Obstetric Lacerations, Episiotomy and Fistula

A first-degree laceration is the smallest tear that happens during delivery, involving injury to the lining of the vagina and/or skin on the perineum (the area between the vagina and anus). This type of tear is common, usually heals well and is associated with minimal pain. Although stiches are not usually needed, if you do have them, they will dissolve on their own within six weeks.

A second-degree laceration is the most common tear occurring during delivery and involves the muscles in the vagina and perineum (the area between the vagina and the anus). This type of tear usually heals well with pain resolving by two weeks after delivery. If stitches are needed, they will dissolve on their own within six weeks.

A third-degree laceration is a tear that involves both the vagina and perineum (the area between the vagina and the anus), extending from the first layer of the vagina through the muscles of the vagina and perineum, and also into the muscles of the anal sphincter (the muscles that control bowel movements). These tears are less common, but happen during delivery due to a variety of factors.

Risk of a third-degree tear is greatest:

• During a first vaginal delivery
• When a baby is delivered in the face-up position
• During a vacuum or forceps delivery
• If the woman requires an episiotomy
• If the baby weighs more than 8 pounds
• If the mother is Asian

While most women heal well from third-degree lacerations, one in five may have an infection early on and one in four may have difficulty with healing. Long-term, some women have lasting vaginal pain or pain with sexual intercourse. Others may have trouble controlling gas or bowel movements.

Signs of infection include pain not controlled by medication or suggested self-care, a foul-smelling discharge or fever of 100.4° F or greater. Contact your doctor if you have any of these symptoms.

Women who have a third-degree laceration have about a 6% risk of third- or fourth-degree lacerations in future vaginal deliveries, but this is still considered a low risk. Clinic director Lisa Hickman, MD, will discuss your individual situation and work with both you and your obstetric provider to create a delivery plan for your next pregnancy.

A fourth-degree laceration is the least common tear, extending from the first layer of the vagina into the muscles of the vagina and perineum, through the muscles of the anal sphincter (muscles that control bowel movements) and into the anus.

Risk of a fourth-degree tear is similar to third-degree tears and is greatest:

• During a first vaginal delivery
• When a baby is delivered in the face-up position
• During a vacuum or forceps delivery
• If the woman is given an episiotomy
• If the baby weighs more than 8 pounds
• If the mother is Asian

While most women heal well from fourth-degree lacerations, one in five may have an infection early on and one in four may have difficulty with healing. Long-term, some women have lasting vaginal pain or pain with sexual intercourse or bowel movements. Others may have trouble controlling gas or bowel movements.

Signs of infection include pain not controlled by medication or suggested self-care, a foul-smelling discharge or fever of 100.4° F or higher. Contact your doctor if you have any of these symptoms.

Women who have a fourth-degree laceration have about an 8% risk of third- or fourth-degree lacerations in future vaginal deliveries, but this is still considered a low risk. Clinic director Lisa Hickman, MD, will discuss your individual situation and work with both you and your obstetric provider to create a delivery plan for your next pregnancy.

When a woman suffers a third- or fourth-degree tear, this is classified as an obstetric anal sphincter injury or OASIS. These more extensive tears involve the anal muscles and in the most severe cases, the anal lining as well. Even after proper repair by your obstetric provider at the time of your delivery, OASIS can lead to difficulty with bowel control or other problems.

Many women are concerned that a tear prevents a future vaginal delivery. This is not always the case — in fact your risk of a future third- or fourth-degree tear following OASIS is only about 6% for future deliveries. Of course, every woman’s situation is different, so your doctors will work with you to set goals, identify risks and plan for your next delivery.

An episiotomy is an incision in the perineum to help quicken the delivery of a baby. There are two types: median and mediolateral. ­

• A median episiotomy is where the incision starts in the middle of the vaginal opening and extends straight down at a 90-degree angle. ­
• For a mediolateral episiotomy, the incision starts in the middle of the vaginal opening but extends down at a 45-degree angle toward the buttocks to reduce risk of an anal tear.

When women do require an episiotomy, there can be increased risk of blood loss, more severe pain, increased infection risk, a more challenging repair, difficulty with bowel control (especially with a median episiotomy), and postpartum or long-term discomfort, especially during sexual intercourse.

An obstetric fistula is an abnormal connection or small tunnel that develops between the birth canal (vagina) and either the bladder, urethra or rectum. These fistulas tend to occur more frequently with prolonged or traumatic labor, and occur very rarely in the United States.

These muscles provide important pelvic organ support, and it’s common for the vaginal muscles to be injured during a vaginal delivery due to stretching and tearing, or weakened due to the pressure caused by the growing uterus in pregnancy.

Muscle weakness or injury can lead to a variety of issues, including bowel or bladder control problems or lasting pain, even years after delivery.

A woman may also develop pelvic organ prolapse, which is when one or more of the pelvic organs — the uterus, bladder or rectum — weaken or drop and press into or out of the vagina. This is typically experienced by women as a vaginal pressure or fullness, or a bulge they can see or feel in or coming out of the vagina.