion on the NHS. Ask your GP to refer you back to Gynaecology, specifically for a second opinion by a different CONSULTANT, preferably one with an interest in pelvic floor reconstruction.

      Make sure you explain any functional symptoms you have-pain, loss of sexual function, incontinence etc and if these symptoms are causing you significant distress say so.

      I very much hope that you will find a second opinion helpful.

      • Sarah Wynne Fuller

        Thank you Dr Kitty, I have been back to my GP and she told me to tell them I’m not happy with the advice. Ive also put in a complaint about the surgeon’s conduct because she was very dismissive to the point of insulting. Im waiting to have a meeting with her manager.
        She laid on the line the risks of surgery but it’s affecting me so badly I’m more than willing to take the risk.

        • Dr Kitty

          I’m glad you’re moving forward, I do hope you get the outcome you hope for.
          Sometimes the only thing to remember when dealing with the NHS bureaucracy is that “the squeaky wheel gets the oil”, so keep fighting your corner.

  • Danielle Hall

    I suffered 4th degree tears during labor 14 years ago…. I had a bad Dr. And now it’s becoming a problem the is no separation between the vagina and anus. It hurts to have intercourse and I have issues with my Bm’s and gas. Its so gross looking I’m so embarrassed and want to get it fixed but not sure if I can. Can you give me any advice??? Can it be repaired and look and feel normal???

    • Amy Tuteur, MD

      Yes, it can definitely be repaired.

      You can ask your gynecologist whether he or she does such repairs or whether you can be referred to a gynecologist who does. If there was extensive damage to the anus, a colo-rectal surgeon might be a better choice. First you need to be evaluated to find out exactly what is wrong and what needs to be fixed, but it definitely can be fixed with surgery.

      • Danielle Hall

        Thank you so much….. This was beyond helpful!!!!!

    • Captain Obvious

      An endoanal ultrasound can be done to check for the anal sphincter integrity. The perineum can look normal, but the sphincter can be weak or broken down. Pelvic physical therapy can help or surgery to repair the sphincter can be down.

  • Lady1

    Thank you!! Valuable information, I’m very relieved.

  • mom0f2

    I just had my son 11 days ago and have a 4th degree tear. I saw the doctor 3 days ago and my stitches were fine, then I had poop going into my vagina yesterday and he said there is now a hole in there. Talk about making you feel like less of a person. I have to see a specialist in a few days to see about having everything redone. pooping myself is not how I envisioned my maternity leave with my child. Running for the bathroom praying I make it in time, crying my eyes out about it.

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  • Liz R.

    Thank you for your post! I also have PTSD from my 3rd/4th degree tear that was improperly treated by a certified nurse-midwife practice at a birth center. No other problems with pregnancy or birth – otherwise both were pretty easy – but because of that treatment I’m in my second pregnancy scared out of my mind due to that lasting scar from the exact topic of this article. I’ve had extensive therapy, but PTSD is what it is, and I can never trust a midwife again. It was too many calls, too much of me asking for medical help as a first time mom, and being blown off by them until complications had mounted to an even more severe level six weeks later. Believe me – cutting if I hadn’t needed to be cut would have been easier to recover from than still not being fully recovered 5 years later. The midwife birth came at too high of a cost to mine and my family’s health because they didn’t treat the tear properly. The natural birth approach with midwives – who I had been told knew techniques to prevent this in the first place – did not prevent such a huge birth injury from occurring. It was relieving to find someone else with PTSD from this also – I’ve been thinking I was the only one.