Third- or Fourth Degree Tear

What is a third- or fourth degree tear?

A third degree tear is a tear that involves the anal sphincter muscles. These control your ability to control your passage of gas and stools.

A fourth degree tear extends further into the lining of the anus or rectum.

These occur in 6 in 100 first time mothers undergoing a vaginal birth, and 2 in 100 mothers with previous vaginal deliveries. 

What are the risk factors of third- and fourth degree tears?

• First time mothers
• No mediolateral episiotomy
• Big baby 
• Fast and strong pushing during the second stage of labor 
• Short perineum (distance of tissue between your vagina and anus)
• Assisted vaginal delivery (e.g. vacuum or forceps)

What happens if I get a third- or fourth degree tear?

Your tear will need to be repaired with additional stitches. This can be done in the labour ward room if you are comfortable with an epidural, or in the operating theatre, where a regional (half-body) anaesthesia can be administered. You will need a urinary catheter to drain your urine until you are able to move around. 

How should I care for my repair?

Your repair will be stitched with dissolvable sutures i.e. there is no need for stitch removal. You will be given painkillers after delivery, which you should take regularly at least for the first few days. Antibiotics will also be given, which you will need to complete. Sitting on doughnut cushions and using warm salt baths may help. You should move about normally. Stool softeners will be prescribed so that you do not get constipated. 

You will need to do your Kegel (pelvic floor) exercises to strengthen your muscles as they will be weakened after the delivery. Initially you may feel that you have little sensation “down below”, but as you continue doing your exercise, this will improve. You may be referred to a physiotherapist who can help you with it. 

Keeping your repair clean and dry is key – change your sanitary pads regularly and remember to wash daily and gently pad the area dry with clean towels before wearing your underwear. The wound typically heals well, and will be checked by your gynaecologist during your follow-up clinic visit.

How does having a third- or fourth degree tear affect me?

Most women with third- and fourth degree tears that are repaired heal well and have no problems controlling their bowels or gas. However, some women may experience difficulty where they are not able to control passing wind or motion. This may occur soon after delivery or many years after. Doing regular Kegel exercises can reduce this risk. You should speak to your gynaecologist if you experience any issues.

Will this affect my next pregnancy?

Women with a previous third- or fourth-degree tear have a 7-10 in 100 chance of having another similar tear in their next vaginal delivery. 

If you have recovered well and have no problems controlling their bowels or gas, you may consider vaginal birth for your next pregnancy. There may be an option of doing an ultrasound scan to check if your anal sphincter muscles have healed well.

If you are experiencing difficulty where you are not able to control passing wind or motion, or if you have had an ultrasound scan which showed that your muscles have not healed well, you may be advised for a caesarean section.

Other factors will need to be considered – you should discuss this with your gynaecologist so that you can make a balanced decision.