When I had my son, I experienced a lightning fast labor and complicated delivery. He was born less than three hours after I got to the hospital, in a position commonly referred to as a "complex presentation." That means he came out not only facing the wrong direction, but also arm first. While my OB-GYN was amazing and supportive, I still suffered a near-fourth degree tear that hurt in ways I can't describe. A fourth degree is pretty uncommon, but it's devastating. How to cope with a fourth degree tear is not only an exercise in patience, but also understanding you're not superwoman and you shouldn't have to be.
According to the Royal College of Obstetricians and Gynaecologists (RCOG), most third and fourth degree tears cannot be prevented and cannot be predicted. It is one of those tricks of childbirth you do not see coming. A fourth degree perineal tear is officially known as an obstetric anal sphincter injury (OASI). This is because the tear goes through the vaginal opening, down the perineum, through the muscles, and into the anal wall. Treatment for the injury must be precise and quick, not only because of the high risk of bacterial infection, but also because it affects how your body operates when it's eliminating waste. In all likelihood, according to RCOG, you will be prescribed a course of prophylactic antibiotics, given a not insignificant amount of painkillers, and ice will be used liberally.
When I went through mine, I remember being terrified to sit down, terrified to stand up, and I didn't want anyone near me. Of course, this wasn't an option, as I'd just had my first baby. People were coming, whether I wanted them to or not. I tried to put on my big girl panties, but all that worked with the enormous diaper like pads I had to wear were the mesh panties the hospital gives you. Pro-tip: if your child rips you a new a-hole, they'll throw as many as you want in your going away package. Thanks, nurses of Roosevelt Hospital. You're aces.
According to Mater hospital, the care routine currently prescribed is essentially identical to how I was told to cope with a fourth degree tear. This includes washing the perineum several times a day with warm, soapy water or warm sterile saline, depending on the instructions of your doctor. You're not going to wash it with a cloth, but instead using a squirt bottle aimed at your perineum. You can also use a sitz bath basin and spraying device that fits over your toilet. You may or may not be prescribed topical antibiotics or anesthetics that will need applying after washing your perineum. Honestly, I asked for every available treatment I didn't have to swallow because me and painkillers are not friends.
The flip side of the painkillers, helpful in pain relief as they are for some moms, is that they have a really problematic side effect, especially for women with tender and torn back doors. They cause constipation, noted Harvard University, and the last thing you want when you're terrified of even urinating is straining to defecate. And let me tell you, the first time you do? It's a pain that rivals childbirth. I actually screamed. Loudly. My nurse ran into the bathroom and I was a bleeding mess, crying on the toilet. She didn't even have to ask what happened before she helped me get cleaned up. Again, nurses are just the salt of the earth.
This is a big reason the RCOG recommends the prescription of prophylactic non-stimulant laxatives post-tear. In the United States, if you have a tear, chances are that when they bring you your pain relief, they'll also bring you water and Colace, or docusate sodium, which is a stool softener that works to relieve the need to bear down at all. However, be prepared. A few days on Colace, and it's a bit like rocket poop. Not kidding.
According to Clinical Advisor, your activities are severely curtailed for weeks, if not months. For me, I wasn't meant to be on my feet for six weeks postpartum, and I really wish I'd followed their directions more closely. Because I didn't, my recovery was much slower. As for sex, ignore all of the advice laid out for women who didn't have a tear like yours. It may take months to be able to comfortably have sex again, and it might still be uncomfortable. Talk to your doctor, keep a dialogue open with your partner, and go at your own pace.
Healing from a fourth degree tear is individual, and nearly everything from riding a bike to swimming to picking up your child's car seat will depend on your own rate of healing. Thankfully, Clinical Advisor noted that most women are asymptomatic at one year, but will require clinical counseling if they intend to get pregnant again, because delivery can be a challenge the next time.
In the meantime, give yourself space to be angry and in pain. That's 100 percent normal. Be open with those you love, and ask for patience. Remember, your provider is there for you, but you need to advocate for yourself. Keep that line of communication open, and go to your appointments. Hopefully, this will pass sooner than you anticipate.
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