Birth After a Fourth Degree Tear

[HeidiC]

Ok, I know this has been discussed before but almost everything I have found has to do with episiotomies gone bad.

I had been in labor with no progress for several days when I was admitted at 8 pm, at about midnight my water was broken. At 7 am I started pushing. At 7:42 my son was born. I ended up with a fourth degree tear. The doctor got there too late to do an episiotomy. The tear went out sideways and then tore back into my rectum in a v shape. The doctor (of 30 years) said that it was the worst he had seen. Recovery was a nightmare. I have ended up with a recto-vaginal fistula and incontinence problems.

My husband and I are TTC again and I am trying to way the consequences of delivering vaginally again versus scheduling a cesarean. Since my tear was not a result of an episiotomy I am afraid that my skin is simply not very elastic would tear again. If I were to tear again I have been told I would have major incontinence issues and would require additional repair surgeries. I am not sure I am willing to risk this. Is there anyone who has had a similar situation? Please, I would love any input!

[Smokering]

I haven't been in that situation, but just wanted to offer sympathy - that sounds awful!

Can you tell us more about your labour, especially the pushing phase? I'm just wondering if it's possible there were circumstances in your labour which contributed to the tearing, which you might be able to avoid in a subsequent labour (if you decide to go for that, rather than a C-section). Did you have an epidural? Was it "purple pushing", where the OB/midwife/whoever coaches you to push while counting to ten? Or were you able to listen to your body and just push involuntarily, which is known as "breathing the baby out"? Were you in the lithotomy position, or upright? How big was your baby?

I didn't tear with either birth (despite a nuchal hand with baby #1 and a 9 pound 6 baby #2), and according to my MWs, that was because I didn't deliberately push, just let my body do its thing; and because I was in an upright position (squatting with the first birth, standing with the second). That said, those factors aren't always within your control, so I think partly I just got lucky. But if you're not familiar with the concept, definitely google "breathing baby out" or "mother-directed pushing", as well as "upright birth", to see if it rings any bells.

Hope you get some good advice here!

[Kimcarrots]

Hello Heidi,

I am pregnant with my fourth after three homebirths which resulted in a 3rd degree, 3rd degree and then 4th degree tears (with post birth stitch up at the hospital).  

I have elected to do the c/s route with this baby.

There is a thread somewhere on the this forum about birthing after a 4th degree tear and other mothers have gone on to have vaginal births with little or no tearing.  I just had too much history and accepted that my body just didn't stretch to give birth without a tear.  I worried when deciding about having to have more surgery if I birthed vaginally again (or not being able to hold my water/other matter in the coming years).

I would to share more about my process with you so feel free to PM me.

Best of luck in your decision!

[2littlebirds]

With my first, I had a 4th degree tear. Basically I tore 2 ways. The forceps split me open up the side, and DS's foot kicked and split me open up the back towards my rectum. It was a unique 4th degree since it was techinally like 2 seperate 2nd degrees. With DD, I birthed her drug free and the pushing phase came fast and hard, and then she had her head cocked to the side and I'm thinking that those factors are what caused what my OB called an almost 3rd degree tear. I healed quickly and easily both times and have zero reservations about birthing vaginally. Hopefully next time I'll be a little more trained to control my pushing so I can ease the baby out better.

I really like what Carla Hartley says about tearing in a recent issue of Midwifery Today. "Tears are not an awful thing, our perineums were meant to tear and heal and usually do so beyond our expectations." While I don't think it happens nicely like that every single time and can cause issues like incontinence, it is an encouraging thought :)