Fourth degree lacerations involve the rectal mucous membranes. Most spontaneous tears are only first or second degree. Third and fourth degree tears rarely occur spontaneously if the woman has not had an episiotomy. It is not unusual, however, for episiotomies to extend into third or fourth degree tears. So in reality, the risk of having a serious tear is much greater with an episiotomy than without one.
Episiotomies are easier to repair than tears and cause less pain during healing.
Most tears are small and straight. They are repaired in the same fashion as an episiotomy. Sometimes a tear will require a bit more creativity in its repair than an episiotomy, but this is not beyond the ability of a skilled midwife or doctor. Studies have shown that there is little or no significant difference between second degree tears and episiotomies in terms of pain in the first few days after delivery. These studies have shown, however, that episiotomies may cause more long term discomfort and pain with intercourse which can last for many months.