When first-time mom Sophia delivered her daughter eight months ago, she knew she had a tight pelvic floor and expected some degree of tearing. But she never knew she could tear so much. After safely delivering via vacuum assist, which was recommended because her baby’s heart rate was abnormal, Sophia was told she would need stitches. “Did I tear very badly?” she asked, having felt no pain thanks to her epidural. “Yes,” she was told, “you had a fourth-degree tear.”
Sophia soon found out that she had torn straight through her perineum and anal sphincter into her rectal mucosa—the most severe type of tear possible with a vaginal delivery. After she was stitched up in the delivery room, she stayed in the hospital for 24 hours. “I just assumed that giving birth felt pretty bad,” she says. “There’s a heaviness and I really couldn’t stand very much, but I had to stand up to go to the bathroom.” She bled profusely, had to change Depends every two hours and experienced tortuous bowel movements.
Sophia required plenty of family support during her first few weeks at home. She had trouble walking up and down stairs for the first week and had to lie down to breastfeed her baby because it hurt to sit. For three months after childbirth, she had to sit on a foam pillow made for people with broken tailbones to ease the pain. Now, more than eight months postpartum, she still has vaginal and anal nerve pain, as well as fissures and a pulling sensation when she goes to the washroom. Her proctologist told her that she was sewn too tightly, so her rectum is too narrow, which causes the fissures. “It’s hard to know what it would be like if I wasn’t breastfeeding because it really compounds things,” says Sophia. “I’m having a really hard time with hormones, so I’ve got a lot of tenderness in my vagina and anus.”
Sophia still hasn’t been able to have sex with her husband. “We tried at six months and I couldn’t fully get it in,” she says. “My husband was like ‘I feel like I could push through’ and I said, ‘No, don’t!’” She believes that she is over-squeezing because she is both physically and psychologically traumatized—a common aftereffect of a difficult childbirth or recovery. “My initial OB, who did my surgery, told me, ‘You have to push through it. It’s going to hurt, but you just have to deal with it because you’re going to have pain for the rest of your life and you can’t let that stop things.’” She was shocked by the callous advice and switched doctors.
Though her doctors say her tear has healed well, Sophia still has a build-up of scar tissue and continues to see a pelvic health physiotherapist and an acupuncturist. She has also met with a proctologist, who prescribed Diltiazem (a drug that relaxes a tight sphincter), as well as a gynaecologist, who gave her estrogen cream to see if it would help with the overtightness and rawness she experiences. “I don’t have time for these things,” she says. “I’m pretty mad. It makes me want to cry when I think of how much easier it is for other people. My daughter really loves breastfeeding, so even though I’m in pain, I’m still going to do it until she seems ready to be done with it. I probably won’t go past a year, though, because of how much discomfort it brings me.”
Because fourth-degree tears are uncommon and a little scary to contemplate, many mothers have trouble getting adequate information before delivery and feel unprepared and unsupported during recovery. Those who experience further complications or excessive pain many months postpartum—rarer still—often feel very alone.
That’s why being educated about complications during childbirth, including severe tearing, is the key to developing a birth plan and recovering after delivery if issues arise. Here’s your first step to learning everything you need to know about fourth-degree tears, from prevalence to prevention to postpartum care.
The four degrees of tearing
There are four types of tearing that can occur during a vaginal birth:
The least severe type of tear, it involves the skin around the vagina and entering the perineum. These tears usually heal on their own without stitches.
The next level of tear builds off a first-degree tear but also affects the perineal muscle.
A third-degree tear extends even further, into the anal sphincter, which is the muscle that controls the anus.
The most severe type, a fourth-degree tear passes through the anal sphincter and into the mucous membrane that lines the rectum, known as the rectal mucosa.
According to Ellen Giesbrecht, OB/GYN and senior medical director of the maternal newborn program at BC Women’s Hospital and Health Centre, third- and fourth-degree tears are “different from a repair perspective, but indistinguishable in recovery from a patient’s perspective.” An anal sphincter disruption causes the most difficulty and symptoms for patients, and that muscle is affected in third- and fourth-degree tears.
Fourth-degree tears: How often do they happen?
Obstetric lacerations, ranging from first to fourth degree, are common and occur in 53 to 79 percent of vaginal births, according to the American Congress of Obstetricians and Gynecologists. (There is less data in Canada.) Fourth-degree tears happen much less frequently. Though the numbers vary depending on your source, third- and fourth-degree tears (which are often lumped together) typically affect about three percent of women who have vaginal births, with the number increasing to six percent for first vaginal births and decreasing to two percent for women who have had one or more vaginal births. The prevalence of fourth-degree tears specifically is even lower.
Fourth-degree-tear risk factors
You’re more at risk for a third- or fourth-degree tear if:
- It’s your first vaginal birth
- You have a forceps- or vacuum-assisted vaginal delivery
- You deliver a large baby (over eight pounds, 13 ounces, or four kilograms)
- You’re induced
- You experience a prolonged second stage of labour (the time between when the cervix is fully dilated and delivery)
- You deliver a child whose shoulder gets stuck behind your pubic bone
- Your baby is in the persistent occiput posterior (OP) position (where the head is down and the child faces your belly)
But even if you have all of those risk factors, you might not tear at all. And if you have none of them, you could still tear to your bum. “Can I tell you why some women get tears and some women don’t?” asks Giesbrecht. “No, because we don’t always know. Part of it is the patient’s anatomy, which is what the body looks like, and another part is the physiology, or the stretchability of the skin and muscles. It’s very individual. You can’t predict with 100 percent accuracy who will tear and who won’t.”
That said, Kirstyn Richards, a pelvic health physiotherapist at Moss Postpartum House in Calgary, notes that many women have a hypertonic pelvic floor, which means that the muscles are too tight and unable to relax, which could increase the risk of tearing. If you have pain during intercourse, pain when inserting a tampon or chronic lower back pain, it could be a sign of a tight pelvic floor. Urge incontinence, which is the sudden and strong need to urinate, is another common symptom.
Prevention of fourth-degree tears
There’s nothing you can do to prevent third- and fourth-degree tearing because there are many factors outside of your control, including the size of your baby and your anatomy. Still, seeing a pelvic health physiotherapist in the months before giving birth can help by providing useful exercises to reduce the chances of first- and second-degree tears and improve recovery after delivery, no matter how severe the tear. Here are some of the main benefits of visiting a pelvic health physiotherapist.
You’ll strengthen your core, pelvic floor and hips
“I always try to encourage patients to see a pelvic health physiotherapist in their first trimester,” says Richards. “Our goal in the beginning is to build stability and strength in their core, pelvic floor and hips to give them support and start connecting them to those muscles.”
You’ll learn to let go
“Once a patient reaches 35 or 36 weeks, it’s all about connecting to those muscles and learning how to let go using their breath,” says Richards.
You’ll learn about ideal birthing positions
Certain positions close off the pelvic inlet and make it harder for the baby to come out. “How we typically give birth, with legs out wide and on our backs, shuts off the pelvic inlet,” says Richards. “Something as simple as rotating your knees inward opens it up.”
You’ll practise perineal massage and stretching
“Our clients actually massage the perineal area and the muscles between the vagina and anus to make those tissues move and become as pliable as possible,” says Richards. She suggests avoiding any oils and creams for this type of massage because it’s key for “friction and warmth to come into that tissue and mobilize it that much more effectively.”
Giesbrecht also highly recommends an active pregnancy that includes at least 30 minutes of exercise, such as vigorous walking, five times a week and regular Kegel exercises. Though these activities may not prevent tears, they will decrease your time in labour and help you recover faster if you do tear. “There’s a significant amount of physical exertion during labour, and there’s a lot of mobility required in the immediate postpartum,” says Giesbrecht. “If you go into that in a better state of health, you’re going to [perform] better. With Kegels, it has to do with muscle memory. If you go to the gym and work out, it builds your muscles. Then if you take a break and go back, it takes less time to build your muscles again. The same thing happens with your pelvic floor.”
Tearing vs episiotomy: Is one better?
An episiotomy, where the doctor makes an incision in the perineum, is no longer a routine part of delivery, and most doctors will only make the intervention if it’s absolutely necessary—say, if the baby needs to be delivered immediately because their heart rate is dropping. “Some people think it’s better to tear than to cut, but that’s not universal,” says Giesbrecht. “Depending on the anatomy and flexibility of the tissue, some doctors will make a small episiotomy to guide how the tear happens rather than have multiple tears occur. It’s done at the discretion of the healthcare provider in consultation with the patient.” That’s why it’s important to deliver with a practitioner you trust and respect whenever possible. However, an episiotomy will not prevent tearing to, and through, the anal sphincter.
You’ve had a fourth-degree tear: What next?
In an ideal situation, your doctor will accurately identify the severity of your tear and request a surgical repair by an obstetrician who has experience with third- and fourth-degree tears. It is not an easy surgery and requires someone with experience and skill because all kinds of secondary problems can occur if you aren’t stitched fully or correctly.
In rare cases, a fourth-degree tear is misdiagnosed, which happened to mother Nicki during the delivery of her third child. “I had a postpartum hemorrhage, so that became the focus,” she says. “I needed a blood transfusion, and everything else was overlooked.” Her doctor misdiagnosed her tear as only second degree and stitched it up accordingly. “I’m still not really sure how that happened,” she says. “Eight or nine days later, I discovered that I had torn really badly and also had a rectovaginal fistula [a canal that passes between the rectum and vagina]. It was my first bowel movement and it came through the vagina, so I knew there was a major problem.” Nicki headed straight to the emergency room, where she was referred to a colorectal surgeon and another OB/GYN.
First-time mom Chey was correctly diagnosed, but her anal sphincter muscles weren’t properly reattached. Since she wasn’t given any information about the severity of fourth-degree tears or what to expect, she believed that her fecal incontinence was a typical symptom of childbirth. By the three-month mark, Chey started to realize that something was wrong when she hadn’t healed yet. “I had trouble leaving the house with my daughter because I was having accidents,” she says. “It was giving me a lot of anxiety.” After doing some online research, she realized that she had a fistula and went to a colorectal surgeon immediately. The surgeon recommended a sphincteroplasty and fistula repair to fix her damaged anal sphincter muscles.
Potential symptoms of fourth-degree tears
Pain, including pain during intercourse, and urinary incontinence are common side effects of any vaginal delivery, especially in the first four to six weeks. Women who experience third- and fourth-degree tears also have trouble holding in gas. “However, stool incontinence is quite rare,” says Giesbrecht. If you notice stool leakage or stool exiting through your vagina, it’s important to notify your doctor immediately. You could require the repair of a rectovaginal fistula or additional surgery if your muscles are severely damaged.
Richards also notes that she sees vaginal and rectal prolapses because support to the bowels is decreased when a tear goes to the anus. A posterior vaginal prolapse is where the front wall of the rectum bulges into the back wall of the vagina. If it’s small, there are usually no symptoms, but it can create difficulties when trying to empty the bowels.
Healing from a fourth-degree tear
The six-month period after childbirth is key to a good recovery. Here’s what to expect and what you need to do to have the best possible outcome.
Manage your pain
Your doctor will likely recommend pain medicines, including ibuprofen (Advil), naproxen (Aleve) and acetaminophen (Tylenol), or a morphine derivative if required, but never codeine. “A lot of women are scared to take pain medications because they’re breastfeeding, but these medications are completely safe unless you have another contraindication,” says Giesbrecht. “It’s best to take your meds regularly and stay mobile because it improves your recovery.”
Promote soft bowel movements
Your doctor will prescribe stool softeners and plenty of fluids, which can help prevent the pain of passing hard stools. Breastfeeding women are already at risk for constipation because they have to take in a couple of extra ounces of fluid for every ounce of breast milk they produce, says Giesbrecht. Even if you hate getting up to go the bathroom constantly or find it painful, do not restrict your fluids.
Do pelvic health physiotherapy
One of the most important ways to improve recovery is to work with a pelvic health physiotherapist, says Giesbrecht. Though Richards doesn’t see her patients until six weeks after childbirth (whether they’ve torn or not), she’ll give them a postpartum recovery program if they’ve visited her before delivery. The program involves deep-core activation and breathing exercises that mobilize the scar from day one. Then, at six weeks, she continues to teach her patients how to mobilize again, connect with their pelvic floor and strengthen their muscles, she says. She also works on massaging out scar tissue, so they get full mobility and their muscles can contract and act like they should.
Follow up with a healthcare practitioner
Attend your follow-up appointments as scheduled and be sure to report any issues, including fecal incontinence, as soon as they arise. The sooner you report them, the better your chances of getting timely care. Don’t be scared to push to have your questions answered or your voice heard.
Over the first six months with your new baby, you should continue to see improvements in your muscle strength and a reduction in symptoms if you consistently do the work. However, you probably won’t see a full improvement until you stop breastfeeding. “Estrogen is critical to your pelvic floor, especially the tone and tissues there,” says Giesbrecht. If you’re breastfeeding and your estrogen levels are suppressed so that you don’t have your period, you may even see better tone and strength once you finish breastfeeding.
While it’s true that you will never be exactly the same as before childbirth, the chances of recovering well from a fourth-degree tear are high. “Everyone looks different after they’ve had a baby vaginally compared to before,” says Giesbrecht. “But with good care and dedication to pelvic physiotherapy, the vast majority of women will go back to a very good quality of life.”
Fistulas and severe tissue damage are not automatic side effects of fourth-degree tears, but they do happen sometimes, as was the case for Nicki and Chey. Since then, both have had reparative surgeries: a sphincteroplasty and perineoplasty for Nicki, and a fistula repair and sphincteroplasty for Chey. Though they were long and painful processes, they have improved their fecal incontinence. “I can go outside and resume my normal life,” says Chey. “I don’t have to run to the bathroom—I can hold it now. But I still need to see a pelvic health physiotherapist because I continue to experience frequent urinary incontinence.”
Being your own advocate
No one wants to experience a fourth-degree tear, but if it happens to you, the best thing you can do is educate yourself and push for proper diagnosis and care. If your doctor is unfamiliar with fourth-degree tears and how to treat them, you could end up with long-term difficulties that require additional surgery. “I know stuff happens that you can’t control, but women need so much more support,” says Nicki. “It’s not fair that I had to Google everything and talk to women around the world to try to relate to somebody. It made me feel very alone.”
If you’ve experienced a fourth-degree tear and need peer support, visit Mothers with 4th Degree Tears on Facebook.
This article was originally published online in May 2019.
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