Looking for info. on 4th degree tears

[happyartmama]

I know a woman being encouraged by her docs to do a c-section with baby #2 because she had a 4th degree tear with #1. Rationale being that if she tears again, she can have problems controlling her bowel movements later on, and a higher risk in general of tearing again since she tore the first time. I haven't heard much or have solid knowledge specifically regarding 4th degree tears. Anyone have info. I can pass along?

[Mindi22]

I'm wondering why she had such a bad tear in the first place? What is a quick labor or was the baby big or something else?

[liseux]

If her tear healed well the 1st time and she has had a pretty good amount of time between births, she will probably be fine. I highly recommend sitting in a sitz bath (in the tub) every day starting at 35 weeks. It can get the tissues ready to stretch. If she has incontinence now, that's a different story.

[ctdoula]

I had a 4th degree with my 1st as a result of an episiotomy gone wrong (thanks Dr. X). Anyway, with my second the midwife told me the scar tissue isn't as flexible/stretchy, so I would have a greater risk of tear along the scar, but that it wouldn't be as bad. My son was 1.5lbs bigger than my dd, and I only had a tiny skid mark, not even close to the scar.

I think if she has a provider who is willing to really support her perineium during birth, she will do fine.

[DoomaYula]

I know a woman who had a bad tear with her first birth, and she went to see a new doc for her second pregnancy, and asked him if she would tear again. He said, (rightly) I don't know, I can't predict that.

That wasn't a good enough answer for her, so she went to another doc who whipped out his magic 8 ball and told her she WOULD DEFINITELY tear, and WHEN she did tear she'd be incontinent for life and would need a colostomy bag.

So she happily scheduled a c-s for 39w.

Anyway, other than the tissues, it depends on position (mom's and baby's) and a host of other things. I wouldn't want major abdominal surgery to prevent possibly tearing although I've never had a tear.

[Midwife Kris]

Here is what a pal of mine says (she is a perinatologist):

Because women who have had a previous 4th degree (and some also say 3rd degree) are at much higher risk for another severe perineal injury than women who didn't have a 3rd/4th degree; and because women who have a second 3rd/4th degree are at like a 20-50% risk of incontinence of stool and flatus, we will typically counsel women about those risks and offer them a c-section with the next birth. Certainly, most of these women can have a 2nd vaginal delivery without incident, but the small number that have another severe laceration with their next vaginal delivery are at pretty high risk for anal incontinence, and some women don't think that the incontinence is worth it.

[pamamidwife]

there are quite a few threads on this - and quite a few women here who have had vaginal births after a fourth degree tear. I've seen it one time in my own practice -

I had a third degree and would definitely go on to have a vaginal birth. But you can bet I wouldn't hire a hands-on surgeon to attend my birth. It would have to be under my control with only MY hands touching me during pushing!

[happyartmama]

Thanks for all the responses; I will pass along the info. and hopefully she can have a more informaed discussion with her doc and make a decision. Thanks!

[Gr8ful Momma]

So, I had a 4th degree tear when I delivered my first son almost 16 years ago, since then I have had one c-section (breech twins). I would really like to do VBAC with my next pg. but after reading this I am concerned about the risk. What are the actual odds and is a repair to stop the poss. incontinence avail? Since my twin pg I some times have a little urine leakage when I have a severe cough or multiple sneezes.

[pamamidwife]

the odds of a horrific tear are much less with a hands-off provider, the mother birthing anywhere but on her back or tailbone and no purple pushing.

I think that many homebirth midwives see much, much better results than OBs.

[crystaldawn]

I have seen a couple of deliveries personally that the mom had a 4th degree with the last baby and with the next one had a "skid mark" or first degree tear only... It does depend on a lot of factors, size of baby and whether forceps or a vac were used, position of baby etc.

There was a woman I was caring for not too long ago that had a "traumatic" delivery with her first baby. That baby was over 8lbs and she had a 3rd or 4th degree tear and opted for a c/s at 38.5 wks with baby number 2 and delivered a 6 lb baby. She probably could have delivered the kid without an issue.

I personally would do a vag delivery if I had a 4 degree with either of my kids (thankfully I didn't)...

[MsBlack]

I'm with Pamamidwife and others on this. Only thing I would add is that such a mom would probably benefit greatly from doing perineal and vaginal massage with a high quality vit e oil, during pregnancy. Both the massage and the vit e will help here--even 'old' scar tissue will respond well to the benefits of vit e (and other healing things like comfrey and calendula).

Just had a birth with a mom that had a 3rd degree tear (extension of episiotomy) w/her first birth. She was so worried about tearing, especially as I do not suture. She ended up w/a FAST delivery, I didn't even get there in time and so she had no perineal support for birth--she said she tried to hold back with the ring of fire, but still 2nd stage with 10lb 5oz baby was less than 10 min. She did tear on her scar--but only 2nd degree. Her doc said she would probably heal fine, he didn't stitch her (talked to her same day, saw her next day).

Yes, it has everything to do with position (all circumstances mom faces) at birth and no interference but maybe perineal support and certainly some control of delivery by mom.

[onlyboys]

I had a 4th degree with my first, and minimal tearing with my others. My rule was NO ONE touches my perineum. Period.

I would never consider a cesarean for a previous 4th degree.