Obstetric tears and pelvic floor injury

How does this happen?

As the baby's head is born, the tissues of the perineum stretch. If they stretch beyond what they can take, they tear.

The degrees describe how deep the tear goes. ¹

• First degree: skin and the lining of the vagina only.
• Second degree: into the muscle of the perineum. This is the most common tear needing stitches.
• Third degree: into the anal sphincter, the ring of muscle that controls the anus. It is further subdivided by how much of the sphincter is involved.
• Fourth degree: through the sphincter and into the lining of the anus itself.

Separately, the pelvic floor muscles and the nerves supplying them can be stretched or injured without any visible tear. That is why someone with no tear at all can still have significant pelvic floor symptoms, and why "you didn't tear" is not the same as "nothing happened."

The pelvic floor supports the bladder, the uterus and the bowel, and it keeps the openings closed until you decide otherwise. When the muscle or its nerve supply is injured, the result is leaking, urgency, a sensation of something bulging, or pain.

Guidance addresses prevention, including that routine episiotomy is not recommended and that midline episiotomy carries a higher rate of severe tearing. ¹

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• A first vaginal birth, where the tissues have not stretched before. ¹
• A large baby, whose weight could not be reliably predicted. ³
• A fast second stage, which gives less time for stretching.
• The baby's position, including a head that is facing upward.
• shoulder dystocia, where the maneuvers required carry their own risk. ⁴
• Operative vaginal birth that was genuinely indicated. ⁵
• breech or other malpresentation. ⁶
• Individual tissue differences, which cannot be predicted. A general patient reference describes perineal tearing as a common occurrence at vaginal birth. ⁷

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Routine or midline episiotomy, where guidance does not support routine use and notes the association of midline episiotomy with severe tearing. ¹
• A third or fourth degree tear not recognized. Examination after birth, including a rectal examination where indicated, is how these are found. A tear that is missed is repaired late or not at all. ¹
• Repair by someone without appropriate training, or with inappropriate technique or materials. ¹
• Antibiotics not given where indicated for a severe tear. ¹
• No follow-up arranged after a third or fourth degree tear. ²
• Symptoms dismissed as normal after childbirth, which is the single most common failure described by people living with these injuries.
• Pelvic floor physiotherapy not offered.

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. Severe tears occur despite good care.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Pain and bleeding at the time of birth.
• The degree should be assessed and documented at delivery, including by rectal examination where indicated. ¹

Ask what degree of tear you had. Many people are never told, and it is written in the notes.

The first week

• Pain, swelling and bruising.
• Difficulty sitting.
• Stinging when passing urine.
• Fear of opening the bowels, which is very common and leads to constipation, which makes everything worse.
• Report urgently: increasing pain, foul-smelling discharge, fever, or the wound opening. These suggest infection or breakdown of the repair. ²

Around 3 months

• Leaking urine when coughing, laughing or exercising.
• Urgency, or not making it to the toilet in time.
• Difficulty controlling wind or stool. This is the symptom people are least likely to mention and most need to. ¹
• Pain during sex.
• A sensation of heaviness or of something bulging.

Around 6 months

• Persistent incontinence, which should be assessed and not accepted.
• Pain that has not settled.
• Scar tissue causing discomfort.

Around 12 months

• Ongoing symptoms in some people, all of which have treatments.
• Anxiety about a future birth, which is a legitimate reason to plan carefully.

Toddler years

• Symptoms can appear or worsen years later, particularly around menopause, in people who had a sphincter injury. This is worth knowing so it is not treated as unrelated.

School age

• Not applicable.

How is it diagnosed?

Examination immediately after birth, which should classify the tear by degree. A rectal examination is used to identify sphincter involvement, because a third degree tear can look like a second degree tear from the outside. ¹

Ask what degree you had and make sure you have it in writing.

Later assessment where symptoms persist:

• Examination by a specialist in pelvic floor disorders.
• Endoanal ultrasound, which shows whether the sphincter muscle is intact.
• Anorectal manometry, which measures the strength of the sphincter.
• Urodynamic studies where urinary symptoms are the main problem.

A record of the birth itself, including the delivery note and any operative note, which you are entitled to request. ⁸

Ask to be asked. Guidance treats postpartum care as an ongoing process, and symptoms of incontinence should be actively enquired about. If nobody asks you, raise it yourself. Many people wait years. ²

What is the treatment?

Repair at the time of birth, by an appropriately trained clinician, with attention to technique. Third and fourth degree tears are repaired in an operating room with adequate anesthesia. Antibiotics are given where indicated. ¹

Immediate aftercare: pain relief, stool softeners to avoid straining, ice, and hygiene advice. Stool softeners are important and are frequently the difference between a comfortable first week and a miserable one.

Pelvic floor physiotherapy, which is the mainstay for pelvic floor symptoms and which many people are never offered. Ask for it by name.

Further treatment where symptoms persist:

• Bowel management, including diet and medication for stool consistency.
• Biofeedback.
• Sacral nerve stimulation.
• Surgical repair of the sphincter, where indicated.
• Treatment for urinary incontinence, including physiotherapy first, then other options.

Planning a future birth. After a third or fourth degree tear, the mode of delivery for a subsequent pregnancy should be discussed specifically, taking symptoms and sphincter integrity into account. Raise it at the first appointment. ¹

What is the long-term outlook?

Most first and second degree tears heal well with no lasting effects. ¹

Most third and fourth degree tears heal with good function after proper repair and follow-up, but a meaningful proportion of people have ongoing symptoms with control of wind or stool. Those symptoms have treatments and should be pursued.

Pelvic floor symptoms very often improve substantially with physiotherapy, which is under-offered.

Symptoms can appear or worsen years later, particularly around menopause, in people who had a sphincter injury. Knowing that is useful, because it means new symptoms in later life are not unrelated and are worth investigating properly.

The most consequential thing in this whole area is whether someone asks. Many people do not volunteer these symptoms and are never asked, and then live with them for decades. ²

What does daily life look like?

The first weeks: pain, difficulty sitting, and the fear of the first bowel movement. Stool softeners, water and not straining are the practical answers.

Afterward, for people with ongoing symptoms, life gets organized around toilets, and that is a large and hidden burden.

Sex is often painful for a period, and sometimes for a long period, and this is treatable rather than something to endure. Raise it.

Ask for pelvic floor physiotherapy by name. In many places you will not be offered it unless you ask.

Write down what degree of tear you had and keep it. It is relevant to any future birth and to your care decades from now.

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for obstetric tears and this site does not invent one.

Costs are the repair, physiotherapy, and where needed further surgery. Coverage for pelvic floor physiotherapy varies substantially by insurer.

See paying for care.

What can you do this week?

1. Find out what degree of tear you had and get it in writing.
2. Ask for stool softeners and use them.
3. Report urgently: increasing pain, fever, foul discharge, or the wound opening.
4. Ask for pelvic floor physiotherapy by name.
5. If you are leaking urine, wind or stool, say so. It is common and it is treatable.
6. Ask what follow-up is arranged after a third or fourth degree tear.
7. Ask what this means for a future birth, and note the answer.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the obstetrician or midwife

• What degree of tear did I have, and was there sphincter involvement?
• Was a rectal examination done to check?
• Who repaired it, and where?
• Were antibiotics given?
• What follow-up is arranged, and when?

For the pelvic floor specialist

• Is my sphincter intact on imaging?
• What is causing my symptoms specifically?
• What is the first-line treatment, and how long before we know if it works?
• What are the options if physiotherapy is not enough?

For a future pregnancy

• Given my previous tear and my symptoms, what mode of delivery do you recommend?
• What would you want assessed before I go into labor?

You can also build a printable list with the question generator.