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

Hello hello!

A huge thank you to everyone who read the fistula stories from the past 2 weeks! You guys were so wonderful and sympathetic and thankful that I shared my story. Please continue to spread the story among birth workers! If you missed them, read the story here and here.

Today we’re chatting about a recent JOGNN article: Effects of Fourth-Degree Perineal Lacerations on Women’s Physical and Mental Health” by Cheryl Tatano Beck published in March 2021.

I had intended to share my fistula story but had only read a few articles published in the obstetric literature. While I was post-surgery, my monthly JOGNN journal showed up with this article and I knew I had to share it. If you read my story, you know that there is a lot that happens around fistulas that is qualitative – or, hard to measure – and some things can only be told from a person’s perspective. That was the goal of this study – “to describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth” (Beck, 2021, p.133). And to date, only five qualitative studies have been completed on significant perineal lacerations and none of those studies were conducted in the United States.

The study was well designed and the author was clear about when saturation occurred. I did note in the population of 18 women, 1 woman was Asian while the other 17 women were White. For mode of delivery, 6 women had a vaginal delivery and 12 women had an operative birth. There were 13 women that sustained thier laceration with their first birth and 5 that sustained their injury with their second birth. And 5 women developed a rectovaginal fistula while the other 13 did not. Also important to note is that 50% of the women reported post-traumatic stress disorder after thier laceration occurred (Beck, 2021).

The study included women from around the world – the United States, the United Kingdom, Australia and Canada. These countries were often the same countries I found in the online support groups but the women from this study were specifically recruited from a group called “Mothers with 4th Degree Tears” (Beck, 2021).

The author described 7 themes from their stories:

  • Why wasn’t I informed I had this injury?
  • The unthinkable: Fecal incontinence and so much more
  • Seeking relief: Enduring surgery after surgery
  • Why didn’t anyone ask me about my mental health?
  • To have more children, that is the question.
  • Are there any positives in all of this?

It’s like the author read my mind! All seven of these themes are spot on.

Before you think “I’ll never see someone with this…”, let’s do a review of how often these kinds of lacerations occur.

Third and fourth-degree tears occur in 0.25% and 6% of women worldwide. The risk is higher for women having their first baby, 1.4% to 16%, and lower for women having their second child or more, 0.4% to 2.7%. Recurrence in a subsequent birth is also high in women that have had a prior third or fourth-degree laceration, 5.1% to 10.7% (Beck, 2021)..

For birth workers, think of it this way: approximately 1 in 100 women will have a fourth-degree laceration while up to 6 in 100 women will have a third-degree laceration (Beck, 2021). Said another way, if you practice in a place with only 200 births a year, you might only see a third or fourth-degree laceration a couple times a year. If your hospital births 2,000 babes a year, you may see as many as 20 fourth-degree lacerations in a year (or more).

Current evidence shows that the biggest risk factors for a third or fourth-degree lacerations are: nulliparity, operative delivery, and infants weighing greater than 4000 grams (about 9 pounds). Also interesting is this: about 20% of women that have a fourth-degree laceration choose to have a cesarean section for thier next birth. In my practice, I see this about 5% of the time – but I think this is influenced by a multitude of factors (counseling, OB provider type, personal factors, trauma from experience, etc…) (Beck, 2021)..

Okay, let’s run through some findings noted in the themes.

Theme 1: Why wasn’t I informed I had this in jury?

This theme is rooted in miscommunication. Women reported that no one told them they had a fourth-degree laceration. They also noted that when an operative delivery was offered that the risks were not reviewed. Some women reported that they would have chosen as cesarean section if the risks had been reviewed. One woman was even told “just use a sitz bath and make sure poop isn’t coming out your vagina” (Beck, 2021, p.137).

Theme 2: The Unthinkable: Fecal Incontinence and so much more

When women noted that gas and stool were coming from their vaginas, many of them were dismissed and told their symptoms were normal after birth or that they had a hemorrhoid. Some women noted symptoms right after birth and some noted symptoms weeks after birth. A multiparous mama described that her “vagina and rectum were now one hole!” (Beck, 2021, p.138).

Theme 3: It has cost me so much

On participant described feelings this way: “[The laceration affects] what I eat, when I eat, where I go, if I have sex, how I view myself, what I wear, how I interact in social situations, etc” (Beck, 2021, p.138). Another described it as:

“From the moment I get up it’s a question of when am I going to have a bowel movement so I’m close to the bathroom and have my wet wipes because toilet paper and my bottom no longer get along. Once I have a bowel movement, the next questions is will I have seepage and irritation all dat or can I take a shower to rinse off?” (Beck, 2021, p.138).

Some women reported carrying adult diapers in their purses or ostomy supplies.

Some women reported intimacy as a struggle because the fistulas cause noise during intercourse or stool leakage occurs (Beck, 2021).

Theme 4: Seeking relief from everything: Surgery after surgery

Of the 18 women, 7 women underwent surgery to fix their fistulas. For 3 women, the first surgery was successful. For the remaining 4 women, additional surgeries were needed and 2 of the women required ileostomies.

One woman stated this: “At 6 months postpartum, my OBGYN referred me to a colon-rectal specialist. That was the first time I heard the term ‘fourth-degree tear.” The doctor suggested a sphincteroplasty to repair my rectal muscle, which was torn in half” (Beck, 2021, p.137).

Theme 5: Why didn’t anyone ask about my mental health?

The women repeatedly asked why no one asked about their mental health. Many suffered in silence from the shame of not being able to control their bowels. Many women struggled with PTSD from their experience and women had not shared their experience until they enrolled in the study (Beck, 2021).

Theme 6: To have more children? That is the question.

Many women struggled with two questions: Should I have more children and should I deliver vaginally or by cesarean section? For the first question, many women reported they worried about worsening symptoms. For the latter question, some women were offered cesarean sections while other chose water births. Regardless of what a woman chooses, it’s important to understand that these are heavy, unknown questions that occur before the pregnancy, during the pregnancy, and up to the day of birth (Beck, 2021).

Theme 7: Are there any positives in this?

Women offered some really inspiring points. Women reported joining a support group was very helpful. Many also reported that sharing their story was healing and they were able to offer support to other women. Another woman became an active advocate for women in childbirth by sharing her story at a large conference. Another stated “I am grateful for my healing in these ways and for the work that God has done in and through me as a result of all of this” (Beck, 2021, p.141). Another woman put her anger into a policy development to make a discharge protocol for women with severe perineal lacerations. Many refused to let their laceration ruin their lives.

One woman summed it up this way: “If I’ve got to live with it forever, then I will just get on with it. There is always someone worse than you, so I just get on with life and enjoy it as much as I can and be the best mother I can” (Beck, 2021, p. 141).


Women’s concerns are often dismissed by providers (Beck, 2021).

Practice implication: Investigate any concern of passing gas or stool through the vagina. An interval visit before the postpartum visit offers an opportunity for an exam, an early diagnosis and education.

The study supported that women do not receive information about life-altering birth injuriesThere is a lack of education about fourth-degree tears in pregnancy and the postpartum periods (Beck, 2021).

Practice implication: Tell a woman she has a fourth-degree laceration at the time if occurs; ensure the woman understands what to expect, how to care for her laceration and what resources are available to her. Also review options for a vaginal or cesarean delivery for subsequent births.

Mental health conditions of PTSD or postpartum depression in women with fourth-degree lacerations have not been previously studied (previously only fear and anxiety have been studied) (Beck, 2021).

Practice implication: Understand that women with gas or stool know that something is not right – they are carrying a burden of shame and embarrassment and this leads to isolation. Screen for coping, depression, PTSD, etc. often and review resources for support groups. Also remember that many of these women are navigating how to be a mother in the midst of their symptoms and healing.

Wow. It was a good article. I think there’s a huge opportunity to learn more about how to better serve this population – from diagnosis to long term care. For example, how do you care and educate a woman who is 45 years old and has had a fistula for 20 years?

I think the study was really well done and I hope the study contributes to the small body of research about this population. From my own experience, finding support groups was the most beneficial thing in my own education and healing. There are so many questions that you cannot find the answers to outside of support groups. But I’ll be honest, before I had a fistula, I didn’t even know there were support groups. Next time, I’ll know, and I hope you will too.

The 16 week visit is live Wednesday!




Beck, C.T. (2021). Effects of fourth-degree perineal lacerations on women’s physical and mental health. Journal of Obstetric, Gynecologic and Neonatal Nursing, 50(2), 133-142. doi: http://10.1016/j.jogn.1010.10.009

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