Fourth Degree Tear – Severe Tearing During Childbirth

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

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

You might not want all the details. The truth is, though, 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 labor pain, nothing comes up as frequently as the fear of tearing.

Fourth degree tears – what you need to know

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

Fortunately, knowledge is definitely power.

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

Knowing about the risks of 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.

Here’s everything you need to know about severe degree perineal lacerations.

What is a perineal fourth degree 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 suturing.

For a few women, factors like the baby’s position and size, the mother’s position during pushing, birth interventions, the need for an instrumental assisted birth, and a few other variables can result in a more severe vaginal laceration.

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

First degree tear

This degree of perineal laceration involves just the skin and the mucous membrane of the vagina. They are often left to heal on their own, unless they are bleeding and the bleeding doesn’t stop after applying pressure.

Sometimes, if the laceration is awkward looking, your midwife or doctor might offer a repair for aesthetical purposes. They will always discuss your options with you before proceeding with a surgical repair.

Second degree tear

This kind of perineal laceration involves the muscular tissue of the vagina and perineum.

Whether they just involve a few muscle fibers or several pelvic floor muscles they are classified as second degree lacerations.

The degree of damage an episiotomy causes is considered similar to a second degree tear as it involves the perineal muscles.

If an episiotomy, or a second or first degree tear needs to be repaired, this can be done in the delivery room. This type of repair requires just local anesthesia.

Third degree tear

Third and fourth degree tears will involve damage to the anal sphincter and might cause both short and long term complications, such as fistula (a communication between the vagina and the rectum), or fecal incontinence.

The anal sphincter is a muscular ring at the end of the rectum.

The extent of an anal sphincter injury will also have different classifications, depending on the severity of the damage.

A third degree tear will be classified as a, b, or c, depending on how deep into the sphincter muscles the laceration occurs.

Fourth degree tear

A fourth degree perineal tear involves tissue around your vagina and perineum and extends from the vaginal opening through the anal sphincter muscle AND the rectal mucosa.

Yes, a tear right through from the vagina to the anus. It sounds scary, uncomfortable, and definitely worthy of our anxieties.

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

Both third and fourth degree tears (obstetric anal sphincter injuries) might be repaired in the operating room, if available, as the lighting conditions are the most appropriate for this kind of procedure.

Risk factors of fourth degree tears

There hasn’t been a lot of research done solely on fourth degree tears, as most studies include all types of anal sphincter lacerations, including third degree lacerations.

The main identified risk factors for this anal sphincter type of tear are being a first time mother, and the position in which the baby is born.

When the baby is born in an occipito-posterior (OP) position, back to back, there is a higher risk of injury to the anal sphincter.

In an OP presentation, the baby is facing the opposite way, and the neck is often straightened instead of bent so the head requires more space to negotiate the birth canal.

If the baby is in the OP position and a manual rotation is not possible, due to fetal distress, your doctor or midwife will determine whether an assisted vaginal birth delivery or cesarean delivery is required.

There is little research into what causes tearing of the rectal mucosa but there’s a suspicion that the use of forceps could play a significant role in fourth degree tearing.

How is a fourth degree tear treated?

A fourth degree tear is treated as one of the most severe complications of having a vaginal birth.

Tears that cause an anal sphincter injury – third and fourth degree tears – will not heal spontaneously and need to be surgically repaired.

The treatment takes care of repairs to the anal sphincter muscles and muscles on the pelvic floor.

This surgical repair is very important to avoid anal incontinence – both gas and fecal incontinence.

The wound caused by a severe degree tear means there is a communication between the vagina and the rectum; therefore, in a severe degree tear the anal mucosa will also need to be cautiously and thoroughly repaired.

Third or fourth degree tears repair

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

In many cases, spinal or epidural analgesia is used.

You can read more about the differences in this article: Spinal Or Epidural Blocks – What’s The Difference?

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

Unlike any other time a woman needs medical attention, this time at least you have a new bundle of joy to distract you.

Skin-to-skin with your baby during your perineal repair will help you release oxytocin.

This hormone will not only help you bond with your baby but will also trigger the release of endorphins, our body’s natural painkillers.

Here is a very useful article about 5 Ways New Mothers Can Get Their Oxytocin Flowing.

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 the theatre.

In that case, your birthing partner can provide care for your new baby. 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 many stitches do you have in third or fourth degree tears?

‘How many stitches will I have’ is one of the most frequently asked questions when women talk about postpartum perineal lacerations and tears repair.

Knowing that third and fourth degree tears are the most severe perineal wounds, we assume the number of stitches will be considerably high.

There is no fixed number of stitches. It all depends on the degree of damage, and also the repair technique and suture material an individual doctor uses.

In days gone by, stitches were done individually, especially when repairing the skin. Nowadays, most of the stitches are continuous, like when you sew two pieces of fabric together.

Depending on the doctor who does your perineal repair, you might end up with nothing more than a couple of visible knots in your perineal area.

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’s 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 you should not be feeling nearly as uncomfortable as you did in the first week.

The biggest factors in healing after a perineal wound are time, rest, and care of the area.

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

Time, rest, and poop!

For most women, once their third or fourth degree tear has been repaired, the biggest worry is usually number 2 becoming the number 1 most feared experience.

Don’t worry! We have some advice to help you care for your pelvic floor while you let your bowels get rid of its products without suffering.

Eat a healthy diet

A very important part of your recovery comes with a healthy diet that includes plenty of fruit and veg and is full of fiber.

Stay hydrated

Drinking plenty of water will not only help you with the healing of the perineal tissue but will also prevent your stools from becoming hard and difficult to pass.

Don’t delay it

The first time you have a bowel movement after a perineal repair can be daunting but delaying it will only make things more difficult.

Your mission to help a third or fourth degree tear heal faster starts with you answering your bowels’ call as soon as it happens to avoid further complications.

• Ask your partner or a relative to take care of your baby while you do what you need to do
• Try to stay relaxed. If you relax your muscles will too
• Place a warm damp cloth on your perineum. The sutures in your wound will not break when you poop. Supporting your pelvic floor will help you accomplish this mission
• Be patient and avoid straining when having a bowel movement
• A stool softener, which has most likely been prescribed by your doctor, will also help make this task easier
• Clean yourself thoroughly, making sure you don’t get any faeces in the perineal area as this could lead to a wound infection. Use a peri-bottle, and dab rather than wipe after using the toilet.

As well as resting and avoiding constipation, there are several other things you can do to help the healing process:

• 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 healing, but it can help you cope during the immediate postnatal period
•  Taking sitz baths or soaking the area with Epsom salt and/or herbs will also help your recovery
• Use ice packs or cool compresses
• Apply witch hazel or use frozen witch hazel pads.

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

How can I avoid a fourth degree tear?

In some very rare situations, a severe degree tear might be the only way to get the baby out. This is the exception and certainly not the rule, however, when it comes to vaginal childbirth.

There are several risk factors for a severe third or fourth degree tear, and they are:

• 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 risk 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 an instrumental 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.

Can you have a natural birth after a fourth degree tear?

Having a previous severe tear can slightly 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.

The likelihood of you suffering severe tearing is very small if you keep active during pregnancy and birth, adopt upright positions, listen to your body and your baby, and if no one touches your perineum.

When you are the main driver of your own birth the chances of tearing will reduce exponentially.

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 laceration around the vagina is unlikely, but if you’ve experienced one, you know it can happen. However, most women who have a severe tear 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 experience minor to moderate discomfort during sex in the early months. But for most, their pelvic area is back to normal after a few months.

Whether or not you have experienced tearing, you might benefit from physiotherapy with a women’s health physiotherapist.

After the 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 make an appointment to see a pelvic specialist.

And although 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