What is a 4th Degree Tear?


If you have suffered a 4th degree or buttonhole tear, please find our Facebook support group. If you suffered any other type of tear, please join the Birth Tear Support group.

What exactly is a 4th degree tear?
Most people who have a vaginal birth will have some degree of tearing, but how much tearing can vary significantly. A 4th degree tear is most severe tearing, and one of the worst maternal complications of a vaginal delivery that can have life altering effects. Not only can they lead to fecal or gas incontinence, painful or inability to have sex, temporary or permanent colostomies, but also infection or postpartum hemorrhages. Read some of our stories here.

There are four degrees of perineal tearing:

Everything you need to know about perineal tearing during labor | BabyCenter

  • 1ST DEGREE – involves the SKIN only. These are the least severe, involving the skin between the vaginal opening and the rectum and the tissue directly beneath the skin. You might experience some mild pain or stinging during urination. These tears might or might not require stitches and typically heal within a few weeks.
  • 2ND DEGREE – involves the SKIN, MUSCLES, and FASCIA of the perineum. Second-degree tears typically require stitches and heal within a few weeks. This is also the degree of most episiotomies.
  • 3RD DEGREE – involves the SKIN, MUSCLES, and FASCIA of the perineum, and extends into the ANAL SPHINCTERS. There are different levels of 3rd degree tears – 3a, 3b, and 3c.
  • 3a – less than 50% of the external anal sphincter is torn, and the internal anal sphincter is intact
  • 3b – more than 50% of the external anal sphincter is torn, and the internal anal sphincter is intact
  • 3c – the external anal sphincter is completely torn and the internal anal sphincter is also torn, the rectum is intact (not torn)
  • 4TH DEGREE – involves the SKIN, MUSCLES, and FASCIA of the perineum, and extends through both ANAL SPHINCTERS and into the RECTUM. These are the most severe tears which sometimes require repair with anesthesia in an operating room — rather than the delivery room — and might take longer than a few weeks to heal. Complications such as stool leakage (fecal incontinence), infection, rectovaginal fistula, and painful intercourse are possible. If these problems occur, talk to your health care provider.


  • BUTTONHOLE TEAR – these tears are INTERNAL tears that can extend all the way to the rectum. Externally the perineum and/or anal sphincters can be intact (not torn), but internally the tissue between the vagina and rectum have been torn. If these tears are not immediately diagnosed and repaired, they can lead to RECTOVAGINAL FISTULA, which is basically a tunnel between the vagina and rectum allowing gas or stool to pass through.

This video shows the different degrees of tearing.

Rectovaginal Fistula Treatment | Mercy St. Louis
Mistakes in managing perianal disease and how to avoid them | UEG - United  European Gastroenterology

–  refers to the actual opening in your abdomen
STOMA –  refers to the end of the intestine that’s sewn into the ostomy.
stoma chameleon
Gill Castle of Stoma Chameleon is raising awareness of birth injuries and stomas. Click her picture to check out her website.

FECAL INCONTINENCE – the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. Also called bowel incontinence, fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control.

GAS/WIND INCONTINENCE – the inability to control gas/wind. It is often the most difficult aspect of bowel control. Many people find that diet has a big influence on how much gas your bowel produces and how it smells.

URINARY INCONTINENCE – Loss of bladder control, varying from a slight loss of urine after sneezing, coughing, or laughing to complete inability to control urination.



CYSTOCELE – Anterior vaginal prolapse, happens when the bladder falls down into the vagina.

RECTOCELE – Posterior vaginal prolapse, is when the wall separating the rectum from the vagina weakens. This allows the rectum to bulge into the vagina.

UTERINE PROLAPSE – when the uterus droops down into the vagina.

APICAL PROLAPSE (VAGINAL VAULT PROLAPSE) – when the cervix or upper part of the vagina falls down into the vagina.


PELVIC FLOOR PHYSICAL THERAPY(PFT, PT)/PHYSIOTHERAPY/PHYSIO – involves the pelvic floor muscle group, which is responsible for a variety of functions. These muscles support the pelvic organs, assist in bowel and bladder control, and contribute to sexual arousal and orgasm. A person may be referred to pelvic floor physical therapy to treat incontinence, difficulty with urination or bowel movements, constipation, chronic pelvic pain, and painful intercourse.

UROGYNECOLOGIST/FPMRS/Female Pelvic Medicine and Reconstructive Surgeon – a doctor who has received special training to diagnose and treat females with pelvic floor disorders

COLORECTAL SURGEON – a doctor who specializes in the diagnosis and treatment of anorectal and colorectal conditions (conditions of the colon, rectum and anus).

Find a trusted professional on our map here.