Vaginal lacerations are extremely common during delivery. Not to be graphic, but you did just fit a cantaloupe through a hole the size of a tennis ball. Fortunately, the vaginal tissue is forgiving and stretches significantly during the vaginal birthing process. However, the vagina still does tear. There are four main categories of tears that occur during delivery based on the depth of the tear: first-degree laceration, second-degree laceration, third-degree laceration, and fourth-degree laceration. First and second-degree vaginal lacerations are the most common tears that occur during a vaginal delivery. Third-degree vaginal lacerations are less common, and fourth-degree vaginal lacerations are the least common of the types of tears; only occurring in about 1-2% of non-instrumented (forceps or vacuum) vaginal births. Unfortunately there is no fail proof way to prevent vaginal tearing. Most of it is dependent on your anatomy, the size of the baby, length of labor and use of instruments to aid in delivery (forceps or a vacuum).
First-degree lacerations are the most shallow of the four types of tears involving the outer most surface layer of vaginal tissue. First-degree tears usually heal quickly without complication. In general, first-degree tears will require some stitches to repair the tissue so that it heals correctly. Your physician or midwife places those stitches immediately after delivery. The stitches will dissolve in 6-8 weeks.
Second-degree lacerations involve slightly more tissue than the first degree, but only involve vaginal tissue and do not extend any deeper. Just like first-degree tears, second-degree tears heal quickly without any major complications. Stitches are required to bring the vaginal tissue back together to allow for healing. The stitches will dissolve in 6-8 weeks.
Third-degree vaginal lacerations involve the vaginal tissue and the anal sphincter, which is the ring of muscle that prevents you from leaking stool. These tears require stitches to repair the muscle as well as the vaginal tissue. The stitches will dissolve in 6-8 weeks. These tears have a higher risk of poor healing. Women with third degree vaginal tears can experience incontinence of stool and flatus (uncontrolled passing of stool and gas) even after repair. Many women will require pelvic floor physical therapy and a few women will require additional surgery in the future.
Fourth-degree vaginal lacerations involve the vaginal tissue, the anal sphincter and the rectum. These tears require a great deal of stitches to repair all of the torn tissue. These tears often do not heal well. Women who have fourth-degree tears are at high risk of developing a fistula (connection) between the vagina and the rectum. It is common after a fourth degree laceration to have incontinence of stool and flatus. Frequently these tears require multiple surgeries after delivery to correct the injury. Women with fourth degree tears will need pelvic floor physical therapy.
Cesarean sections are the most commonly performed abdominal surgery in the United States. Approximately 30% of all deliveries are cesarean sections. A majority of cesarean sections are performed due to complications of the labor process. Only about 1% of cesarean sections are elective. In my experience with my patients as well as being a patient recovering from a cesarean section, it is commonly forgotten that a cesarean section is major abdominal surgery. Here are five important things to keep in mind when recovering from a cesarean section:
- Time. I thought I would be able to hop right up and start back into my normal routine within two weeks of surgery. Ummm…that was a big fat NO. I have seen some patients be able to do this and I credit these ladies for their strength, incredible pain tolerance and faster than normal healing process. However, this is very rare and you should not compare your experience to anyone else’s because it can vary so widely. Most of us will need good old fashion time. Remember to give yourself time to recover. Six weeks is the minimum amount of time to allow for healing prior to returning to full activity. Now, of course, light activity is encouraged immediately after surgery, as tolerated. My rule of thumb is: if it hurts don’t do it. The first 6-8 weeks after a cesarean section is not the time to push your body. Do not push past the warning signs. At the least be sure to give yourself a full 6 weeks to recover after your cesarean section.
- Patience. I found this one difficult too. If you are normally a very active person, recovery from a cesarean section can be frustrating at times. Pain and fatigue will limit your activity for the first 4-6 weeks and even longer. I found that I wasn’t able to run normally without pain for about 12 weeks. Have patience to give your-self the time to recover. I think I was afraid that the first 4-6 weeks after delivery were the new norm, so I tried to push myself, which always ended in frustration resulting in impatience with everyone around me to include myself. If you are patient, nine times out of ten your body will return to its pre-pregnancy state. The pain will resolve, the swelling will resolve, the fatigue will resolve.
- Help. You need help. You can’t recover from a cesarean section and take care of your new baby all by yourself. The more help you can enlist, the better. You will need help with routine chores (ie washing clothes, vacuuming, mopping floors, cooking dinner, etc) for at least the first two weeks after delivery, but potentially longer depending on how you feel. Do not feel guilty asking for help. Help does not mean you are an incapable momma.
- Sleep. Hahaha, yah, I know sleep and newborn are an oxymoron, but this is where help comes in. The adage of sleeping when baby sleeps cannot be overstated for women who have had a cesarean section. During the first 4-6 weeks postpartum the household chores can be completed by helpers (family, friends, or paid professionals). The most important activities for you during the first 4-6 weeks after your cesarean section are feeding baby, bonding with baby and sleeping. When you are breast-feeding, sleep is definitely a commodity because unless you are pumping, no one else can help you feed the baby in the middle of the night so that you can sleep. You will have to remind yourself that every time baby naps, you should be napping as well, day or night. Do not underestimate the importance of sleep. During the time you are sleeping, your body is healing itself. Sleep deprived individuals do not heal as well and are at risk for both physical and mental illness. Even though it may feel like ground hog’s day for a month or so, getting good sleep in the first 4-6 weeks after your surgery will set you up for a healthier postpartum period.
- Pain relievers. I have not encountered a patient (myself included) who was able to tolerate the postoperative pain of a cesarean section without some kind of pain medication. Some women are able to tolerate the pain with ibuprofen and Tylenol, and that is fantastic as long as the pain is managed well enough that you are able to get out of bed and perform activities of daily living (i.e. get dressed, move around the house, fix a meal, sit on the toilet, etc) without agonizing pain. A majority of women will require some sort of narcotic containing pain medication for the first 3 to 5 days after their cesarean section. It is ideal to take the lowest effective dose of narcotics to control pain and to wean off narcotics within 5-7 days after surgery. You should be able to control postoperative pain with ibuprofen and Tylenol by 5-7 days after surgery.