Getting Through 4th Degree Perineal (Vaginal) Tears

4^th degree perineal tears are the most severe form of tear a woman can experience during the end stages of labor. There are in fact different degrees of perineal tears: Minimal tearing such as 1^st or 2^nd degree tears are common and expected. 3^rd degree or 4^th degree perineal tears occur more rarely.

It is considered a 4^th degree tear when the vaginal membranes stretch so thin that those membranes at the back of the vaginal wall tear completely. These tears extend through the muscles of the perineum, through the anal sphincter and further down into the mucus membranes of the rectum. 4th degree vaginal tears always require surgical repair under anesthesia from a specialist. Regretfully,  it can take many months to heal after childbirth.

What causes a 4^th degree perineal tear

These severe tears occur from a variety of reasons but some of the most common factors include:

• The baby’s head and shoulders being too large to pass through the birth canal. A recent study published in 2022 from Asia claimed that a birth weight of more than 3.5 kilogram was significantly associated with have a major tear.

• An unusual or malposition of the baby when the back of the baby’s head rests against the mother’s tailbone, but body faces front toward the mother’s belly.

• A first baby. This is often because the muscles and vaginal tissue is not flexible enough to stretch adequately.

• A birth that proceeds too quickly, not allowing for the vagina to fully dilate.

• A forceps or vacuum assisted birth. This is sometimes acutely necessary but can cause serious risk of vaginal tears and damage to the uterus and bladder.

• A previous delivery that had caused 3^rd or 4^th degree tears. In that case, the membranes are more susceptible to re-injury.

• A prolonged and difficult labor.

The effects of 4^th degree perineal tears

Experiencing a 4^th degree perineal tear may have serious consequences and long-lasting problems for women. Problems may be both physical and emotional.

Physical effects

After childbirth, perineal tears could be a major source of pain for the mother no matter what degree she experiences. These tears can leave women with pain and a variety of short-term physical problems as the tissue heals. Common issues include fecal urinary incontinence, temporary sexual dysfunction, and in some cases nerve damage. Many of these postnatal symptoms will heal themselves in a course of six to eight weeks of care.

Experiencing a 4^th degree tear, however, can have even further reaching physical problems as well as emotional ones. The amount of time for these tissues to fully repair is much longer than normal. A study from Italy showed that severe lacerations and pelvic floor dysfunction even after 12 months from delivery.

Recovery from childbirth and can cause a more serious emotional toll on the mother as well.

Emotional effects

Caring for a newborn is exhausting in itself. With the added physical issues the mother is going through, it can be quite frustrating to deal with all of it at once. Sleepless nights, feeding demands and general care of the child leaves little personal time for the mother. This often makes her start to feel resentful that she can’t adequately care for herself. Since it can take a minimum of six months or more for the mother to recover from a 4^th degree surgical  tear repair, some mothers experience a psychological urge of detachment from their babies. Postpartum depression becomes more acute. Because of these overwhelming feelings, resentment towards baby, doctor and even spouse can build significantly. Some women feel that their bodies will never heal to return to normal so impatiently become bitter toward the birthing experience. They psychologically start to feel vulnerable, dis-empowered and bitter. These consequences can be serious to the welfare of both mother and child. It is therefore extremely important to take precautionary measures to reduce or prevent significant vaginal tears from the very beginning of pregnancy.

Caring for 4^th degree perineal tears

There are certain procedures that the mother will be asked to do to care for these surgically repaired tears. Following these requests could expedite healing and prevent complications.

• In order to prevent the possibility of infection, the mother will be given a course of antibiotics. It is important that these be taken consistently as this area is easily prone to infection. Pain relieving medications will also be prescribed.

• Applying ice packs every 2 hours will also help in relieving discomfort of swelling, pain and itching.

• Resting as much as possible is recommended as there will be many demands from the newborn child and sleepless nights. Dealing with postpartum pain, standing and sitting will continue to be difficult. A preferable position while resting is by laying on her side rather than back which will relieve pressure on the stitches and healing muscles.

• Taking laxatives will help to soften the stool making it less painful to evacuate the bowels. It is important that the mother drinks lots of water throughout the day and concentrates on eating plenty of fibrous fruits and vegetables.

• Streaming warm or cool water over the perineal area while urinating often helps to prevent stabbing pain.

• After using the toilet, it is imperative that the wounds are gently washed and patted dry, avoiding rubbing. Personal hygiene is of the utmost importance to keep the perineum area clean by bathing or showering each day.

• Sitz baths in warm water are recommended to soothe and help relax the pelvic muscles. Submerging only the hips and buttocks in warm water until the water cools is recommended to begin within the first 24 hours after delivery.

• Sanitary pads should be changed frequently. Washing hands before and after changing these pads will also help to prevent infection.

• Resuming perineal exercises such as Kegel exercises will strengthen the muscles that have been weakened near the tear and will help stimulate blood circulation to the area which will speed the healing process.

• Acknowledging the need for and receiving assistance will help the mother to work through the pain and discomfort during this extended healing time both psychologically and physically.

Reducing the risk of 4^th degree vaginal tears

There are things that can be done to reduce the risk of massive vaginal tearing. If the expectant mother understands the serious risks involved with 4^th degree perineal tears, she will more likely take some of the following precautionary suggestions seriously and incorporate them in her prenatal care routine.

Exercising during pregnancy

Exercising during pregnancy is always encouraged. It is an integral part to prepare the mind, body, and perineum for labor. Healthy exercising will strengthen muscles of the entire body and especially the heart. It reduces constipation and relieves pack pain, improves posture, helps with sleeping issues and relieves stress. By helping to gain control over breathing during exercise, it will help control pain during labor. Continuing to exercise after birth will help the mother quickly regain her per-pregnancy body and provide more stamina in caring for the newborn.

Perineal exercises

Perineal exercises are one of the most important things a woman can do to prepare the pelvic floor muscles for a healthy birth. The muscles, ligaments and tendons involved are located in the lower pelvis that support the uterus, bladder and bowel. These muscles stretch from the pubic bone in front to the tailbone in the back. Strengthening these perineal muscles during pregnancy helps support the weight of the growing child which causes strain on the entire pelvic floor. Exercising to strengthen these muscles will help produce a smoother vaginal delivery with less exhaustion and trauma during the process of labor. Learning to tighten and relax these muscles as contractions deepen will help as the mother starts to push hard to deliver the baby, lessening the possibility of significant perineal damage or tearing. Kegel exercises are highly recommended as they are one of the best ways to strengthen these muscles. If continued after childbirth, Kegel exercises could have lasting benefits for the mother as she resumes sexual activities. Prenatal yoga could help too.

Warm compresses

Warm compresses applied to the perineum continuously during and between contractions starting at the second stage of labor has been found to significantly reduce the incidence of more serious degrees of tearing by soothing and relaxing the perineal muscles. You should request your midwife to apply these to try to prevent tearing during childbirth.

Perineal massage

Started after about the 35^th week of pregnancy can also reduce the risk of tears. Perineal massage (also called perineum massage) involves stroking the perineaum a few times a week for a few minutes each time. The objective of the massage is to make the perineal tissue more supple and flexible in preparation for childbirth. There are many guides online about how to do perineal massage correctly in addition to excellent perineal massage videos.

Returning to normal life after experiencing a 4^th degree tear

Resuming sexual activity

The thought of returning to normal life after postpartum trauma may be difficult to imagine. After an uncomplicated birth, a woman’s body will need at least several weeks to recover. It is suggested that starting to engage in sex is best only when the woman feels fully recovered from giving birth. This is perhaps better once the stitches have been removed or dissolve to prevent injury to the area.

Women who have experienced a severe 4^th degree perineal tear, however, will need a much longer period of time for the traumatized muscles to heal. This usually takes a minimum of four to six months depending on the amount of surgical repair that was necessary and how well the vagina and related muscles have healed.

There is no real right or wrong time to resume sexual activities and depends completely on the woman’s decision as she will be able to access how she is feeling both physically as well as emotionally. During this time, a woman’s decision should be respected, and spousal patience should be practiced.

Seek help from doctors and physiotherapists

After experiencing a traumatic birth, it is often suggested that the woman seek counsel from a medical professional who specializes in issues that might arise such as postnatal mood and anxiety disorders which can also result in severe postpartum depression and fear of resuming sexual relations.

Another suggestion that has helped in the recovery process is to see a physiotherapist for advice on perineal massage. As the scars begin to heal, they will feel tight and often uncomfortable. After approximately 6 weeks, the area will become less sensitive. It might be the prefect time to visit with a physiotherapist who will massage the perineum to relax and stretch it. This process will teach the woman how to do perineal massager at home. Managing scar tissue consistently will keep the skin relaxed and more comfortable. The therapist will be able to suggest a physical therapy routine to help eliminate discomfort and pain. They can also address embarrassing issues such as fecal and urinary leaking and how to prevent pelvic organ prolapse by strengthening the pelvic floor muscles.

Open communication is key

Open communication with the Ob/Gyn and taking the measures listed above, before, during and after pregnancy will help lessen or prevent experiencing a 4^th degree vaginal tear. 

References:

Mayo Clinic: sls-20077129 Fourth Degree Vaginal Tears

Berkowitz LR, etal, Postpartum perineal care and management of complications http://www.update.com/contents/search

Baby Centre: What is perineal massage and how is it done? Http://www.babycentre.co.uk/x1955/what-is-perineal-massage-and-how-is-it-done

NHS: Information on 3^rd and 4^th Degree Tears, Http://hey.nhs/patient-leaflet/information-3rd-4th-degree-tears

WebMD: How to relieve the pain of episiotomy or vaginal tear after childbirth.