JOGNN: Effects of Fourth-Degree Perineal Lacerations on Women’s Physical and Mental Health

During childbirth, a fourth-degree perineal laceration is a full-thickness tear that extends through the internal anal sphincter and into the rectal mucosa (see Figure 1). These lacerations differ from third-degree perineal lacerations, which only extend into the muscle surrounding the anal sphincter. In the 1998 to 2010 U.S. Nationwide Inpatient Sample, the rate of fourth-degree lacerations was reported to be 1.1% in women who had vaginal births (). In a literature review, reported the prevalence of third- and fourth-degree lacerations in women who gave birth vaginally to be between 0.25% and 6% worldwide. In women who were primiparous, the rate was 1.4% to 16%, and in women who were multiparous, the rate was 0.4% to 2.7%. For women with histories of third- and fourth-degree perineal lacerations, the risk of reoccurrence was between 5.1% and 10.7% in subsequent births (). Severe perineal lacerations that extend into or through the anal sphincter are also referred to as obstetric anal sphincter injuries. The lack of a uniform classification system for severe perineal lacerations is one of the reasons for the wide variation in the reported rates.


Women were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi’s method for phenomenological analysis.


The devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn’t I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn’t Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This?


Women need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women’s mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.