What To Do After A Third Or Fourth-Degree Laceration
Women often reach out to me with questions about the pelvic floor. I recently was asked what should be done after a fourth-degree laceration- how should you deliver the next time? This is a great question with lots of nuances. So, let’s explore this topic. And let me start by saying that while pregnancy is hard, I think delivering is often even harder. Of all the women who have their first baby vaginally, more than half of them do not have a visible tear or have a small tear. But about 4% of women will have a big tear, a third or fourth-degree laceration. What should these women do?
What kind of tears happens during delivery?
The most common tears that happen during a vaginal delivery are perineal tears. Perineum is the skin and underlying tissue between the vagina and the rectum. There is a lot of pressure on these tissues when the head and shoulders push through, and it is likely to tear.
- A first-degree tear involves just the skin.
- A second-degree tear involves more of the perineal tissue and muscles.
- A third-degree tear involves part of the anal sphincter muscle.
- A fourth-degree tear tears all the way through the anal sphincter into the rectum.
The Mayo Clinic has some great images on these tears if you are interested (https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/multimedia/vaginal-tears/sls-20077129?s=3)
Third and fourth-degree tears create the most trauma on the pelvic floor. The healing process can be long and difficult.
What should be done in the short term?
Third and fourth-degree lacerations are wounds that need time to heal. Women with these tears have more pain and more bleeding. These tears are more likely to get infected and heal poorly than more mild tearing. Constipation can be a huge problem and needs to be avoided to protect the repair while it is healing. Having soft stools will also lessen pain during bowel movements. Sometimes a second repair is needed to heal the area properly.
It is easy to watch these tears heal. But there can also be damage underneath the tissues you can not see with the naked eye. You need to have an MRI or ultrasound to see this damage. Other types of damage that can happen include:
- Swelling in the pelvic floor muscle and soft tissue
- Tearing and damage to the pelvic floor muscles
- Swelling and subcortical fractures in the pubic bone
- Stretching and damage to the local nerves
This type of damage is more common in women who have had third and fourth-degree lacerations. The more damage there is, the more likely you will have pain, bladder and bowel incontinence, and prolapse. For some women, it can take more than six months for healing to complete. It is important that women are supported during this time. Managing these symptoms while caring for a new baby is hard. Physical therapy should be offered and can be very beneficial. A pessary to support the tissue or help with bladder leaking can also help.
Some institutions have developed specialized clinics to help with education, healing, and support during this period. These clinics have been shown to facilitate the healing process, improve outcomes, and greatly improve the postpartum experience for women.
What does all of this mean for the long term?
The good news is that 60-80% of women with a large tear have no symptoms a year after their delivery. But this does not mean that there is no ongoing injury. These women are more likely to have weaker pelvic floor muscles and anal sphincter muscles. They may still have damage to the sphincter muscle. And these changes may cause issues later in life.
Some women have ongoing issues and symptoms. Around 38% will have urgency with bowel movements and need to rush to get there. More than 15% will leak stool and be unable to control bowel movements. And 1-2% will develop rectovaginal fistulas (a hole between the vagina and rectum). These women are also more likely to have issues with bladder leakage.
What about future deliveries?
This is really the big question for many women. There isn’t enough research here to be able to offer broad guidelines. Each case is unique, and it is reasonable to be evaluated by a urogynecologist to discuss how you should deliver in the future. We know that usually, most of the damage that happens to the pelvic floor happens in the first delivery. Less trauma usually happens with later deliveries. But a small amount of additional trauma can cause big problems.
When thinking about how to deliver in the future, you must consider what is important to you. Women who had a very traumatic first delivery often want to avoid this experience again. And, women who had complications healing often want to avoid a vaginal delivery. Women who have recovered without issue may value the experience of vaginal delivery and want to repeat it. And, women who want big families shouldn’t have lots of cesareans- each one is a little more risky. All of these factors are important and should weigh into your consideration.
So, what are the risks to the pelvic floor?
The risk of having a second sphincter laceration is low, about 7%. But this risk is about three times higher than it is in women who have not had a sphincter laceration. In England, the current recommendation is that an elective cesarean is offered to women with either ongoing bowel symptoms or a sphincter defect seen on ultrasound. About 20-25% of women with a third or fourth-degree laceration will have worsening fecal symptoms after a second vaginal delivery, even if there is no sphincter tear. And if there is a second sphincter tear, it is more challenging to fix. Prolapse may worsen after a second delivery, but I don’t usually recommend a cesarean for prolapse, only to protect nerve, muscle, and sphincter function.
Most of us want a way to look into the future and predict what will happen to the pelvic floor. The Cleveland Clinic offers some risk calculators for the urinary and fecal incontinence after the first delivery (https://riskcalc.org/FemalePelvicMedandReconSurgUrinaryandFecalIncontinence/), but risk models for future pregnancies haven’t been developed.
Pregnancy alone impacts the pelvic floor, and an elective cesarean (one before labor) is not 100% protective. Women who have an elective cesarean section won’t have a third or fourth-degree tear. Their risk of fecal incontinence is less than women who deliver vaginally, and their risk of urinary incontinence is less than women with forceps or vacuum delivery. It is hard to predict who will need this type of delivery. And it is important to remember that a cesarean holds more risk for the infant. These babies have a little more trouble breathing after delivery, although this is usually a short-term problem.
Whether or not to deliver by cesarean is a very personal decision, and it depends on how you weigh all of this information.
My view on all of this is skewed because I see women having trouble with controlling stool. I always want to protect the sphincter. And it is easier to avoid additional trauma than to correct it. But not everyone views the world this way. I cringe when I read posts about the low risk of sphincter damage in the second delivery in women who have had a third or fourth-degree tear. While this is true, it is only part of the story. Even without a tear, sphincter function can be negatively impacted.
I hope this information helps. But I would also say that I strongly believe that this is something that needs to be discussed and “talked out.” You can’t make an educated decision without knowing the degree of damage that you personally had and considering all the little details.
Williams Pelvic Floor Med Reconstruct Surg 2019
Miller JM AJOG 2015
Hickman LC AJOG 2020
NICE Guideline: 3rd and 4th-degreesth degree perineal tears 2015
Lowder JL AJOG 2007
Pirhonen J Arch Gynecol Obstet 2020
ACOG Committee Opinion 761 2019
NICE guideline: Cesarean 2019
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