Tearing might be on your mind as you get nearer to the birth of your baby. We know you are worried about the pain and how it might impact on your pelvic floor health. Your sex life. Your continence.

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For first time mamas, please know everybody gets a little bit of tearing. Whether it is a little – like a graze, or a lot, like a rare fourth degree tear – depends on a few factors and we have tips in this episode to help prevent or minimise your tearing. We also talk about what to do after you have birthed your baby to give you the best chance of pelvic floor recovery.

In this episode we talk about:

• Some anatomy. Perineum, anus, vulva. All the good bits.
• Things to prevent or minimise tearing.
• How your birth team can coach you during pushing to help slow tearing.
• What is an episiotomy and when might it be used.
• The difference between a first, second, third and fourth degree tear.
• What we mean by “Don’t fear the tear, it’s the undiagnosed tear without repair”
• We answer a listener’s question “should I have a Caesarean to avoid tearing?”
• Why you should have a full inspection of your perineum on the day of giving birth.
• What to do for your second baby if you’ve had tearing with your first.

Brigid [00:00:36] Well, hello, everyone. Here we are. Episode 28 and it’s tearing in child birth, what you need to know, it’s quite a big topic as well. Paddy isn’t it? It is. Yeah. I thought we’d start by reading out a review that we got from somebody on our team in Instagram. And I’m going to call her Daisy. And Daisy said. Hi, guys. So I just have to tell you how much I love your podcast. I found it back in October when my partner and I decided to go off the pill. I started listening to you, dreaming of one day being pregnant. Well, turns out only a short few weeks later I was. I tried a few other podcasts, but I kept coming back to yours and I still do. And it’s my favourite. I feel like it’s helped me not panic or feel overwhelmed, particularly the episode involving Down syndrome testing. I feel you guys have helped me make an informed decision that when I did my further research, I had a real solid base to start on. So thank you from the bottom of my and my baby boy’s heart. You definitely have a lifetime listener. You guys rock and I love hearing you together. Oh, it’s great, Daisy. Daisy. That’s not her name, by the way, people. I just like making people’s names up because I’d like to keep it as anonymous as possible. And Pat, you’re going to read something from someone I’ve called Isabelle yet. 

Patrick [00:01:50] So this is some from Isabel. Thank you for your excellent podcast. I have learned so much from it. Is there any chance you could do an episode about the change of your body after pregnancy? I have a lot of friends who have decided to have a C-section because they believe their vagina and sex life is going to be over after giving birth. I would love to hear your opinions. 

Brigid [00:02:13] One of my opinions is there’s a lot more going on after birth than just your vagina. When it comes to sex. Yeah. Well, that’s true, isn’t it? So. Got milk mountains of breasts that feel tender and sore. Crying. Baby crying. You’re exhausted. 

Patrick [00:02:29] Yeah. Sleep deprivation. So, you know, I mean, I think people everyone goes back to sex eventually. Yeah, but vaginal tears, you know, minor vaginal tearing or or abrasions or grazing heal relatively quickly. But the in terms of frequency of intercourse, there are. There are. It’s a time of enormous change. Yeah. And that may take ages to to to return to what it was. 

Brigid [00:03:05] Yeah. And sometimes there’s no set hard and fast rule on when people return to sex. Like sometimes it’s immediate and sometimes it’s whenever you know, whenever you’re ready. 

Brigid [00:03:18] They should be a time that you give yourself, you know, if. 

Patrick [00:03:20] It’s not something that people should feel like a lot of externally imposed pressure over. I think it’s pretty clear to most couples when the time is right. Yeah. So. So the question about should all of that affect our birth choices? Yeah, that’s a that’s a biggie. 

Brigid [00:03:38] Yeah. What do you think? What do you think people are trying to prevent? If they say, look, I’m going to have a caesarean section rather than a vaginal birth? 

Patrick [00:03:45] I think one of the things that that’s on people’s mind is not the minor grazing or abrasions in the vagina, which they know will heal quickly and are unlikely to cause any long term problems. But I think there’s a real fear about major issues, including tears into the anal sphincter. And I think some people have heard some horror stories about about those happening. Yeah. Not being recognised or expertly repaired and leaving that woman with a long term deficit, incontinence, continence in particular, anal continence. 

Patrick [00:04:25] And I guess that’s what people are most afraid of. Right. And I think today’s discussion is about helping to put that into perspective. Yes. And to help people make some some informed choices on that. 

Brigid [00:04:41] And this might seem basic, but I actually think that we should start back with the anatomy. Can we talk about what we’re talking about when we say Perineum and Tears first? Sure. And we’ll go into degrees of tearing, but I just think might be interesting. So, yeah. 

Patrick [00:04:57] So the easiest way to think of it is the Perinuem is the tissue between the vagina and the anus. 

Brigid [00:05:03] And its muscle. Is it?

Patrick [00:05:05] Mostly made up of muscle. Yeah. Yeah. And that’s the bit that will usually tear in when having your first baby, big head comes out a small vagina. And and that bit will often tear as the head comes through. What we don’t want to happen is for that tear to be large enough to tear into the fibres of the anal sphincter, which is the circular muscle surrounding our backside that that helps keep our backside closed other than when we went to go to the toilet. Yeah. All right. 

Patrick [00:05:44] So the tears have got a classification system and a first degree tear is just a tear in the vagina itself. And those are the easiest to fix and the fastest to recover. And do they? Well, we’ll go into fixing in the minute. Sorry, I interrupted second. Then there’s a second degree tear which is into the perineum, which is common and again, relatively straightforward to fix. That goes into the muscle fibres. Yeah. Yeah. But, um, but it’s common. It’s relatively easy to diagnose and repair. Then there’s a third degree tear which go into the anal sphincter and they need expert assessment and repair on the day of the delivery, immediately. And then there’s something called a fourth degree tear, which is mercifully rare. And that’s where a tear might go all the way through the perineum, through the anal sphincter and open up the the canal and the rectum itself. 

Brigid [00:06:44] Is that an obstetric fistula? No. 

Patrick [00:06:47] No. An obstetric fistula is is a possible consequence of a fourth degree tear.  That’s not diagnosed or that’s in expertly repaired. And that’s where an abnormal passage opens up between the bowel and the vagina, allowing contents from the bowel to come out the vagina. Globally, the most common cause of that is countries that don’t have access to immediate obstetric care. Because if your pregnancy obstructs at full dilatation and the fetal head sits there for too long, days, and then the tissue on the back wall of the vagina will break down and a hole will open up between the rectum and the vagina. 

Brigid [00:07:38] I’m sorry to even bring that up. It’s just because we because it’s so rare in Australia. Oh, absolutely. Yes. So well in developed countries. 

Patrick [00:07:46] So we see fistulas in Australia in people with cancers and other odder situations like that. But we don’t see that in Australia from obstetric neglect. Yeah, give or take because we’re able to deal with obstructed labour in a timely way. 

Brigid [00:08:06] So that’s rare. What about the. And fourth is. But what about 1, 2 and 3? How common is that degree of tearing? 

Patrick [00:08:15] Well, something’s going to tear a little bit if you’re having your first baby. Yeah. Okay. It’s very, very rare to get nothing. Yeah. Yeah. 

Patrick [00:08:21] Now it might be someone’s lucky and and things go super well with the first baby and the tearing is very trivial and we can just leave it alone. So. You know, I often say to people who, you know, that thing where you accidentally bite the inside of your mouth and and bite your cheek and and there’s blood. And that must be like a abrasion there. But after 10 minutes, it’s all stopped. And then. And then it’s after half an hour. It seems like it’s totally to heal. And so, yeah, your mouth got a really good blood supply and things heal quickly. 

Brigid [00:08:53] And mucous membrane heals pretty quickly, doesn’t it? 

Patrick [00:08:56] Yeah, but. But much faster than the same injury to your skin for example. And the vagina is a bit like that. It’ll heal quickly. So the very most minor really don’t need any attention at all. And then  the thing with second degree tears is. It is. We don’t find them if we don’t look. So it’s the sort of third indignity you’ve got the head coming out the vagina and then the attention that we give to people to make sure the placenta is delivered promptly because we know that prompt delivery of the placenta minimizes postpartum haemorrhage. And then we’re gonna have a really good look to see what the tearing’s like. And that’s that point where we tend to put your feet up in the air, bring the big overhead light in. Yeah. And examine the perineum for injuries. 

Patrick [00:09:50] And, you know, over the course of my specialist career, the cases I’ve been involved in where somebody might have wound up with a very poor result and very poor anal continence. You look back through the history, it’s not that it’s not that a third degree tear was diagnosed and fixed wrong. It’s that it was never diagnosed.

Brigid [00:10:13] Never diagnosed in the first place. 

Patrick [00:10:14] And why not? Because we didn’t look. So that’s that’s what we’re doing. You won’t find it unless you look and and it’s so important that we look carefully. And if that involves putting a bunch of local anaesthetic in, we do so. And then for a proper third degree tear we might even put in a spinal anaesthetic for someone who’s just had a baby with no anaesthetic. Yeah, because we want to be able to take our time and meticulously find and reconstruct the fibres from the anal sphincter. 

Brigid [00:10:48] I could imagine that. I mean, I ended up with four caesareans, but I could imagine that you’ve set up your birth room. Low lights, calm music. Sure. All your creature comforts around you. So you can have this lovely calm birth and then the big lights come on just to check your perineum. 

Patrick [00:11:07] Yeah. Also, I think there’s this there’s a way of doing that as respectfully as possible. But I think the main thing you could do if is if you’re worried, if someone you know, if a small woman had a four kilo baby and you think there must be a tear there somewhere, then the main thing you want is a block for pain. Yeah. Yeah. So whatever it takes to make that examination not painful I think is critical. 

Brigid [00:11:32] And does a local getting the needle in the first place and local anaesthetic, does that hurt? 

Patrick [00:11:38] Yeah it definitely it hurts.  That definitely does hurt. It’s traumatized tissue anyway. So there might be pain there already. 

Brigid [00:11:49] Yeah, it’s all swollen and. Yeah. 

Patrick [00:11:51] So we’re relatively quickly blocked the area with local anaesthetic then. Wait. So if there’s not terrible bleeding or anything, you know, I’m always saying to my junior docs just wait for it to work. You know, think of something else for a minute until the locals had a chance to take effect. Yeah. And after, you know, ten minutes, then have a proper look and look up the vagina and make sure you can see what’s called the apex of the tear, the top of it. Right. And then look down into the perennial body and make sure you can see the bottom of it. Yeah. And make sure  that it stops short of the anal sphincter fibres. 

Brigid [00:12:30] I’m gonna ask this question only because we hear it, while I hear it. You know, our friends sort of and come home from their birth or whatever and said, I’ve had 14 stitches or what? How many? What are we talking what what sort of repair are you doing? 

Patrick [00:12:43] Yeah, it’s not normally separate stitches like you might have in your finger. Okay. It’s a running stitch like the edge of a blanket. 

Brigid [00:12:49] A blanket stitch, I know how to do a blanket stich. And are they dissolving blankets. Yeah. 

Patrick [00:12:58] And they’re the stitches that you might have up the back wall of the vagina which is usually where the tear is and then and then some deep ones in the perineum. Yeah. And then a little one in the skin of the perineum. Try to close that skin. 

Brigid [00:13:18] And how do you do it. Yeah. We got a speculum like this. Like how do you get to the back wall of the vagina. 

Patrick [00:13:26] Ideally with a proper block, if you put two fingers in the woman’s vagina and separate those two fingers, you’ll separate the vaginal walls and you’ll see the tear. Yeah. Right. And then you’d get you get good at picking up the suit. 

Brigid [00:13:41] So you’d have to be very dexterous. Yeah. 

Patrick [00:13:44] Pick up the suture with your other hand. But this is this is routine stuff so. So we teach second degree vaginal tear repairs to our junior docs on the um on the labour ward and after a few weeks we would expect them to be able to assess that properly and and repair it without assistance. 

Brigid [00:14:00] And can anyone do the repair or is it always the obstetrician? 

Patrick [00:14:06] There are some midwives who are trained in in printing repairs up to a certain extent. Yeah. And then absolutely if there’s third degree involvement. Yes. Then that’s a job for a specialist obstetrician. Yeah. Because it’s it’s harder than it looks. 

Brigid [00:14:23] So for example, there someone’s been in a midwife led care. Would that mean that they transfer over or an obstetrician just gets called in? 

Patrick [00:14:31] Well, yeah, I don’t think that they need to to transfer out of her out of a midwifery model of care. But we would want the midwife to ring us up and say, look, this the tear looks like looks worse than I’m comfortable with. Could you come in, have a look please. And then we might take that patient to theatre, put in a spinal block to an expert third degree and then return them back to the usual postpartum care offered by the midwife program. Yeah. And and that’s that’s how it would work in a perfect world. And and then there’s some special stuff that will bring in for that woman over the first few days and then the first few months to maximize the result. 

Brigid [00:15:10] OK. We’ll get on to that. That’s where you’re talking about physio or something. Yeah. Yeah. So there’s. Yeah. Yeah. How about that. Yeah. So he talked about grazing. So he’s grazing just like biting eaglet. Yeah. Okay. Yeah. Everybody gets a bit of that. Mm hmm. It’s common to have a first degree. Less common to have a second and even less common to have a third. That’s right. 

Patrick [00:15:31] Yeah. Less and less and less common as they go along. That’s right. 

Brigid [00:15:34] Until you rare for the fourth. So can you predict who’s going to have a day. So this person is thinking about well. Should I have a cesarean section to prevent a tear? Like can you predict that that’s a good idea? Yeah. 

Patrick [00:15:47] Maybe there might be some things that we can do to predict it, but we would frequently be wrong.  But one of the factors is predicted size of the baby. So if we’ve got a petite woman with a very tall husband who’s his baby is. 

Brigid [00:16:12] With a big head. 

Patrick [00:16:13] Yeah. Babies more than four kilos on on our predicted weight on ultrasound. Yeah. Then that person is at risk. And we might say we you know, that might be one of the few situations these days where we would potentially recommend an episotomy cut, which is a deliberate cut made in the vagina. 

Brigid [00:16:39] Going where? Where does it start? 

Patrick [00:16:41] Then if you imagine the the crowning head and then the cuts made in the big the vagina, that’s at the six o’clock position. Okay. And. And on an angle away from the anus. Okay. So to direct to direct the forces away from the anus. That’s what it’s for. And that’s often the direction in which in which a tear would go. But the episiotomy is thought to be more more likely to stay away from the anus and also have nice clean surgical edges to sew back together rather than a tear, which is a bit can be ragged.

Brigid [00:17:23] So that used to be routine, but it’s not now, is it? 

Patrick [00:17:26] It’s not. That’s right. And back in the day, not that long ago, it was thought to be a good idea for pretty much everyone having their first baby. And it was thought that it was going to really help to cut down on the number of the degree tears. But like a lot of things in the medical world that we used to do, the evidence behind it was really lacking. And when we look at some of these things in detail. Turns out the evidence supports the opposite point of view. Yeah. 

Brigid [00:17:53] So a tear heals quicker and better. Yeah. 

Patrick [00:17:56] And that and that routine episiotomy is actually not that useful in reducing the type of tears that we’re talking about. So you know, the most severe ones. So and it’s routine use across the whole population might do more harm than good. Yeah. Right. So these days it’s a selected case issue. Yeah. And I’m sure I’m sure there are some obstetricians who cut more episiotomies than others and they might just have a lower cut off for where they think it’s useful. But lots of us do very, very few. Yeah. And once again, one of the cases where I might be a good evidence that the baby was really big. Yeah. And of course, the other situation where it’s routine to do it would be using forceps. Oh yeah. Cause, you know, forceps go round the outside of the head. So they were adding to the diameter. Yeah. Of of what has to come through the vaginal opening. Yeah. And also when the forceps are on your your adding in some unusual extra force and there’s definitely a higher risk of third degree tears related to instrumental births. Yeah. So cutting in a episiotomies and that sort of situation would be would be pretty routine. 

Brigid [00:19:21] Now we’re gonna cover assisted birth. We’ve been putting it off haven’t we. We’ve got it all planned. It was was due to be done in a few episodes. Yeah. I think we’re getting it. Yeah. Yeah, yeah. 

Patrick [00:19:30] Well you know my view on that, I think that that is that if you’re having your first baby needing an assisted delivery is not rare. Yes. So. So I think it’s something that people so commonly say, I wish I knew I know something about it. Yeah. Post-Fact. Yeah. Before they did it to me. Yeah. And when we look at how common it is, a vacuum or forceps amongst women having their first babies, as many as a third. Mm hmm. Seems like something we should know about. 

Brigid [00:20:06] Absolutely. Yeah. Yeah. And I think it’s well worth. This woman sort of talking about tearing. You know, it’s it’s self preservation. We want to be ourselves after we’ve had babies. You know, we want to have a good, healthy sex life. We want to feel like we’re continent. We’ve got that right, if you like. 

Patrick [00:20:24] Absolutely. So there’s this. It’s absolutely smart and sensible and normal to want to reduce that risk. But but but with direct reference to her question, is it worth doing a Caesar to reduce their risk? 

Patrick [00:20:39] The simple answer across the whole population in an average person with an average sized baby is probably no. Yeah. 

Patrick [00:20:55] Obviously, there are some risks and so forth associated with having a Caesar which have to be weighed up against it and you won’t get a third degree anal spincter from a caesar, but you could get a wound infection or God knows else. So all in all, for a standard risk person, the answer to that question is probably no. But there’s other things we can do to reduce the risk of tearing.Ok so what are they? Judicious us of episotomies for someone having a very large baby. There is some evidence that stretching the perinuem before labour.

Brigid [00:21:34] Now, I tried that. Like I’m you know, there’s a sample of one, but I tried that. But it’s just I gave up on it because I thought, well, what’s the point, really? Because there is no way that I can self stretch my perineum to 10 centimetres and that’s how far the perineum has to stretch. Yeah. 

Patrick [00:21:51] Well you certainly can’t or shouldn’t stretch to 10 centimetres. That’s right. But that’s what the head’s going to do. Yeah. But I guess the theory is if you, if it’s just made a little bit more stretchy in the right spot that the tearing might be less severe. 

Brigid [00:22:05] And I’ve just got a little description of what that is. So you insert your fingers into your vagina and you exert pressure on the perennial floor towards the bowel and to both sides until you feel a burning sensation. You maintain that for about a minute and then rest and then do it again. Yeah. Yeah. 

Patrick [00:22:23] So this is like stretching before exercise. It’s that we’re less likely to get it tear if the area is already a little bit stretchy. And there’s a commercially available device called an epiNo and that that sort of does the same thing. It’s a bit like a balloon. The idea that you blow up and it will stretch that perineum and that, you know, they actually have some published data in support of the use of their device. 

Brigid [00:22:49] Have you ever had any patients of yours using it? 

[00:22:52] Yes but I must say, I haven’t kept an eye on how they went from their point of view. But in this study supporting the epiNo you know, obviously that’s what they looked at. 

Brigid [00:23:03] Some health care providers do that perennial stretching during Labour 

Patrick [00:23:09] Yeah, that’s one of those things that we don’t actually know whether that helps or not. So I think the things that that to me seem likely to help are good coaching. 

Patrick [00:23:24] Yeah. So that so that the woman can be coached to allow the crowning to happen slowly. And and that the baby can be in a in a perfect vaginal delivery can be eased out rather than blasted out. 

Brigid [00:23:43] Oh my God. I’ve got a story about this. One of our friends, you know, we live in a small town, so Pat’s obviously delivered lots of our friends babies. Just by chance you delivered one of our good friends. And she said, oh, yeah. The thing about Pat was he told me to push. And then he said, hey, slow down. 

Brigid [00:23:58] You’re gonna push it out across the room. Yes, sir. Yeah. 

Patrick [00:24:01] So I’m sure that helps. Yeah. It makes sense that we if we give the tissue a chance to stretch. 

Brigid [00:24:07] Yes. Yeah. That’s right. Instead of really bearing down and pushing hard. Yeah. But you do need to push a little bit. 

Patrick [00:24:13] Well you do and you know the best pushing is achieved at the point where the woman says she can’t help but push. Yeah. So she’s she’s um reached an irresistible point of no pushing like a reflex. Yeah. Yeah. Yeah. Can’t you. There’s nothing I can do but push yeah. So but but with good coaching the strength of that push can be modified to to help ease the head out instead. Yeah. 

Patrick [00:24:40] And I think the other things that probably help are if the if the birth assistant be that a doctor midwife, whoever is providing some support to the perineum with sort of a pinching manoeuvre on the on the perineum between the thumb and forefinger to to give it a bit of extra support. Okay. And less likely to you know, really spring apart yes. And and I’m a believer that if we help keep the fetal head flexed as it comes down as well, then it’s small as it comes in. 

Brigid [00:25:20] How do you keep the fetal head flexed? 

Patrick [00:25:22] Well, just as it crowns up, yeah. If I’m right handed. So with my left hand, I’ll just be touching the baby’s head and pushing and trying to push the head down towards the floor. Yeah. It tucks the baby’s chin under and means that the diameter of fetal head that being presented to the vaginal opening is a little smaller. Yeah, because if the heads deflexed in the chin and the chin comes up, then a bigger diameter of head. Remember when the baby comes out, the head’s mo. 

Brigid [00:25:53] I remember it well. This happened to me my first two births, where both boys, their head was de flexed and that which, you know, they were coming out forehead first. 

Patrick [00:26:00] Yeah. So. That’s right. So the head, you know, the especially at the end of a long first birth. The head is more like a tube than a ball. Yeah. And and not every diameter of it is the same. Yes. Big diameter and small diameters yeah. So if we can encourage the head as it crowns up to be in the smallest of those diameters as possible then then that surely helps as well. 

Brigid [00:26:24] And what about birthing positions. Does that impact on tearing at all? 

Patrick [00:26:29] Yeah, there’s a bit of data about this. So there’s that. There’s another. You know, that’s another age old question is what? What’s the best position? I think the answer is wherever the woman wants to be. But some of the birthing positions other than lying on your back have better data for unassisted delivery and better data for this and that. But but maybe slightly worse data for second tearing

Brigid [00:27:01] Yeah, I can imagine if you’re squatting or or standing even like it’s that expulsion, like the gravity might be just too much. Is that why you reckon tearing might happen? Yeah. 

Patrick [00:27:12] I don’t know if gravity strictly comes into it, but I think that there might be and this is a personal opinion only them. It might be harder to control the the the strength of pushing during crowning if you’re squatting than if you’re lying down. 

Brigid [00:27:27] Yeah. Okay. All right. Okay. So what about other things that, you know, we all want to do the very most we can do for ourselves. 

Brigid [00:27:34] So, you know, what about things such as warm water or towels or anything like that to put on the perineum? 

Patrick [00:27:45] So I think the things using a warm compress on the perineum I think is helpful for comfort. Yeah. And therefore may well be helpful in that overall sense of control. Yeah. So one of the things that might want to make you push uncontrollably might be the dreadful pain you are in. Yes. And you just want that to be over. Yeah. So whatever we can do to help manage that, such that the woman at that point can say or I’ve still got it in me to hold off just a little. And I have a birth that’s more control. Yeah. Might be things that help with the pain. Yeah. And like like a warm compress on the perineum, like the inhaled gas Yeah. And one of the aspects of the birthing programs like HypnoBirthing that we really like is that they concentrate on, you know, mantras, breathing the baby, breathing the baby out and a positive visualizations and mental places to go to in a crisis that can help with to make a birth what the woman wants.

Brigid [00:29:12] And calmbirth, they’re the two techniques that we talk about a lot, hypnobirth and calmbirth. 

Patrick [00:29:17] Yeah. So they they, you know, commercial names of courses that people can go to to really learn some of these techniques which can can help people’s odds of achieving a birth that’s really what they’re looking for,. 

Brigid [00:29:33] It is about birth satisfaction. Yeah, exactly. Yeah. 

Patrick [00:29:36] Do they change overall outcomes? I don’t know. But, you know. But satisfaction, if I’ve got somewhere where I’ve been trained where I have some techniques that I’ve been trained to use so that when it gets tough, I can rely on those things, then I may be able to dig deep using those techniques and and have a birth that’s more like what I imagined, a vaginal birth unassisted and so forth. 

Brigid [00:30:04] All right. So we’ve talked about how perhaps we might prevent it, but we’ve gone on. And we’ve done all this and perhaps we’ve had a tear.

Patrick [00:30:12] Still got a tear anyway. 

Brigid [00:30:13] So what happens now? So it’s a second or third degree day. 

Patrick [00:30:20] So as we’ve talked about, a lot of first degree tears, they might need a stitch if they’re bleeding, or they might might be able to be left alone. Second degree tear is best repaired. And the trick to that is a proper block so you can have a proper look. Find the extent of it and suture it properly. 

Brigid [00:30:37] And are you still in the same room that you had the baby in for a second? 

Patrick [00:30:40] Yes. For a third. We tend to go to theatre. Right. Not not always in the situation where we might not. Might be we’ve got an excellent view. Yes. We’ve maybe got an assistant. Yeah. And the woman has already had an epi, a really good epi or they have a spinal. Yes. So maybe we’ve put in a spinal to do a forceps or something or we’ve topped up the epi. Yeah. To do a forceps. And then there’s a tear that needs fixing. Well under perfect circumstances we might do it then and there in the labour ward. But mostly to get those perfect circumstances we want to go to the operating theatre. Assistant. Proper anaesthetic. The overhead lights. Yes. Everything. We need to get the result as good as possible. 

Brigid [00:31:29] And you don’t have your baby with you at any of this stage? 

Patrick [00:31:33] No baby will be with with dad, usually partner and go into theatre. Yeah. And sometimes general anaesthetic. Sometimes spinal anaesthetic. Yeah, right. Yeah. Yeah. And then. 

Patrick [00:31:46] And then you know, just just take our time to fix it properly because the price is high. Yeah. Everybody on the planet values their anal continence and we want to get this right. And then put in a plan over the next few days so that we might you know, here in Australia in the first few days after childbirth, well, I use in my practise some medication given given rectally for pain relief, like high dose anti-inflammatories, for example. And they work super well and they don’t upset your tummy if you have them in your bottom.  So we might not do that in someone who’s just had a third degree tear repair.We want to be really diligent with constipation. Yeah. A lot of women, if they’ve just had a baby, get constipated for a number of important reasons. But we would we would really go to town in someone who’s had a recent third degree tear repair to make really super sure that they didn’t push against that repair through constipation. 

Brigid [00:32:55] So they already on constipation medication is just food?  

Patrick [00:33:01] What they what they’re eating. Yeah. And you know, pear juice, prune juice prejudic, right up to drugs to help keep the the motion as soft as possible so that she’s not sitting on the toilet for half an hour pushing against the repair while the repair is trying to heal. 

Brigid [00:33:19] Yeah. Have you ever seen that with repairs come undone? 

Patrick [00:33:23] They don’t come undone. Okay. But we think they don’t work as well. Yeah. Yeah. So they’re they’re very, very likely to come undone such that we can see it. But down at a tissue level, up on the inside where you can’t see, it seems unlikely it’s healing as good as it could be. Yeah. 

Patrick [00:33:38] If it’s being really significantly stretched at least once a day. And then further down the track we we would say to the woman with a third degree tear that her post-partum pelvic floor stuff was really not optional. Definitely better long term results by by exercising the pelvic floor. Yeah. And by and long term attention to diet. Yeah. So that we can avoid constipation as much as possible and then try and train that woman to continue to do those exercises even in the absence of symptoms. 

Brigid [00:34:23] Yes. And things such as we return to exercise like, you know, proper exercise as well, I would imagine is a big thing. 

Brigid [00:34:30] You don’t want to be there lifting big weights and putting pressure on an area that has time to heal. Absolutely. Yeah. So someone with a third degree, they’ve had it repaired. Well, even second degree. How long’s that take to heal? 

Patrick [00:34:44] I think the second degree you can hardly tell you’ve had one after about three weeks. And then by the time people return to intercourse, it maybe maybe from six weeks or something, it’s fine. There are some problems we occasionally see with some second degrees that don’t quite heal properly. Some can get infected, there can be wound breakdown, and that’s why I like to have a look at about two weeks to make sure everything’s on the right track. And then at the six week review, we have another look. 

Brigid [00:35:24] So if a woman feels that, what would she be feeling herself to know to come and see you at two weeks? Or do you automatically book that in or should somebody automatically book that? 

Patrick [00:35:32] I think somebody’s having a look at two weeks is a good idea. In the setting of one breakdown or infection, the woman’s likely to experience pain.

Brigid [00:35:43] Yeah. Okay. So that’s your your siren. Are you feeling pain? Go on and have it assessed. 

Patrick [00:35:50] It should be. Give or take. Painless after a few weeks. And then with third degrees, it’s more complicated. We’re likely to have that woman in at least that close surveillance. Yeah. And, um. And then sometimes people will say, well, we’ll what should I do next time. Yes. And that’s a can be a difficult question to answer. Yeah. A first and a second degree tear. The most common answer would be nothing different. You know, if had even if it happened again we’d fix it again. Yeah. Yeah. And there’d be no great consequence if you got a second degree tear again. If it was expertly assessed and repaired. 

Patrick [00:36:36] The third degree is different. You know, it may be that that anal sphincter sort of got one tear in it. And that recurrent tears may have poorer long term results even if the repair is good and the post partum care is good. And some people, in order to avoid that, might have caesarean sections for subsequent births. 

Brigid [00:37:04] Yeah. Back to that first question. Why didn’t you have one in the first place? 

Patrick [00:37:09] But anyway, yes, I do it a lot. Unfortunately, the two separate questions here. One, is it. 

Patrick [00:37:15] Is it worth having a Caesar to prevent this? Yeah. When I’m not at high risk. Probably not. No. Is it worth having a Caesar to prevent more of these? Now that I’m known to be at high risk because what has already happened to me? It’s separate question and question and answer. And the answer’s probably yes. 

Brigid [00:37:34] So if someone has had a third degree tear and it’s it’s repaired and it’s healed as well as what we think. What’s it like for her to return eventually to sex? 

Patrick [00:37:47] So, yeah, people will often report that it’s painful at the start and that the scar itself is a sore. And I think if that’s what women are experiencing, then it should be checked out to make sure that the healing has actually, is actually complete. Yeah. 

Patrick [00:38:05] And in particular, you know, we talk about the suture material taking six weeks to dissolve, but some people it’s much longer and they’ll still be a knot of suture material right there at the perineum after longer than that. Wow. And so that can just be removed. Usually if you just pick it up, it’ll break off. Yeah, because it’s dissolving suture and it’s mostly dissolved. And then some people will have a a tender area in the scar that goes on and on and on. It’s possible for that to be sometimes treated by rubbing oestrogen cream into it. Yeah. What before sex. Or just as a treatment. As a treatment to help it heal. And I think there’s probably more pain in women who are breastfeeding some of the hormones of breastfeeding might make the perennial tissue more tender. So rubbing some oestrogen cream in there like we might using a post-menopausal woman for vaginal comfort is some can be effective and eases. 

Brigid [00:39:05] So is this after the 6 week take. Yeah. 

Patrick [00:39:07] People don’t tend to sort of complain about it until they try and return to intercourse. And then occasionally there’s a role for very occasionally there’s a role for a redo. 

Patrick [00:39:19] And is that done by a well by you or is that a plastic surgeon or just by the by an obstetrician gynaecologist? 

Patrick [00:39:26] Sometimes it’s for cosmetic reasons. Sometimes it might be really unhappy  the way the scar has come together. Yeah. And, you know, we don’t judge people for that. Not not. Some people don’t care about the appearance of their genitals, but some really do. So. It might be for cosmetic reasons. But I think that the re-dos of obstetrics scars are something that a general obstetrician gynaecologist would be called upon to do from time to time. 

Brigid [00:39:52] And do you see a rise in that? 

Patrick [00:39:54] Can’t say I have seen a rise in that in particular. Certainly seen a rise in people who are worried about the appearance of their genitals. 

Brigid [00:40:01] That’s a different that’s a different topic is mentioned, you know? Yeah, that is a different topic. 

Brigid [00:40:06] There was something on Mamamia’s Instagram the other day. A woman has done a study where she’s taken photos of something like 50 different vulvas just to show the differences. Nobody’s got the same vulva. 

Patrick [00:40:22] That’s right. Yeah. So this enormous variation, variation in normal anatomy. Yeah. Yeah. And, um, I think a lot. That’s something we sometimes see in younger women who are particularly concerned about that. After childbirth I must say that’s not really the complaint that I’m getting. It would be more about persistent pain. Persistent pain. Yeah. All right. 

Patrick [00:40:45] I think, you know, in general, we should be looking at tearing as a really a normal part of vaginal childbirth. In particular, first time and, you know, a degree of tearing, hopefully minor, hopefully not major is likely to happen. And and, you know, when I’m seeing women, for antenatal care and then they talk about it being really worried about that. I try and steer them away from worried about whether it happens or not because a degree of it is probably going to happen. 

Patrick [00:41:21] There’s much more to worry about if if the tear is not properly assessed, not properly diagnosed and not properly repaired. And one thing we should be guaranteeing ourpatients is that they will be properly assessed, diagnosed and repaired.

Brigid [00:41:36] So what would a woman do to make sure she can advocate for that? 

Patrick [00:41:43] Yes. Excellent question. I think that if somebody goes through a low risk birth model and is told for whatever reason that a proper examination isn’t necessary. I think people should say should be feeling very much empowered to say, no, I’d like to have a proper look please. And in my view, a proper look means you leave isn’t an overhead light yet and or a headlight on the person doing the examination and your legs apart. And you’ve got some sort of pain relief on board so that we can have a proper look. Yeah, we know that some of these are missed. Mm hmm. And institutions that report high level of third degree tears, not a huge level, but a higher level of third degree tears than they used to. Sometimes the authorities will say, what’s going wrong in your hospital? You’re getting more third degree tears than you used to. And our response, you know, we’re finding more third degree tears than we used to. We could report and an incidents of zero if you want us to by not looking. So it’s a good thing. We Look, we find we fix. 

Brigid [00:42:57] Again. So don’t fear the tear. It’s the undiagnosed repair. Oh my god that rhymes.

Patrick [00:43:07] Yeah the undone repair. The repair that we should have done and it didn’t happen. 

Brigid [00:43:09] Yeah. What happens post say six weeks in and for some reason that you think that there’s been an undiagnosed repair. What happens to that.

Patrick [00:43:22] Well the tissue will all stick back together. Yeah. So it’s not like that. If you examine the woman, she’s going to have a gap. It’ll all stick back together. But down in the anal sphincter, the ends are just not attached. 

Patrick [00:43:35] It’s a doughnut shaped piece of muscle. Yeah. And if it’s broken, it doesn’t work. Right. So if that is a is partially torn and then the muscle will be weaker. Yeah. And that woman might go away experiencing some fecal soiling or inability to hold in a fart and that might be permanent. Yeah. And if the muscle was completely torn. And God forbid that wasn’t diagnosed then those problems will be so much worse. Yeah. Right. So then eventually that person would come back and say, look, my backside isn’t working properly. And there’s an ultrasound that can be done, sort of like a full circle ultrasound that can be done by putting a little ultrasound, probing the anus that takes a picture all the way around, like an OPG for your wisdom teeth. 

Brigid [00:44:34] That’s right. Yeah. 

Patrick [00:44:35] And then, you know, when you look at the image and there’s a bit missing. Yeah. Right. OK. And that’s the bit we should fix. 

Brigid [00:44:41] And what can you do then? 

Patrick [00:44:42] Well, the the sphincter can be reconstructed by a colorectal surgeon. But that opportunity has, you know, in many ways been missed. 

Brigid [00:44:53] Yeah. And that must really boil your blood, does it? 

Patrick [00:44:56] I think it’s it’s disappointing if it was missed because nobody looked. Yeah. Yeah. Then then that’s you know, that that is disappointing, I think. I think these are not not that rare. Yes. And the least we should be doing for people is is finding them and fixing. Yep. 

Brigid [00:45:13] All right. So I reckon the take home message is that you have the information now women, you can be your own advocates and you can ask after your child’s been born to have somebody probably check and assess with proper lighting your legs up. I know it sounds. It is. 

Brigid [00:45:27] It is undignified. 

Patrick [00:45:28] Undignified. Yes. Yeah. But, um, but that might be a much smarter thing. Yeah. Than asking for a Caesar in the first place. 

Brigid [00:45:36] Yes. Or a lifetime of, you know, painful sex or incontinence. Absolutely. All right. Good. 

Patrick [00:45:42] I think we’re we’re done. I hope that was informative for everybody. Thanks for listening, everybody. Thanks for listening. And we’ll see you next week.