Third and Fourth Degree Perineal Tears Clinical Care Standard

Throughout pregnancy, provide information and support women who are planning a vaginal birth to make decisions about the care they may receive during pregnancy, labour and birth.

By the third trimester, discuss the potential for a third or fourth degree perineal tear.

Discuss the following points together with the woman:

• the fact that perineal tears are common and most heal well without complications
• the fact that third or fourth degree tears are less common (around 3% of all women who give birth vaginally and 5% of first vaginal births)
• relevant risk factors for the individual woman, including her obstetric history (see Table 1), noting that it is not possible to predict who will have a third or fourth degree perineal tear
• what can be done to reduce risk according to current evidence
• the possible use of induction of labour, epidural analgesia, instruments, episiotomy and an unplanned caesarean section, and their risks and benefits
• the woman’s preference for how she would like to give birth
• assessment and examination to expect after the birth
• how a third or fourth degree perineal tear will be treated if it does occur, and what can be done to assist recovery and improve outcomes (noting that many woman do not have faecal incontinence).

Midwives providing antenatal care for women with added risks (for example female genital mutilation or a previous third or fourth degree perineal tear) should arrange consultation with an obstetrician or GP obstetrician.

Decisions about the mode of birth for a woman with a history of a third or fourth degree perineal tear should include consideration of the risks and benefits of a vaginal birth compared with a caesarean section. Discussion should consider current urgency or incontinence symptoms, the degree of previous trauma, the risk of recurrence, the success of the repair, any psychological effects, or the woman’s request for a caesarean section.

Provide information in a way that meets the woman’s health literacy and cultural needs. Also offer support services, such as interpreter services, or support from an Aboriginal health worker, if needed.

Document the outcome of discussions, and any decisions or preferences, in the woman’s healthcare record.

Table 1: Risk factors associated with third or fourth degree perineal tears

*      > 3.5 or 4 kg in epidemiological studies
**     Risk may be indirectly associated with prolonged second stage of labour or instrumental delivery.
***   A midline episiotomy is associated with an increased risk compared to medio-lateral episiotomy.

Ensure that policies, procedures and protocols are in place to support information provision, shared decision making and informed consent, consistent with the requirements of the NSQHS Standards.

Ensure that information about third and fourth degree perineal tears and their management is consistent with current evidence and meets the woman’s health literacy and cultural needs. Information should be easy to use and accessible.

Ensure that healthcare professionals are appropriately trained and skilled to undertake clinical assessment of the risk of third and fourth degree tears and to communicate with women regarding risks, as part of shared decision making, and to obtain informed consent.

Ensure that systems are in place to record the key outcomes of discussions and assessments to enable appropriate clinical communication between clinicians. This is especially important when care is provided by a multidisciplinary team, a shared-care model is used, or women are referred to another clinician or transferred to a different care setting.

Throughout pregnancy, you will receive information that will help you to make informed decisions about your care during pregnancy, labour and birth.

Birth is a natural process and many women give birth without medical intervention. However, your healthcare team should help you understand the possible risks and complications that sometimes occur, even if the risk is low.

Most women who give birth vaginally do not have severe damage to their perineum or anus. Around 3% have a third or fourth degree perineal tear.

It is not possible to prevent all third and fourth degree perineal tears, but there are ways to reduce their likelihood. Discussing the potential benefits and harms of different options, and your own preferences, with your healthcare team can help you understand and make decisions about your care.

If you are planning a vaginal birth, you and a member of your healthcare team should discuss:

• relevant individual risk factors and your birth history, including a previous third or fourth degree perineal tear
• the care you might be offered during labour and birth, including the use of induction of labour, epidural for pain relief, forceps or vacuum, or a caesarean section
• what you or your healthcare team can do to reduce your risk
• how a perineal tear is identified
• the treatment and likely outcomes if a third or fourth degree perineal tear is identified.

A record of this discussion will be kept in your healthcare record. During labour and birth you will be supported to make decisions and to provide informed consent for the care that is offered to you.

During pregnancy, advise the woman about evidence-based options that may reduce the risk of a third or fourth degree perineal tear, as follows:

During pregnancy:

• perineal self-massage (or by her partner) after 34 weeks of pregnancy can reduce the risk of third and fourth degree perineal tears
• pelvic floor muscle training may help women prepare for labour and birth and reduce the risk of third and fourth degree perineal tears. Ensure that the woman understands the correct technique to use and refer her to an appropriate clinician for training, if needed.

During a vaginal birth:

• applying warm compresses on perineal distention can significantly reduce risk (moderate grade evidence)
• slowing the fetal head at crowning and the birth of the shoulders may reduce risk (low to moderate grade evidence)
• perineal massage during the second stage of labour may reduce risk, however, the acceptability of this practice to women has not been established (low to moderate grade evidence).

Before birth, the possibility of an episiotomy, forceps, vacuum or an unplanned caesarean section should be explained so that the woman is aware of the risks and benefits, and has the opportunity to ask questions.

The selective use of episiotomy (see Box 2) may result in fewer women experiencing a third or fourth degree perineal tear (low to moderate grade evidence). If an episiotomy is performed, a medio-lateral technique with the incision angle 60° from the midline is recommended.

Medio-lateral episiotomy should be offered in instrumental vaginal birth, especially for nulliparous women. 

Perineal tear outcome data should be collected and reviewed regularly at clinical review meetings.

Ensure that policies, procedures and protocols detail evidence-based care to reduce the risk of third and fourth degree perineal tears. Ensure relevant clinicians act in accordance with policies and evidence-based guidelines.

Ensure that relevant clinicians are appropriately trained and skilled in assessment and classification of perineal tears.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, and respond to risk, as per Action 1.28 in the NSQHS Standards (2nd ed.).

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

There are ways to reduce the likelihood of a third or fourth degree perineal tear. You will have the opportunity to talk to your healthcare team about these options.

During pregnancy:

• perineal self-massage (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third and fourth degree perineal tears.
• pelvic floor muscle training may help prepare you for labour and birth and reduce the possibility of a third or fourth degree perineal tear.

During a vaginal birth:

• applying warm compresses to the perineum during the second stage of labour can significantly reduce the risk of a third or fourth degree perineal tear
• slowing the rate at which the baby’s head and shoulders emerge, with the help of your birth attendants, may help prevent perineal injuries
• perineal massage performed by your healthcare professional during the second stage of labour may reduce the risk of third and fourth degree perineal tears. However some women may not feel comfortable with this option and it is not recommended for everyone.

If there is a clinical need, a member of your healthcare team may suggest an episiotomy where a cut is made in the vaginal opening to help make more space. After the birth, the cut will be repaired with stitches. If you consent to an episiotomy, the cut should be made at the correct angle to reduce the risk of a perineal tear.

Discussing these options with your healthcare team during pregnancy can prepare you to make informed decisions during labour and birth. You will always be asked for your preferences and consent for the care offered to you.

When an instrumental vaginal birth is indicated and more than one instrument may be appropriate, the choice of intervention should take into account evidence of the relative benefits and risks of the various instruments, the clinician’s skill and the woman’s preference.

Instrumental vaginal birth may be indicated when there is:

• fetal compromise
• a need to reduce the effects of the second stage of labour because of a medical condition
• slow progress in the second stage of labour, associated with risks to the woman or fetus.

Current guidance from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Royal College of Obstetricians and Gynaecologists (RCOG) include recommendations regarding the conditions for a safe instrumental vaginal birth (see Box 3).

Table 2: Summary of risk associated with forceps and vacuum-assisted birth

No significant difference between instruments

• any neonatal injury
• low Apgar score (<7) at 5 minutes
• low pH (<7.2) in umbilical artery at birth.

CI = confidence interval; RR = relative risk

During a first vaginal birth where instruments are used, medio-lateral episiotomy (with an incision angle of 60°) reduces the risk of a third or fourth degree tear. Tools to help ensure the correct angle of incision include special episiotomy scissors, such as Episcissors‑60, which may assist midwives and obstetricians achieve a post-suturing angle of 40–60°. The protective effect of episiotomy is highest when forceps are used, especially with a first time vaginal birth.

Additional planning is recommended in case a vaginal birth is not achieved with the first approach, and the risks of subsequent options should be considered (for example, sequential use of instruments or caesarean section at full dilatation).

Early discussion during pregnancy about these possible interventions may help prepare the woman should she face this situation. The discussion and her consent should be documented in her healthcare record.

Ensure that policies, procedures and protocols include the management of instrumental vaginal birth, discussion with the woman about the possible benefits and risks associated with the available options and informed consent.

Ensure that conditions for a safe instrumental vaginal birth, as described in relevant clinical guidelines, are met within the facility, particularly with regard to availability of senior staff, facilities and back-up plans in case an instrumental birth is not successful.

Ensure that clinicians are appropriately trained and experienced to provide safe, high-quality care during an instrumental vaginal birth in accordance with professional standards, and are working within their scope of clinical practice. Ensure junior staff who do not have the requisite skills are supported by an experienced clinician.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, as per Action 1.28 in the NSQHS Standards (2nd ed.), including rates of instrumental births and perineal trauma.

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

Record risks and the planned mitigation strategies in the risk management system.

If your doctor or midwife is concerned about your health or the health of your baby during labour, they may suggest active assistance using either forceps or vacuum to help you have a vaginal birth.

Most instrumental births occur without complications, but there is a chance of serious risk to you or your baby. These risks need to be balanced against the risk of ‘waiting’ or using a different intervention.

Both forceps and vacuum increase the risk of a third or fourth degree perineal tear, especially for women having their first vaginal birth. The risk is higher with forceps than with vacuum. However, each woman’s situation is different and a number of factors will be considered before an instrument is recommended for you. If forceps or vacuum are used, you may be offered an episiotomy to lower the chance of having a third or fourth degree perineal tear.

In very few situations, an alternative to using forceps or vacuum may be an unplanned caesarean section where you have an operation and the baby is born via a cut through the abdomen and uterus.

A member of your healthcare team will discuss your situation with you, including the possible benefits and risks to you and your baby, for each available option. You may wish to discuss these options during pregnancy, in case you are offered forceps or vacuum during labour.

This care will be only be provided with consent from you, or your legal representative or guardian.

After a vaginal birth, offer to examine the woman for a perineal tear. Discuss why examination may be recommended, based on the woman’s experience and evidence of perineal injury. Explain what is involved with examination and seek consent for any examination. Document the offer, and any examination conducted, in the medical record.

Offer appropriate pain management and conduct the examination with due respect for the woman’s recent trauma. If a tear is suspected or identified on examination of the perineum, further assessment is recommended, including a rectal examination to assess whether the internal or external anal sphincters have been damaged.

Use the RCOG classification described in Box 4 to grade the severity of the injury. Whenever possible, ask a second, experienced clinician to be present during the examination to assist with identifying and classifying the tear. If in doubt about the degree of injury, classify the tear to a higher degree. Incorrect classification can result in a suboptimal repair and may increase maternal morbidity in the longer term.

Record the outcome of the examination in the woman’s healthcare record.

Note: Rectal buttonhole injuries involve a tear of the rectal mucosa with an intact anal sphincter complex and, visually, there is no obvious damage to the perineum. If not recognised and repaired, this type of tear may lead to a rectovaginal fistula. These types of injuries should be repaired.

Rectal buttonhole tears are not included in the RCOG classification and should be documented separately.

Ensure that policies, procedures and protocols for classifying and reporting perineal tears are consistent with current evidence-based guidelines such as the RCOG classification system, and incorporate respectful communication regarding the examination and the request for verbal consent.

Ensure that clinicians are appropriately trained in perineal anatomy and skilled in assessment and use of the RCOG classification system. Communication with the woman should be offered in a respectful manner and consent sought. Ensure junior staff who do not have the requisite skills are supported by an experienced clinician when a tear is being classified. If possible, a second, experienced clinician should be available during assessment to confirm the classification of the tear.

If a perineal tear occurs, it is important that it is assessed and treated promptly. Accurate identification of a third or fourth degree perineal tear will help ensure that you receive the correct treatment.

Soon after your baby is born, your doctor or midwife may recommend an examination to check for perineal tears. This examination will be offered and carried out in a respectful manner. You have the right to refuse, or to ask your doctor or midwife to stop at any time.

Some perineal injuries may be difficult to see, especially if there is swelling in the area. Your doctor or midwife will offer to examine the area in and around your vagina and anus. If you consent, the doctor or midwife will place a finger inside your rectum and carefully feel for any damaged tissues. If a third or fourth degree perineal tear is thought to have occurred, a second member of your healthcare team may be present during examination to confirm the diagnosis. You will be offered (or you can request) pain relief for this examination.

Third and fourth degree perineal tears are repaired surgically. If you have this type of injury, you may need to be transferred to a hospital for repair.

Occasionally, a perineal tear may not be detected during examination, so, if you have symptoms that you are concerned about following birth, speak to your healthcare professional.

Accurate identification and prompt repair of severe perineal tears are important to minimise the risk of infection, blood loss, pain and incontinence, as well as long-term physical, emotional and sexual health consequences for women.

Discuss with the woman, the nature of her injury, the procedure for repair and any risks involved. Provide reassurance regarding her recovery and the expected outcome of the repair. Clinicians who respond in a respectful and dignified manner can improve the woman’s experience of care.

Surgical repair should be conducted as soon as possible to minimise the risk of infection and blood loss.

The repair should be performed in a suitable environment with good lighting, sterile conditions and access to appropriate equipment and clinical support. In most cases the repair should be conducted in an operating theatre. If the labour ward replicates the environmental conditions of an operating theatre, a risk assessment should be conducted to determine whether this is a suitable environment.

The repair should be conducted under adequate anaesthesia, using surgical techniques and materials that are consistent with evidence-based guidelines. A rectal examination should be performed after repair to ensure that sutures have not been inadvertently inserted through the anorectal mucosa.

Only appropriately trained and experienced clinicians should repair a third or fourth degree perineal tear. Refer women to an appropriately qualified clinician if required. Registrars should be supervised by a senior clinician, unless they have completed their Assessment of Procedural and Surgical Skills or the equivalent level of credentialing or training for the repair of third or fourth degree perineal tears.

Some women may decline surgical treatment because they do not want to be separated from their baby. Advise the woman whether it is possible for her baby and support person to be present during repair and support her to maintain uninterrupted skin-to-skin contact and breastfeed during the procedure, whenever possible.

The decision to use prophylactic antibiotics should be made on a case-by-case basis, following recommendations in the current Therapeutic Guidelines: Antibiotic. Although evidence is limited, prophylactic antibiotics for third and fourth degree perineal tears are recommended or considered reasonable in most clinical practice guidelines.

Ensure that policies, procedures and protocols for the repair of third and fourth degree perineal tears are consistent with current evidence-based guidelines.

Ensure that clinicians undertaking repairs are trained and credentialed in accordance with professional standards, and are working within their scope of clinical practice.

Ensure that operating theatre policies and protocols enable timely repair of third and fourth degree perineal tears or timely transfer to an appropriate facility and allow for the woman’s baby and support person to be present during the repair whenever possible.

If you have a third or fourth degree perineal tear, your doctor will discuss with you the nature of your injury, the method of repair, any risks involved and the need for follow-up care.

Third and fourth degree perineal tears require surgical repair. The doctor carrying out the repair needs access to appropriate equipment, lighting and support staff, to achieve the best outcome for you. Usually, the repair will take place in an operating theatre.

Only doctors who are trained to do this type of surgery, such as an obstetrician, GP obstetrician or a colorectal surgeon, should carry out the repair.

You will need a local or general anaesthetic for the repair. A urinary catheter may be needed for a short time after surgery to remove urine while you are recovering, and is usually inserted before the repair.  A rectal examination will be conducted with your consent at the end of surgery to check the repair.

If possible, the health service organisation will try to arrange for your baby and support person to stay with you during surgery, if that is your wish.

While the woman is in hospital, give her an opportunity to discuss her recent experience with the clinician(s) present during the birth and to ask them questions. Ensure that the woman is given information about her medicines, how to care for her injury at home, what to expect while recovering, symptoms to look out for and who to contact if she has any concerns. Provide information about follow-up care required in the short and long term.

Arrange an appointment with a healthcare professional with experience in pelvic floor health such as a physiotherapist, as well as with a psychologist, or social worker if she is likely to need support or assistance at home.

If this care cannot be provided before the woman leaves hospital, arrange an appointment so she can obtain care soon afterwards.

Ensure that the woman’s discharge summary notes the care received and any follow-up required.

Ensure that policies, procedures and protocols support clinicians to provide appropriate postoperative care including access to services such as debriefing, physiotherapy, and psychosocial support services.

Ensure discharge policies support appropriate follow-up post-discharge.

After surgery, you may have medicines to help manage pain and constipation, and to prevent infection. A urinary catheter may be used for a short period to drain urine out of your body, because it will be hard for you to urinate normally.

While in hospital, you will have an opportunity to discuss your birth experience with a member of your healthcare team. They will discuss the repair, how to look after your injury at home, what to expect while recovering, how to manage breastfeeding if medicines are required, what symptoms to look out for, who to contact if you have any concerns and any follow-up care required.

You may also see a healthcare professional with experience in pelvic floor health, such as a physiotherapist, who will support your recovery.

If you feel unsettled or distressed, you may like to meet with a psychologist who can provide emotional support, or a social worker who may be able to arrange help with your daily activities at home.

If you leave hospital before having these appointments, arrangements will be made for you to obtain this care soon afterwards. Before leaving hospital, ask if any follow-up appointments have been scheduled for you.

Women who experience a third or fourth degree perineal tear need individualised, specialist follow-up care from clinicians with relevant expertise and experience. In the weeks after birth, ensure that the woman has a follow-up with a clinician who has relevant expertise and is familiar with her medical history, to assess and support the woman’s physical, emotional and psychological recovery.

Offer and arrange for post-discharge care in a multidisciplinary perineal clinic or other services appropriate to her clinical needs and injury, such as:

• clinics that specialise in treating women with a third or fourth degree perineal tear
• specialist medical practitioners, including obstetricians, gynaecologists or colorectal surgeons
• the GP who will provide ongoing care and referral, if needed
• clinicians who specialise in pelvic floor function and postnatal rehabilitation for women with a third or fourth degree perineal tear, such as physiotherapists
• healthcare professionals with specialist expertise providing care to women with third and fourth degree perineal tears, such as midwives
• nurses with specialist expertise in continence management
• psychologists with expertise or experience in postnatal mental health or birth trauma.

Any issues that may affect future births, and the woman’s concerns about these should also be considered. Acknowledge that, if the woman’s support person or partner witnessed a traumatic birth, it may affect their health and wellbeing. Offer them an opportunity to debrief and refer them for support if required.

GPs and other primary care clinicians, will provide health care to the woman after discharge. Ensure that adequate information is recorded in discharge summaries about the birth and the woman’s ongoing care needs including monitoring for late onset symptoms or signs of faecal incontinence, dyspareunia, postnatal anxiety or depression, or relationship difficulties, and provide appropriate referral options.

Women with faecal incontinence will need support to effectively manage their condition. As such problems may emerge sometime after birth, inform women that support is available if needed and encourage them to report symptoms.  

Advise women that a third or fourth degree tear does not exclude a subsequent vaginal birth. Advise them to discuss future birth planning with a maternity healthcare provider who has experience in caring for women with previous third or fourth degree tears, who can provide counselling about future pregnancies and discuss the woman’s preferences.

Ensure that policies, procedures, protocols and referral pathways promote comprehensive care, using a multidisciplinary team-based approach. This should include access to services appropriate for women with third and fourth degree perineal tears, including physiotherapy for pelvic floor rehabilitation, continence management, psychological support and surgical expertise, including in specialised multi-disciplinary clinics. A discharge summary should be forwarded to the woman’s general practitioner, which details the follow-up care and referrals needed.

After leaving hospital, you should receive follow-up care to promote your physical and emotional recovery and to provide advice for future pregnancies. Arrangements for this care should begin while you are in hospital.

In the weeks after your baby is born, you should be offered a follow-up appointment with an experienced member of your healthcare team who is familiar with your history. They will check that your injury is healing and discuss any other problems you are experiencing. They can help you if you have concerns about pain, incontinence, sexual activities, exercise, or relationship difficulties because of your injury. You may also feel sad or tearful for a period after this type of injury.

To support your recovery, a number of specialist services may be offered, such as:

• clinics that specialise in treating women with third and fourth degree perineal tears
• specialist doctors like obstetricians or colorectal surgeons
• healthcare professionals with experience in pelvic floor health, such as a physiotherapist
• psychological services.

Your GP or other primary care provider can provide follow-up care and refer you to other services if required. Information about your care and the recommended follow-up will be provided to them in a discharge summary from the hospital.

It is important to talk to your support person or partner, as they may also need help to understand how to support you while you recover and to look after their own health and wellbeing. You may choose for both of you to go to your appointments.

It is also recommended that you talk to a healthcare professional about your future plans for another pregnancy.

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

• Information sheet for clinicians - Third and Fourth Degree Perineal Tears Clinical Care Standard
• Quality statements and indicators (one-page summary) – Third and Fourth Degree Perineal Tears Clinical Care Standard
• Third and Fourth Degree Perineal Tears Clinical Care Standard - Highlights infographic

Talking about Tears - a video for clinicians

Midwifery and obstetrics experts, and women with experience of perineal tears discuss how to talk about perineal tears - and why it is so important to do so.

These resources have been developed for women to help inform them about their risk of a third or fourth degree perineal tear and to support informed decision making during pregnancy, labour and birth.

• Perineal tears: what you need to know during pregnancy
• Recovering from a third or fourth degree perineal tear
• Information for women - Third and Fourth Degree Perineal Tears Clinical Care Standard

Easy English resources

The resources have been translated into a writing style called ‘Easy English’. It is a writing style that is concise and easy to understand and uses simple language and carefully selected images to support key messages. These useful resources will assist in explaining perineal tears to women.

• Perineal tears - How to reduce the risk - Easy English
• Perineal Tears - How to get better - Easy English

Third and fourth degree tears during labour and birth – a video for women

This video provides advice from women who have experienced a third or fourth degree perineal tear. It provides information about the types of questions you should ask your healthcare team during pregnancy to reduce the risk of having this type of tear. If you have a third or fourth degree perineal tear during childbirth, it will help you understand the treatment and follow-up care you should receive to support your recovery.

The Standard was developed in response to a recommendation in the Second Australian Atlas of Healthcare Variation, for a Clinical Care Standard to improve national consistency in best practice care for the prevention, recognition and management of third and fourth perineal tears. 

The Atlas found that in 2012–14, the number of Australian women who had a third or fourth degree perineal tear ranged from 6 to 71 per 1,000 vaginal births in different areas across Australia. There was up to a 12-fold variation between areas. Australian rates of these tears are above the reported average for countries in the Organisation for Economic Cooperation and Development. 

Third and fourth degree perineal tears affect about 3% of all Australian women who have a vaginal birth, and 5% of women having their first vaginal birth. 

Rates of third and fourth degree perineal tears, vary up to 12-fold across Australia. This clinical care standard aims to reduce unwarranted clinical variation in these rates, and ensure that women who experience a third or fourth degree perineal tear receive care to optimise their physical and psychological recovery. This standard uses a woman-centred approach to ensure that women are informed about their risk and supported to make decisions about their care. 

Read more about the scope and goal of this Standard or see further background in the Third and Fourth Degree Perineal Tears Clinical Care Standard. 

This Standard applies to care provided in the following care settings:

• private obstetric (specialist) care
• private midwifery care
• care provided by general practitioners (GPs) and GP obstetricians
• public hospital maternity and high-risk maternity care, including continuity of care models
• remote area maternity care
• community and home-based care
• postnatal clinics specialising in the treatment of third and fourth degree perineal tears.

Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health involvement where clinically appropriate.

This Standard applies to all pregnant women who are planning a vaginal birth, and to women who experience a third or fourth degree perineal tear. It applies to care provided during pregnancy, labour, birth and the postpartum period, as well as postoperative and longer-term follow-up care.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting.

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Third and Fourth Degree Perineal Tears Clinical Care Standard has been endorsed by seven key professional organisations and colleges including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Australian College of Midwives (ACM) and the Australian Physiotherapists Association (APA). 

• Australian College of Midwives
• Australian College of Rural and Remote Medicine
• Australian Physiotherapy Association
• Centre of Perinatal Excellence
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
• Rural Doctors Association of Australia
• Women's Healthcare Australasia

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Third and Fourth Degree Perineal Tears Clinical Care Standard Topic Working Group provided expert advice in the development of the Standard. In addition, a public consultation process was conducted with key stakeholders.

Third and Fourth Degree Perineal Tears Clinical Care Standard Topic Working Group Members

The role of the Topic Working Group was to:

• advise on the scope and key components of care for the Standard
• advise on key sources of evidence including clinical practice guidelines, standards and empirical literature to build upon the body evidence supporting the existing model
• advise on the formulation of quality statements and supporting indicators
• recommend strategies to support the implementation of the Standard
• actively support raising awareness of the Standard.

The role of Consumer members is to advise the Commission on matters relating to their experience, as a patient or carer, and provide this perspective for the development of the Third and Fourth Degree Perineal Tears Clinical Care Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.  

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence sources underpinning the Standard.

Evidence sources - Management of Peripheral Intravenous Catheters Clinical Care Standard