Fourth Degree Perineal Tears – Everything You Need To Know About Severe Tearing

Fourth Degree Perineal Tears – Everything You Need To Know About Severe Tearing

Is it really necessary to read up on severe, fourth degree perineal tears?

I mean, do you really want to know the details of one of the most feared aspects of childbirth?

You might be thinking you don’t want all the details. The truth is, you’ll probably feel much better about the whole idea once you’re more familiar with it.

In my childbirth classes, with the possible exception of fear about labour pain, nothing comes up as frequently as the fear of tearing.

Fourth Degree Perineal Tears – Everything You Need To Know About Severe Tearing

Put those two fears together and you might end up dreading your upcoming birth.

Fortunately, knowledge is definitely power.

Although both labour pain and tearing are common concerns, if you have the right information, birth doesn’t need to be scary.

Knowing about the risk of a severe tear prevention and healing if it does happen, can help reduce your anxiety about tearing during birth.

The worst type of fear is the fear of the unknown.

So, here’s everything you need to know about severe fourth degree perineal tears.

What Is A Fourth Degree Perineal Tear?

Your perineum is the area between your vaginal opening and your anal sphincter. This area is well designed to facilitate childbirth.

The muscles, tissue and skin are flexible and can make way for your baby’s birth. Even so, it isn’t uncommon to experience a minor or superficial tear of just the perineal skin. These minor tears heal very quickly, and often require no stitches.

For a few women, factors like baby’s position and size, mama’s position during pushing, birth interventions, the need for forceps or vacuum assisted birth, and a few other variables can result in a more severe perineal tear.

Perineal tears are classed as first, second, third or fourth degree; the fourth degree tear is the most severe.

A fourth degree tear involves vaginal tissue, perineal skin and muscles, and extends from the vaginal opening through the anal sphincter. Yes, a tear right through from the vagina to the anus. It sounds scary, uncomfortable and definitely worthy of our anxieties.

However, as scary as it sounds, it’s quite rare, and often heals quite well.

How Is A Fourth Degree Tear Treated?

In the case of a fourth degree tear, you’ll probably receive a very thorough local anaesthesia, in the form of a pudendal nerve block; this will numb the entire genital area.

Occasionally, a very severe tear will require a more traditional surgical-like approach. A mama might end up in the operating theatre with general anesthesia, but it’s only rarely necessary.

When you have adequate anaesthesia, you shouldn’t feel any stitching. Each layer (vaginal tissue, muscle, perineal skin, anal sphincter) will be stitched separately, to make sure everything is properly supported for healing.

Unlike any other times you’ve needed medical attention, this time you have a warm bundle of joy to distract you.

Skin-to-skin during your repair can even help you release oxytocin so you’ll be distracted and can focus on something else.

You might be feeling anxious about the repair. Perhaps a tough birth has left you feeling fatigued. Or you might need to be transferred to theatre. In that case, your partner, doula, a relative or a nurse can provide your new baby with care. And as soon as you’re ready, skin-to-skin will still provide you with the benefits of feeling good, relaxed and bonded to your baby.

If you’re concerned about pain, you can request a topical analgesic after the stitches. For many women, an ice pack right after stitching helps relieve pain, discomfort and swelling.

How Does A Fourth Degree Tear Heal?

Regardless of how birth unfolds, you should expect to need a few weeks to heal. After all, you just grew a human being and then gave birth; it’s no surprise your body needs a period of time to heal.

After severe tearing, you will probably need a little more time before your pelvic area feels it is back to normal. Some women feel fine within a couple of weeks; others take up to several months to heal fully. Nearly all women, however, feel better with each passing day.

Even if you require a few months to heal, towards the end the process should not be as uncomfortable as it was in the first week.

The biggest factors in healing after a severe tear are time and rest.

Read Why You Should Have A Post-Natal Month After The Birth to learn about additional benefits to making rest a priority.

As well as rest, there are several other things you can do to help the healing process:

  • Be very proactive about preventing and treating postnatal constipation. Avoid straining when having a bowel movement.
  • Spend plenty of time resting in ways that don’t put extra pressure on your pelvic floor. Lie down with your feet up, or use an inflated donut when sitting.
  • Use any prescribed or over-the-counter medicine your midwife or doctor recommends for pain, if needed. It might not necessarily aid in healing, but it can help you cope during the immediate postnatal period.
  • Take a sitz bath or soak with Epsom salt and/or herbs.
  • Use ice packs or cool compresses.
  • Apply witch hazel or use frozen witch hazel pads.
  • Use a peri-bottle and dab rather than wipe after using the toilet.

Be sure to read 6 Ways To Heal Your Perineum After Giving Birth for more ways to help heal after a fourth degree tear.

How Can I Avoid A Fourth Degree Tear?

In some situations, a fourth degree tear might be the only way to get baby out. However, this is the exception and certainly not the rule when it comes to vaginal childbirth.

There are several risk factors for a severe tear, and they include:

  • A large baby, due to uncontrolled gestational diabetes or type I diabetes. Generally, our bodies make babies of the right size for them to handle, but things like elevated blood sugars can result in a baby larger than nature intended.
  • Baby’s position, such as a nuchal hand, where a baby’s hand is up by her face, during birth
  • An episiotomy.
  • A previous severe tear.
  • A forceps or vacuum assisted birth.
  • The lithotomy position, where the mother is on her back, with hips and knees flexed. This increases the risk of tearing in general, not necessarily fourth degree tearing.

Even if one or more of these risks factors applies to you, there’s no guarantee you’ll tear. In fact, there are several things you can do to reduce the risk or severity of tearing:

  • Give birth in an upright position, or any position that reduces pressure on the pelvic floor.
  • Avoid an episiotomy that isn’t medically necessary; in rare instances, an episiotomy is medically indicated.
  • Avoid pushing with directed intensity. Only push when you have the urge and try to ‘breathe’ baby out rather than push as hard as you can.
  • Use a warm compress during the pushing stage to help with blood flow and provide perineal support.
  • Make informed decisions about birth interventions, including epidurals. They can increase the risk of needing a forceps or vacuum assisted birth.

Be sure to read Tearing During Birth – 9 Ways To Help Prevent Tearing for more tips on reducing the risk or severity of tearing.

Will I Experience Another Severe Tear?

Having a previous severe tear can increase your risk of another tear, but it isn’t a guarantee – especially if you employ some of the methods above to reduce your risk.

It’s understandable to be anxious about the thought of another vaginal birth and another severe tear, but there’s no reason to assume you’ll tear again.

Take time to read Vaginal Birth After Severe Tearing to learn more about giving birth again after a severe tear and to help you make informed decisions.

A severe tear is unlikely, but if you’ve experienced one, you know it can happen. However, even with a severe tear, most women heal quite well within a few weeks to several months.

It can take a bit of time to be free of all discomfort, and some women will experience minor to moderate discomfort during sex in the early months. But for most women, after a few months, their pelvic area is back to normal.

Whether or not you have experienced tearing, you might benefit from physiotherapy with a women’s health physiotherapist. After your initial postnatal period, if the discomfort and pain are persistent as you go about your everyday life, or even just during sex, it’s important to reach out to your midwife or doctor. You might even choose to reach out to a pelvic specialist.

And while it might be scary to think about tearing, remember this:

“There is a secret in our culture and it is not that birth is painful but that women are strong” – Laura Stavoe

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Maria Pyanov CPD, CCE CONTRIBUTOR

Maria Silver Pyanov is a mama of four energetic boys and one unique little girl. She is also a doula and childbirth educator. She's an advocate for birth options, and adequate prenatal care and support. She believes in the importance of rebuilding the village so no parent feels unsupported.


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