Life after a 4th Degree Obstetric Laceration: A Call for Informed Consent, Interprofessional Teaming, and Repair
*Special thanks to the readers and editor friends who helped support me as I wrote and grappled with how to share this story more publicly. You are too numerous to mention by name and to honor your stories and efforts, I hope this acknowledgement serves as a deep appreciation for your role in bringing this to light as without you this story would remain in my mind and in drafts. I appreciate each and everyone of you.
Kary’s Story… A Story in Process
You may click on the audio link below if you prefer to listen or listen as you read below.
A Few Notes Before We Begin:
What you read below was written in the summer of 2023.
More of the story has unfolded since that time, but as the author I have decided to leave this in its original form.
Why? To serve both as a point in time perspective and as an illustration of what most of us with these injuries know to be true– it can take a long time to be comfortable speaking these things out loud.
Whether sharing out loud comes in written form or in spoken word– it can take even longer to feel comfortable sharing these stories so publicly.
In time, I will add to this story and share more about what has been helpful since the summer of 2023, what new questions have emerged, and what questions remain.
For now, think of this as a glimpse into the decision to shine a light on the subject instead of keeping it quiet or sharing it only in hushed voices.
Hearing the experiences of others with these injuries has made my choice to shine a light on it clear– even if my decision to share it with you took months.
You’ll also notice my writing style includes footnotes. This is in part because I am used to writing more formally. Also, because this information can be intense. Even as an observer or listener, these footnotes are built to provide you as a reader with an exit ramp to pause and regroup and for me as the writer, to expand on some key information.
If you are not a read-the-footnotes kind of person, I’d suggest you consider reading them here for maximum understanding.
And now back to where the sharing of this story first began.
Kary’s story… In Process… Summer 2023
As I sat down to write about this journey, the question of who the reader is came to mind. Questions like, “Who do I anticipate will read this?” and, “Who do I hope will read this?” [1]
Also, the one reader not listed below is me– and it is important to remember that this writing is also intended for my own therapeutic writing process (hence the multiple versions it took to get to the writing you see here).
Whether you are certain this is important information for you or you don’t find yourself easily fitting into one of the categories below, please know this…
Your listening to the stories of people with these injuries during childbirth may just give you enough information to make you a connector to healing in ways you didn’t expect. We all have the ability to be that for one another so it is in that spirit that I share with you my experiences.
Thank you in advance for listening and noticing how this conversation allows you to be part of the healing and prevention process.
Notes Specifically for You Dear Reader
If you’re reading this right now, chances are that you fit into one or more of the following categories:
1) You’ve just given birth and learned that you’ve experienced a 3rd or 4th degree tear, (or maybe you were simply told– it was “a really bad tear”) and are wondering what comes next. Or, you are many years post injury and continue to have questions.
2) You’re pregnant or love someone who is pregnant and are wondering what you need to know to come up with a comprehensive birth plan.
3) You love someone who has experienced a tear and are trying to help them find the resources they need. [2]
4) You are a provider of care in the health care system and recognize that understanding the needs of people who have experienced such injuries, preventing such injuries, and finding other professionals to help be of assistance to those impacted is an important part of your job. [3]
5) You may be here wanting to understand more about things that impact fellow humans whether you’ve experienced them or not.
What Stands to be Gained in Reading This
Now that you know who I imagine the readers of this information to be, you will likely want to know what you may get from reading this and why it is important enough to me and all impacted by severe birth injuries to share these stories out loud and publicly.
If life circumstances bring you to this page and story, I am sorry you find yourselves in need of this support and I hope witnessing this story gives you exactly what this organization is named for– SOLACE.
You’ll hear more about my personal journey soon, but for now it is enough to know that those of us who have experienced such injuries recognize we did not have the support we needed or teams to help us access resources so we’re coming together now in the hope that no one else is faced with that same experience. Our hope is that the long history of insufficient support and resources ends now.
Birth and motherhood are big enough changes on their own– navigating a severe birth injury does not need to be something you manage alone.
Whether this has happened to you or someone you care for personally or professionally, you have support here. I want you to know that there is nothing too embarrassing to share– what is mentionable becomes more manageable, as Mr. Rogers would say.
If you are a member of a healthcare team or a loved one of someone with an injury, please know that not having previously known how to adequately support those you care for is not something you need to hide.
Rather, it is something to be acknowledged and tended to— the answers for how to proceed become clearer the more we all show up committed to partnering together for the best possible outcomes pre-birth, at birth, and beyond.
What if your birth injury happened years ago?
What if it was today?
Whether the laceration is new or a lifetime ago or anywhere in between, we can learn and heal more at any stage. The fact that I am writing this over 10 years post injury and feel like I am only now coming into the middle of my story may resonate with those whose injuries were some time ago–especially if you don’t think or know whether it can get any better. Perhaps like me, you were even told that your current level of healing and recovery is “as good as it gets,” but something in you says it has to get better than this. Trust that inkling.
You may be so new to this information that even the names by which such an injury is known are new to you– I too, am still learning technical medical names for the injury that put me into a group which I did not sign up to be in but am part of anyway. The term OASI (obstetric anal sphincter injuries) is indeed a reference to the injuries those of us with a 4th degree tear have.
OASI, 4th degree tear– they all feel like very technical terms, and although accurate, I can’t help but wonder how they may distance us from the reality of the impact they can have on how we live. They make me wonder what informed consent should really look like – and how it requires more than just these terms listed as footnotes naming, in such overly coded clinical language, a small risk associated with birth.
Those words indicate there is a tear, not just to skin but through multiple layers – through the first layer of the vagina, pelvic muscles, anal sphincter muscles (this is what helps you hold or control bowel movements) and into the rectum. Muscles and nerves can be impacted by those injuries resulting in a change that could mean going from a fully functioning bowel and bladder to now having only one third of the control that had been there – overnight. For some of us, this is our reality. Can you imagine not knowing this had even happened to you and one day needing to go to the bathroom and hold it with only a third of the strength you used to have? It changes your daily habits and routines in life altering ways.
In addition to the physical pain of such an injury, there are the emotional, psychological and social injuries, and those are the injuries that especially increase the risk of PTSD (often they are also the ones that are dismissed or ignored). It messed with my identity, too. The fact that I, as a generally well-informed person and a healthcare professional, did not realize that an OASI was a risk of vaginal birth shook my sense of self and purpose, not only in the beginning, but all through my journey, in ways that I did not expect. When you experience something terrible–especially if it’s something preventable that comes at the hands of others–one of the things that brings emotional, psychological, and social healing is knowing you’ve done something to prevent that terrible thing from happening to anyone else. But for a very long time, that was a brass ring I could not find a way to grab. If I could not prevent my own injuries, as a well-informed healthcare professional who was right there in the room, the sinking helplessness I felt around being able to prevent this from happening to anyone else was something that has quietly haunted me for years.
Knowing what I know now, and after talking to numerous people living with these injuries, I know without a doubt, I would have preferred to know more information prior to birth so I could work as part of my team to do what I could to prevent such an injury (and, yes, I know they cannot all be prevented) and navigate if an injury occurred. If pharmaceutical ads with all sorts of side effects can be played on TV and radio, then I think understanding the true risks of birth is a reasonable and necessary step in providing care in the birthing process.
Before we move on, I invite you to pause here with me for a moment. Personally, I need a tissue, to take a loud audible sigh or take an extra long exhale and be grateful that we got this far.
The four paragraphs above were inserted only after reviewing this piece multiple times and getting feedback from a trusted friend and colleague that a clearer description was required about what an OASI is and what it does to daily living. Even as I set out to write about this topic, fully committed to telling you my story, I found that in version after version, it was too painful to do. I just couldn't get it out. I’m telling you this to help you understand that even people very close to you, and even people you may consider very strong, may not be able to tell you what they’re going through. This is a painful and awkward topic.
The journey to sharing such truths is a winding road filled with flat tires, empty gas tanks, flashing check engine lights and a sense that it just doesn’t feel safe to share one’s story so openly. As you read this, you will see that it is certainly not a conversation that fits easily into fifteen to thirty minute medical appointments. Please be patient with our stories, and with how long it takes us to even begin to tell them.
And with that, back to the story as it was written months ago…
No matter where you enter this conversation, thank you for your commitment to learning and healing together.
Kary Gillenwaters– Ten Years into Healing from a 4th Degree Tear
Sharing these stories takes courage and often a rebuilding of trust. That trust is in oneself and with those entrusted to give us care. Hearing the stories of those who have similar experiences, it is clear that the need to hear and witness these stories is necessary to guide best practices for care and healing.
It is in this spirit that I offer my story as one of many. You may recognize yourself or someone you care for in it. Together, there is so much more we can do.
If you’re reading this and thinking– I would never want to let people know this stuff happened to me– I once was there too. So much so, that after the birth of my first born it completely changed my relationship to writing.
Prior to the birth of my baby I journaled every day, writing what I noticed during my pregnancy, who she was in utero, and how she may be in the world before our eyes ever met. Once I had my injury I stopped writing, knowing that one day I would tell my story but not then. I did not want my story or my baby’s story to be colored by the shock and surprise, and I didn’t want my child to ever see an account of her birth story that was written in a way that was incomplete and came only from that shocked, surprised, and terrified part of me.
Sure, I had talked about it to various people. Slowly I was becoming more comfortable sharing this with certain very close friends and family members. But it wasn’t public knowledge, and I wasn’t interested in this part of my life being known so openly.
So why now?
It has been over 30 years of healing and recovery for some of those I know who have been injured, 10 years for me, and months for some I have recently met. Working with seniors, I began to recognize the signs that they too had likely experienced an injury like this over 50 years ago – even if it never appeared in a medical chart.
In that time, there has not been significant change in how these sorts of injuries have been addressed. Recognizing that this is in part due to the fact these injuries are lesser known, not talked about, and that the learnings from prior experience are here now, waiting to be applied, I realize that the cost of not speaking up comes with consequences I can no longer accept. And for those who are not yet ready to share– we’ve got you, too.
Humor has helped me cope at critical points in this journey. Most notably now, I’m realizing my name may forever be attached to a search question like-- “Kary Gillenwaters, the woman who was ripped a new one”– and I’m okay with that if it means better birth experiences, care for people with OASIs, and more support.
Being Gentle with Ourselves
[4] As I prepared to share my own story with you, I found myself seeking the comfort and solace of water. It was the one place I felt most relief and comfort during the birthing process and only fitting that prior to sharing this with you, allowing water to soothe and center me once again gave me what I needed to begin to speak openly about my experience with you.
No matter when your injury occurred, you also may find times at which you require a little more TLC. And over time, you’ll be able to predict when those times might be, rather than being surprised when they occur. If you haven’t already done so, go ahead and put some things around you that help soothe you and allow you to be gentle with yourself and others– hot or cold water, sitting outside, a cozy blanket, sitting with a pet, or perhaps a candle.
Listening to these stories can be unsettling– sending us into feeling especially charged and wanting to fight against or run from the conversation. It may also send us into the opposite direction of feeling paralyzed and wanting to shut down, freeze, or more. Noticing what we need around us in order to process this information will be part of what allows us to continue to make progress in healing.
The Gift of Peer Support
It has been over ten years since I had my first child and a severe 4th degree tear requiring secondary repair. Over a year ago, I found myself noticing I was in a much better place with my healing journey and wondered if there was any support out there now. Indeed, there was now an online private support group through social media for those living with 4th degree tears– how wonderful! Eager to be able to be a voice of calm and someone to answer questions from experiences at different milestones, I joined the group. In short, I joined to be the change I wished to see in the world.
Fast forward to the last three months; because of Caroline Stadler and the other incredible people of the SOLACE foundation, it was clear that the time had come to join together to enhance the birthing process and to provide support and resources for those experiencing such significant obstetric lacerations. It is an honor to be part of a group of people who are deeply committed to making the birthing experience better for those coming after us and also circling back to support those already impacted by severe obstetric lacerations.
It brings deep comfort just thinking of someone being able to search for support and find that there are people out there who have experienced what they are going through and that there are resources to help them find a way through it. The name of the organization itself speaks to what can be found at SOLACE.
The Difference Online Resources Can Make
Contrast that to over ten years ago, or even prior to online support groups and SOLACE– you can understand why the fact that this support exists is so important.
When I was having my own issues with a 4th degree tear (and secondary repair of that injury) over ten years ago, I was stunned to realize that the severity of such a laceration was even a thing.
In addition, realizing and accepting that I was needing substantial rest to repair the physical wounds my body had endured while simultaneously coming to terms with an outcome I never knew was a possibility with no certainty of how it would all turn out— was a lot to take in and process.
In some ways, my own story was buffered by experiencing two years of fertility issues prior to that pregnancy. We had waited so long to have a baby that hearing I had given birth to a healthy baby, without pain medication, was really all I heard at first. [5]
What the medical team said about a severe tear sounded like a bad cut to me with a lot of stitches but I could manage that. Our baby had arrived, and we were so grateful. Spoiler alert: Those circumstances likely caused me to over function in hindsight– and as you’ll learn later, I accepted the guidance of health care providers who told me it was as good as it could get, even when I had a hunch that simply couldn’t be true.
Back to the birth experience and my process of learning what my injury actually meant. After birthing my child, the nurses were quick to correct the well meaning visitors who quipped that “At least I didn’t need to have a C-section.” They confirmed that I went through “a waaay harder birth than a C-section– I was one tough mama.” They would hand me my baby and say, “Here’s this sweet little thing that did that to you.” (I do remember thinking, “How dare they blame my child for the injury!” but I was both tired and relieved that she had arrived so I let it go). Looking back, it is clear that they knew the severity of my injury, but I did not. To me, “4th degree tear” simply meant “the worst kind of tear”--- not more accurately, “a tear into the anal sphincter and anal canal.”
What did I know at that point?
I knew it felt odd when I laughed, and my birthing experience had been quite painful, but I had nothing to compare it to. Since I knew they expected me to take another 9 hours to give birth, and instead, I dilated from 1-10 in an hour, it made sense to me that I may have torn with that sort of rapid shift. And I knew they stitched me up in the birthing room to try to avoid having to separate me from my newborn baby, which is what my birth plan said to do.
What I didn’t know was with how severe the tear was. Stitching me up under local anesthetic wouldn’t hold up. Two days later my stitches dehisced (burst), and I needed to go back in under anesthesia for a secondary repair. This too was not a thing I realized could happen, and that in itself made it more worrying and confusing. [6]
If my story can serve the purpose of informing others and refining best practices, I would hope people know that it was the lack of clear information and informed decision making that were most problematic and troubling to me. Not knowing the possibilities ahead of time meant even more unnecessary surprises that then took up both time and energy–my two budgets that were already taxed by simply becoming a mother.
In hindsight, had I known what a 4th degree tear actually was, there was the potential to make more informed decisions, and if I knew the repair happening under local anesthesia made the need for secondary repair more likely, managing that event would likely have required far less emotional energy. Not knowing what was happening meant all sorts of worst case scenarios were playing out in my mind as I attempted to fill in the gaps between what I knew I was experiencing and what other terrible things could be happening.
There is so much potential for proactive partnership between people giving birth and health care providers when such an injury has occurred. Staying curious and committed to finding answers and recognizing the impacts of such an injury were what I wanted and needed most in a care team, and I still do to this day.
Members of the care team don’t need to know it all. In fact, I likely feel much safer as a patient when I know you don’t believe you have all the answers, and that you need my input to be a good provider. What I need most are trusted partners committed to bringing our knowledge together to find best next steps not only for me, but in care of such injuries and in the birthing process as a whole.
Where Do We Go from Here?
What those of us who have lived through such lacerations know is that trying to piece together a care plan and resources between feedings at night while bleary eyed and trying to stay awake long enough to take the next scheduled pain pill to recover from the repair is unacceptable. It is an added emotional and mental injury that has the potential to compound the OASI itself and obstruct the healing process.
If you’re reading this, you may have had similar experiences. I remember spending countless hours in the middle of the night between feedings, searching for someone else who had experienced the same thing– searching for guidance that would tell me it would be okay, that I would return to the life I knew or if I could not, they could tell me what to expect going forward. There had to be people farther along in the process than I was, who could offer guidance and suggest resources.
At that time, there was very little to be found. I recall finding a story about an opera singer who was fired from her job for having uncontrollable flatulence (or as we more commonly call it– gas) as a result of a 4th degree tear. This was something people made fun of on the radio– as a laughable news story. But to anyone who had such a life changing injury– it was far from funny. Devastating, humiliating, one of my worst nightmares of possibilities, yes– but hilarious– not an accurate descriptor.
Beyond that, I found no other human on the internet talking openly about having such injuries. It was only because at some point I decided to be open with a few of my closest friends and I discovered that I knew others who also had these injuries, that I realized what I was told about it happening in only 1% of births was likely inaccurate. In reluctantly sharing my symptoms, I heard the familiar hallmarks of these injuries reflected back to me and recognized that this is more of an issue of people keeping quiet about these injuries than them actually being a rare occurrence.
That made me wonder– How could speaking up prevent injuries? Couldn’t people learn from what worked and what did not? What sort of processes already exist or could be created?
Learning the wide variety of the lived experiences of those of us with these injuries– our commonalities and differences–both guides best practices and allows us to offer hope to one another. With every similar and new experience, we have the opportunity to finetune what it means to support the birthing process in a highly effective way and to remember that birth is the first step in living. How do we support those who are growing, birthing, and caring for those birthed?
One year from now, guided by the active seeking and partnering of those giving and receiving care, I hope I can update this story to reflect the many intentional changes made to processes that do just that.
The Unexpected Milestones of Healing and Cause for Hope
In my first year or two of injury, I couldn’t imagine ever again speaking in public, singing in public, going anywhere and not knowing where all the bathrooms were, being willing to be around anyone with whom I would feel uncomfortable explaining why I may need to race to a bathroom or have no control of the gas I passed, or facilitating a group (in a circle of all things– no way to hide or escape without making a scene). I was grateful I worked in geriatrics with people who sometimes couldn’t hear me or would actually relate to my experience, if I had an incident and needed to explain.
The consequences of the injury changed what I spent my time doing, who I felt safe to be with, when I would do things, and how I did just about anything in life. Eating out at a restaurant, working, tolerating sitting in a car or even fully on my bottom, taking my baby for a walk (I couldn’t push a cart or stroller until at least 6 months after her birth, and even then, only in short distances).
So much of who I was and how I did things changed overnight, and yet it seemed the expectation of society was that I should return to work in 6-12 weeks.
Image description:
Kary (a woman with glasses and a turquoise scarf, holding a map) and her husband (in a tan and navy plaid button up shirt) stand behind a stroller with 19 month old daughter (wearing a purple sweater and holding a stuffed gorilla). Yellow leaves of fall foliage show in background. Note: This was a milestone day in recovery— the year prior, it was physically impossible still due to pain and healing still.
There is a lot of experience that happened between that first year and now, but what you may wish most to know is that it did get easier. It got more manageable, and, after a while, it did not take as much of my time or energy to plan for “what if” scenarios. What began as carefully planning what I ate or didn’t eat to cope with fecal and gas incontinence, began to require less attention over time until I realized I hadn’t thought about that for a couple years. It became a much more rare experience.
Over time, I could recognize when I would be more likely to need to be more aware of having issues. And, finding the support of those of SOLACE has taught me that there is still more healing that can happen.
Ten years ago, colorectal surgeons told me the injury to the internal anal sphincter could not be repaired better than it already had been, any surgery was unlikely to result in improvement, and more likely, a surgery could result in more damage and more loss of function. You guessed it, I stuck with what function I have.
Now, I’m not so certain things are as good as they can be for me. In fact, pelvic floor PT and/or OT are showing me there is more that can be done. I was not given a referral for pelvic floor PT when my injury occurred, as the colorectal surgeon did not think it would help. Speaking to people in those professions and listening to the experiences of people with more recent injuries has taught me to continue to assess who belongs on our care teams before, during, and after giving birth. I will begin pelvic floor PT soon.
As a side note, I am an occupational therapist (OT). This injury affected almost every daily occupation/activity I did for 6 months post birth and still requires adaptations to this day. The fact that I was not offered occupational therapy evaluation is worthy of conversation at another time, and I’m happy to say that there are PTs and OTs working to change this standard of care.
Repairing Injuries and Relationships, and Reengaging in What Matters Most
As someone who would describe herself as being further along in the healing process while also still being in the middle of the healing journey, I hope you find comfort here. These injuries may appear to be entirely physical, but it is far more than only the physical condition that deserves tending to. You/We deserve to have our mental, emotional, and spiritual well being tended to as well. And ten years later, it is more clear than ever that even when you feel like confining yourself to a smaller and smaller group of support, expanding that support through trusted peers may be one of the most important steps you take.
Whether it is in reading research, listening to stories, attending peer support events, identifying knowledgeable and trusted health care team members in your area, or any combination of the above, I hope you find what you need.
Wherever you are in your journey, our shared commitment to learning and our equally important commitment to unlearning what isn’t working, will get us through. We may not be able to change what has already happened, but we can make it better for those who come after us and for each other.
I believe in us and I am with you.
Footnotes:
[1] The writing style is intended to be useful for those who want all the details and those who prefer to skim; use the bolded areas to guide key points if you prefer the latter.
[2] If you are seeking out information for someone else– thank you, thank you, thank you. When you’ve experienced such an injury, energy is an extra precious and fluctuating commodity. Having someone share that load of what needs to be done to heal or simply to understand can be both helpful and healing.
[3] Health care team members often have minimal information on this subject or do not always know the combination of resources and professionals needed to care for OASIs. Thank you for recognizing the importance of understanding the lived experience to guide your work.
[4] Reminder: If you like to skip straight to the point, stick to the bolded areas. The weaving in and out of my story itself and what it is like to share it is intentionally left to show how telling a story is not always a linear process and making space to allow people to share in whatever way works for them may be necessary. Reading this, you may have the urge to tell me to get to the point– if so, I invite you to notice that and consider what it is like for people to share these stories and anticipate your response. Looking back at what I’ve written, I can see myself pausing and regrouping throughout to care for myself and the readers. For some, the process will resonate and others will be frustrated by it. Read and digest in ways that work best for you.
[5] The absence of pain medication was significant to me because once I realized I was needing to push I wanted pain medication and it was too late. The intensity of contractions made me scared I couldn’t handle it, so to realize I survived was a relief. In short, I thought the worst was over, and now I would just need those stitches to heal and the motherhood I imagined could begin.
[6] Now I could tell you more about what bursting stitches entails, but I don't know who you are yet. Research it if you would like, or we'll save that for another time when we know each other better.
References:
SOLACE Foundation:
The Solace Foundation referenced above was started by Caroline Stadler, after having a 4th degree tear with the birth of her daughter. Caroline also works in health care as a Physician Assistant (PA) and called a group of women together to start a non-profit to make sure people no longer have to navigate finding needed resources and support alone.
Check out the website by clicking the hyperlink above to learn things like:
-what 3rd and 4th degree tears are
-resources
-peer support
-provider directory
Interested in learning more or sharing how you may help? Reach out to Caroline at caroline@solaceforwomen.org
If you would like to show financial support to those impacted by injuries you can donate here to support the efforts of SOLACE.
