A fourth degree tear should be diagnosed shortly after childbirth during a routine examination.
Diagnosing a fourth degree tear
All women who have given birth vaginally should be given a detailed examination soon after the delivery. This can be carried out by either a midwife or a doctor who must take care to fulfil the following steps:-
- Ask a patient for her consent to perform the examination and provide adequate pain relief
- Ensure good exposure of the perineal injury. If this is not possible, a patient should be placed in the lithotomy position
- Carry out a visual examination of the genitalia
- Perform a vaginal examination to establish the full extent of the vaginal tear
- Lastly, complete a digital rectal examination to exclude injury to the anorectal mucosa and anal sphincter
It is very important that such a thorough examination is achieved because it is the only way to diagnose a fourth degree tear. It is not enough to simply assess the area visually, as a fourth degree tear may be present beneath apparently intact perineal skin. A digital rectal examination is also vital, or it will not be possible to identify obstetric sphincter damage.
Missed fourth degree tears
But unfortunately fourth degree tears do remain undiagnosed, meaning a woman leaves hospital without the necessary treatment. Ordinarily this will happen for one of two reasons:-
1. An examination was not performed after the birth; or
2. An examination was carried out shortly after the delivery, but a fourth degree tear was mistaken for a more minor tear. Often this is because a digital rectal examination was not also performed.
However, a missed fourth degree tear is a serious cause for concern because a woman will return home totally unaware that she has a severe perineal tear. Because this has not been repaired problems will soon start to develop, and will continue to do so until the injury is eventually diagnosed.
Consequences of a missed fourth degree tear
A fourth degree tear that is not diagnosed and treated soon after birth will lead to complications of a distressing nature. One of the most common symptoms is incontinence of faeces and flatus (passing wind). Often this will prompt a woman to seek further medical attention and a fourth degree tear is subsequently discovered.
Treatment can then be provided, but a secondary repair is much less effective than a primary repair (meaning a repair that is carried out shortly after the birth). Long-term complications may therefore ensue.
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