Recovering after 3rd and 4th Degree Tears

Unfortunately, during birth, women can experience perineal tearing. The perineum is the area between the vaginal opening and the back passage. A woman can suffer from varying degrees of tearing, with some short term, but also long term effects on pelvic floor function. This can include bowel and bladder issues or ongoing pain. The worse of these tears are called 3rd & 4th degree perineal tears are also known as Obstetric Anal Sphincter Injuries (OASIS), because the perineal tear extends into the anus.

The varying tears are grouped according to the extent or length of the tear:

• First degree tears — small skin deep tears which heal naturally
• Second degree tears — deeper tears affecting the muscles of the perineum. These are usually repaired with stitches.
• Third degree tears — deeper tears that involve the anal sphincter muscles.
• Fourth degree tears — tears extending further up the anus into the rectum

Some long terms effects of perineal tears and OASIS can include:

• bowel urgency
• difficulty controlling wind
• difficulty controlling bowel matter
• painful sex

What can I do if I have suffered from a perineal tear?

After 6 weeks, and once the perineal area has healed you can begin to do some exercises to strengthen the area and reduce or prevent anal incontinence. You will usually have a pelvic floor or women’s health physio helping and guiding you along the way, and they will teach you the following exercise types. Mind the anus chat to come!

Pelvic Floor Exercises with an Anal Cue

These anal sphincter muscles need to be retrained as part of your pelvic floor, because the perineal injury can cause them to become lazy or switch off. It is easy to focus on this part of the pelvic floor sling. Lying on your back with a neutral pelvis

• Breathe in to relax your pelvic floor down.

• Breathe out as you squeeze and lift your pelvic floor muscles focussing on the anus being pulled up towards your lower back.

• Breathe in to relax the pelvic floor muscles back down.

• Repeat 10 times.

• Repeat another set in active neutral sitting.

• Repeat another set in active neutral standing.

Pelvic Floor Elevator with an Anal Cue

You need to be able to control these muscles at different points so that you are able to control your wind and bowel movements and prevent accidental leaks or accidents. Visualise your anal canal (from your anus to your rectum to the centre of the dimples in your lower back) as 3-storey building with an elevator in it.

• Tighten your anus and pull it up a third of the way — bring the elevator from Ground Floor to Level 1.

• Tighten your anus further and pull it up two thirds of the way — bring the elevator to Level 2.

• Tighten your anus as much as you can and pull it up all the way — bring the elevator to the Roof.

• Slowly release the elevator down to Level 2, then Level 1 and back down to Ground Floor.

• Repeat 3 times.

Anus Quick Flicks

You need your anal sphincter muscles to get stronger in their fast-twitch fibres and especially down at the exit, to help you overcome or manage bowel urgency. Visualise the anus at the exit of your bottom as a circular muscle. Imagine trying to pull up a pea through the anus just 3 mm and back out again.

• Do 10 quick flicks as fast as you can in a pulsing manner as you tighten the circular anus closed and release again.

I need more help…

If you have suffered from a perineal tear after birth, it is important to see a trained women’s health physiotherapist as she can help prescribe even more specific exercises, as well as help you to heal from the injury faster.

Women’s health physiotherapists at The Fix Program physios will help you recover from any birth issues, and perineal tears often require gentle scar tissue massage to release the tissues and muscles that can tighten up after tears. If you are experiencing any bowel issues, your women’s health physiotherapist will help you overcome these issues.

Research shows physiotherapy for just 2 months can significantly improve anal sphincter control and strength to minimize or prevent any wind or fecal incontinence. Your physiotherapist will also discuss important bowel habits advice with you and prescribe you individualized exercises.

Why how you breathe matters!

Anyone who has spent enough time learning about exercise and mindfulness or meditation, comes across a rather strange idea – that there is more than one way to breathe. Most of the time we don’t think about breathing, our body breathes on its own without us having to tell it how! But knowing the full story behind “diaphragm breathing” will help you get deeper and more relaxed breathing, and will help you support your body in a safe, protective posture. 

What does the diaphragm actually look like inside my rib cage?

The diaphragm is a dome-shaped sheet of muscle which joins into the lowest few ribs, internally dividing the chest cavity from the abdominal cavity below. When it contracts it pulls itself down towards the bottom of the ribcage, causing the lungs to expand and fill with air. So, while you feel your chest go in and out while you breathe normally, this is not the primary way your lungs fill up – the internal motion of your diaphragm is actually doing most of the work.

Did you know that the diaphragm actually supports your posture too?

Your diaphragm works as the top of the deep system of core muscles surrounding your abdomen, with the pelvic floor at the bottom, the multifidus muscle at the back near your spine, and the transversus abdominus, or deep abdominal layer on the sides. This set of muscles forms a cylinder deep inside your midsection (your “deep corset”), working to support and stabilise the area and protect against injury.

An easy way to breathe better using your diaphragm

While the diaphragm is essential for all breathing, other muscles can get involved and get our bodies into bad habits. These can include the neck muscles creating increased neck tension, shoulder and chest muscles, closing the chest posture or the belly muscles. What we are going to focus on is making sure that the diaphragm is doing the right amount of work in the right way. 

• Place your hands on your lower ribs and take in some deep breaths, just to feel how they move when you breathe normally.
• Then try and keep taking those deep breaths, only now try and keep your ribs from moving back-to-front, letting them mostly just move side-to-side, feeling how they return close to the centre again when you exhale.
• As you continue, see if you can minimise any changes to your back arch. When breathing with the diaphragm, no increase in your arch should be necessary. Just widening of the ribs into the side-seams of your shirt.
• Check that the neck is be able to stay soft and relaxed as well, reducing any unnecessary effort in the process of deep breathing. 

How often do you think you breathe like this throughout your busy life? Bringing this peaceful kind of breathing into your waking life is going to help keep your body stable and happier. 

How does my breathing coordinate with the other core muscles?

  Your pelvic floor should mirror the movement of your diaphragm. It is great to try to remember that 

• when you inhale and the diaphragm lowers, your pelvic floor should relax and drop, and
• as you exhale and the diaphragm lifts, the pelvic floor muscles should also tighten and lift:

This can take a bit of practice, but it is the best way to make sure that “deep corset” of yours is working as effectively as it can. Try taking five deep breaths in a row, practising your coordination of diaphragm breath with the deep pelvic floor contraction and relaxation.

Now try also gently drawing in the lower abdomen with the exhales as well, making the sides of your deep corset or cylinder work together with the top and bottom. Try this fully coordinated breathing pattern five breaths in a row. 

Why should I do this? 

If you can successfully master the above exercise, you will have just activated all of your core muscles in a safe and supportive way that gently promotes good posture and injury prevention. This form of deep, wide, relaxed breath ensures your abdominal stabilisers wake up, which can in turn help with back and neck problems, improve your core strength, and help with pelvic floor function. It is also the way we breathe when we are most relaxed, and helps with our mental well-being. 

Join an online class from the comfort of your home - Katrina the principle physio at The Fix Program has designed a series of pregnancy exercise programs that will help you immensely.   

So whether it’s to help your sore back, before or during exercise, or just before someone passes you the microphone at karaoke, try breathing with your diaphragm and see how it serves your body and mind in a multitude of ways!

From pregnancy incontinence to pelvic pain to post natal weakness and prolapse.

As physios who treat women’s only pelvic floor problems, we are always overwhelmed by the lack of awareness out there amongst our female friends that this type of physio even exists! Also overwhelming is the lack of proper education and information out there about incontinence, sexual pain and prolapse which can actually be treated well by women’s health physios.

Ban those TENA incontinence pad ads!! Don’t put up with a leaky bladder, pelvic pain or sexual pain. Bladder and bowel control and wellness in women is our philosophy.

At The Fix Program, we have physiotherapists who are expert clinicians in the management of conditions unique to women. They have clinical expertise and excellent diagnostic and therapeutic skills. We specialise in the management of pelvic floor problems. We can help you if you have:

• Urinary incontinence or poor bladder control in pregnancy and beyond
• Bowel incontinence and constipation
• Over active bladder and urge incontinence (going to the loo more than 8 times per day, with ‘eye watering’ urgency sometimes associated with bladder leaks)
• Pregnancy and post-natal care (pregnancy incontinence, post natal pelvic floor weakness, pain, scar management after tearing, prolapse and sexual pain)
• Vaginal prolapse (also known as pelvic organ prolapse, where the bladder, uterus or bowel drop low into the pelvis)
• Painful sex or ‘vaginismus’
• Pelvic and lower back pain

We understand every woman’s pelvic floor physiotherapy needs are different.

OK, all assessments and most treatments will involve an internal vaginal examination. But as a woman, we hope this is tolerated just as we do with our PAP smears every few years. This, along with extensive questioning about your pelvic floor function and habits allow for the best diagnosis and then treatment. The internal examination will also allow for the physiotherapist to properly assess any weakness, spasm or change to your pelvic floor muscles and to assess for any degree of prolapsed (or descent) of your pelvic organs. All of this cannot be achieved externally.

Read more about pelvic floor disorders at our website.

Contact us to chat about any pelvic floor issues you may be experiencing, or to book an appointment at Broadway (within the Fernwood Fitness womens’ gym) or Sydney CBD.

You do not need a referral from a doctor to see us. HICAPS rebates available on all physiotherapy treatments, but check your individual private fund provider for eligibility.