What Is A 4th Degree Tear?
A fourth degree tear is the most serious type of perineal tear that can occur during vaginal childbirth. It extends through the perineal muscles and the internal and external anal sphincters, reaching the lining of the anal canal or rectum.
Although many women experience some degree of perineal trauma during childbirth, only a minority sustain a fourth degree tear. Prompt diagnosis and appropriate treatment are important if the mother is to have the best possible chance of making a good recovery.
What Are The Different Degrees Of Perineal Tear?
Perineal tears are classified according to the extent of the injury:
- First degree tear: an injury to the vaginal tissue or perineal skin.
- Second degree tear: an injury involving the perineal muscles, but not the anal sphincter.
- Third degree tear: an injury extending into the anal sphincter muscles.
- Fourth degree tear: an injury involving the perineal muscles, the internal and external anal sphincters and the lining of the anal canal or rectum.
First and second degree tears are generally less serious. Third and fourth degree tears involve the muscles responsible for controlling the bowel and can therefore cause significant complications.
Why Does A Fourth Degree Tear Happen?
It is not always possible to predict when a fourth degree tear will occur. However, factors already associated with an increased risk include:
- A first vaginal birth;
- A larger than average baby;
- A prolonged second stage of labour;
- An induced labour;
- An assisted delivery involving forceps or ventouse; and
- The baby’s shoulder becoming stuck behind the mother’s pubic bone.
A tear may occur naturally during labour. An episiotomy may also be performed to enlarge the vaginal opening, for example when the baby must be delivered urgently or to assist a forceps delivery.
What Are The Symptoms Of A Fourth Degree Tear?
A fourth degree tear will usually be identified by the medical team shortly after the birth. If the injury is missed or has not been repaired successfully, the mother may experience symptoms including:
- Pain in the perineum;
- Pain or bleeding when using the toilet;
- Difficulty controlling wind;
- Faecal urgency or incontinence;
- Urinary incontinence; and
- Pain during sexual intercourse.
Anyone experiencing these problems following childbirth should seek advice from their consultant, midwife or general practitioner.
How Should A Fourth Degree Tear Be Diagnosed?
Following a vaginal birth, the mother should undergo a thorough examination to identify any damage to the vagina, perineum or anal sphincter. This should include a digital rectal examination, as this can help medical professionals determine whether a third or fourth degree tear has occurred.
The injury must be correctly classified so that the appropriate repair and follow-up treatment can be provided.
How Is A Fourth Degree Tear Treated?
A diagnosed fourth degree tear should be repaired in a well-lit operating theatre by an appropriately qualified and experienced surgeon. The repair will normally be performed under suitable pain relief or anaesthetic and the wound will be closed using dissolvable stitches.
Further treatment and advice may include:
- Antibiotics to reduce the risk of infection;
- Pain-relieving medication;
- Laxatives;
- Advice about keeping the affected area clean;
- Pelvic floor exercises; and
- A follow-up review after approximately six weeks.
What Is The Likely Outcome?
If a fourth degree tear is diagnosed promptly and repaired appropriately, there is a good chance of recovery. However, problems can arise if the tear is missed, incorrectly classified or inadequately repaired.
An untreated defect affecting the anal sphincter can cause continuing bowel urgency, difficulty controlling wind and faecal incontinence. These symptoms can have a serious effect on the mother’s confidence, relationships, employment and everyday life.
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- Tell us what treatment you received and what you believe went wrong
- We assess the initial circumstances
- We explain whether further investigation may be appropriate
Your initial enquiry is free. No Win No Fee funding may be available.
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Tell us what happened
Call us or complete the short enquiry form with a brief outline of the treatment you received and the harm caused.
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We assess the circumstances
A member of our specialist team will review the initial details and may ask you for some further information.
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We will explain whether we may be able to help, the possible next steps and any funding options relevant to your enquiry.
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Can A Fourth Degree Tear Be Prevented?
It is not possible to prevent every fourth degree tear. Existing guidance on the website identifies measures such as perineal massage during the later stages of pregnancy, pelvic floor exercises, good nutrition and a slow, controlled delivery as potentially helpful.
Medical professionals should also take account of any factors that may increase the likelihood of a severe tear when planning and managing the delivery.
Fourth Degree Tears And Medical Negligence
The occurrence of a fourth degree tear does not, by itself, mean that the medical team was negligent. However, concerns may arise if the injury:
- Was not identified following the birth;
- Was incorrectly diagnosed as a less serious tear;
- Was not repaired by an appropriately qualified surgeon;
- Was repaired to an unacceptable standard; or
- Caused avoidable harm because recognised risks were not managed appropriately.
If you believe that poor maternity care has caused you lasting harm, you can find further information on our 4th degree tear claims page.
Can We Help You With A Medical Negligence Enquiry?
Early legal assistance can be vital so please contact us if you would like to discuss your situation. Please call us free on 0800 234 3300 (or from a mobile 01275 334030) or complete our Online Enquiry Form.
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