I too suffered a fourth degree tear with the birth of my daughter 18 months ago. I was 8.5 cm dilated with a lip left on the cervix and the doc said I dilated completely when I pushed so he asked if I wanted to start pushing which I said yes considering I was in labor for 24 hours and ready to get the baby out! It was an unmedicated birth, though at the end when I was pushing the doc offered a local pain shot which I agreed to. I did that pushing where everyone told me how to push and when to push (I was on my back with legs pulled back) - three big pushes during each contraction. DD's head was slightly turned to my left thigh and the doc turned her during one of the pushes.
She started having decels whenever I pushed, but her heartrate would go back up when the doctor stimulated her scalp. At this point the intensity in the room climbed dramatically and all of the nurses/doc/my mom were all shouting PUSH! at the top of their lungs. I was pushing as hard as I possibly could, grunting and screaming like a wild animal. She was born within 45 minutes of me pushing and I ended up with a fourth degree tear.
It took me a year to recover physically due to some scar tissue that caused sex to be painful. I feel fine now though I can still sense where that scar tissue is and I haven't tried wearing thong underwear in a while since the scar tissue would hurt whenever I tried to wear it.
Emotionally the tear took a huge toll on me and I would stay up hours researching all the potential problems I could have from it and whether or not I could give birth vaginally again.
Now that I'm pregnant again (15 wks along), I've had one OB tell me I would absolutely need a c-section and that she's performed 3 c-sections on various patients who had suffered a fourth degree tear, that my repair is good but that she couldn't guarantee a good repair the second time around and that I could end up with a fistula.
Another OB told me I wouldn't necessarily have to have a c-section and that we could wait until labor started and then decide. She did say that I have a small pelvis which may have contributed to it (I'm normally 5'4'' and 110 lbs).
The OB I'm with now (who has been great so far!!!) has me scheduled for a vaginal but said we'd talk more about it as I progress further in the pregnancy. She wouldn't give me an answer one way or the other about whether or not the risks of a c-section were worse than the risks of tearing again. She said we could go the c-section route if that's what I'm most comfortable with but declined to really give me her opinion! She did say I have a very very short perineum which may have contributed to the tear - however I personally think my perineum is shorter now than it was before giving birth.
My biggest concern is obviously tearing again and having irreparable damage, but also I'm worried that giving birth vaginally would result in long-term fecal incontinence when I'm older. I've read on other message boards about women whose colorectal surgeons all said they would NEVER suggest vaginal after fourth degree tears.
Also I've read that even if you don't tear again, you can have damage to the pudendal nerve just from the hours of labor and the baby sitting on the nerve in the birth canal, which could result in fecal incontinence when you are older even if you have no problems now. So my fear is that even if I escape without a tear, I will still suffer the consequences 20 years from now as I age.
Of course, I would hate to have a c-section and then suffer years of pain from internal adhesions or bladder incontinence resulting from the surgery, and I have even read about women who needed a hysterectomy years after their c-section due to adhesions and scar tissue.
I just honestly don't know which poses the highest risk to me and which would result in potentially the worst long-term damage. We aren't planning to have anymore children after this so that is not one of my primary concerns.
I am wondering if I did another unmedicated birth, this time with no local antisthetic (sp?), pushed when my body told me and I was fully 10cm, side-lying position, and hired a doula, plus minimal fingers inside me for checking etc., if I could manage to give birth without another 4th degree. Either way I am filled with anxiety at the thought of another vaginal or a c-section