Evaluating Tears After Birth

After the baby is born and the placenta is out, evaluate the woman for tears. It can be challenging to recognize what tissues are damaged after birth. This video will show how to evaluate tears and how to decide which tears need to be sutured.

Examine for tears. Tears can be hard to see clearly. Use a good light and take your time as you examine each woman. First find the start of the tear, called the apex. This will help you recognize what is torn. Then evaluate how deep the tear is, in the direction of the rectum. This will help you understand the extent of damage to the muscles underneath. The depth can be estimated in fingerwidths. Examine a lot of tears. This is the best way to teach your eyes to see.

Let the woman know you’ll be examining her vagina. Then examine the tear in a systematic way. Using a gentle touch, carefully open the vagina to see how far the tear goes inside. Find the apex. Then, check the depth. Examine the upper part of the vagina and the labia for tears. And last, push the torn sides together to see how they will join.

Here is another example. Gently open the vagina to see the tear. Find the apex. Note the depth of the tear. Examine the upper vagina and labia. And last, see how the tear will come together. If the tear is deep, assess the anal sphincter muscle. The sphincter muscle may be whole and intact, partially torn, or completely torn. Look and feel to assess the tear.

Here the tissue overlying the anal sphincter muscle is smooth and intact. It feels like a firm continuous band of tissue. The muscle tightens together in a circle. If it’s partially torn, you may feel a defect. If it’s completely torn, you may find the ends of the sphincter muscle: One end is here. The other end has retracted and only a round dimple is seen. You will not feel a firm band of tissue. And the muscle cannot tighten in a circle.

With a deep tear, be sure to do a gentle rectal exam to assess the anal sphincter. Palpate the sphincter muscle from 10:00 to 2:00. If it’s not torn, it will feel firm and continuous without any defects. Next, bring your finger up to look for any tears. Notice the smooth intact sphincter muscle. And last, ask the woman to squeeze her anus – you should feel the muscle contract around your finger. Then discard the glove and use a new one. Decide which tears need to be stitched. After examining the tear, share your thoughts with the woman. Decide with her whether to suture the tear or not.

Tears are classified into 4 degrees according to their depth.

A first-degree tear is shallow. It’s less than a finger width deep, doesn’t extend into muscle, and is not bleeding heavily. Small tears may not need to be sewn. They will usually heal well on their own.

A second-degree tear is deeper. The tear is more than one finger width deep, extending into the muscles of the perineum but does not involve the anal sphincter. If it’s sutured it will heal better and restore the tone of the pelvic floor muscles.

A third degree tear extends into the anal sphincter. In this complete third degree tear, we find one end of the muscle here and the other end here; drawn back inside the tissue. Now one end is clamped and the other end is retrieved and then clamped. Third degree tears need to be sewn back together by a skilled clinician.

A fourth degree tear goes through the anal sphincter and the lining of the bowel, into the rectum. Notice the finger inserted into the rectum rises right through the torn tissue demonstrating that the rectum is completely torn.

Third and fourth degree tears must be sewn. The woman can have permanent damage and never be able to hold her stool in again. They are more difficult to repair. If you do not have the experience to repair these tears, be sure to refer the woman to someone with more suturing experience.

Remember, learn how to evaluate tears by examining as many as you can in a systematic way. Gently open the vagina: find the apex, assess the depth, check for upper vaginal and labial tears, and see how the tear goes together. If the tear is deep, be sure to determine whether it involves the anal sphincter.