About the Severe (Third and Fourth Degree) Perineal Tears Clinical Care Standard
The Commission is developing a Clinical Care Standard (CCS) on the prevention and management of third- and fourth-degree perineal tears following a recommendation in the Second Australian Atlas of Healthcare Variation. This CCS aims to reduce the variation in best-practice care provided to women, to minimise the risk of a 3rd or 4th degree perineal tear, and, to improve the care provided to women who experience a 3rd or 4th degree perineal tear, including assessment of the injury, repair and holistic follow-up care.
A draft CCS was prepared following a literature review, extensive key informant interviews, a round table of experts and consumers, and, a series of meetings with a select working group.
Recent public consultation
The draft CCS was released for public consultation in October 2019 and the Commission will incorporate feedback received in the final version, which is due for completion in mid-2020.
Description of perineal tears
Severe perineal trauma is experienced by a small proportion of women who give birth vaginally. Third or fourth degree perineal tears and obstetric anal sphincter injuries (OASI) are other terms used to describe this type of injury. A third degree tear is an injury to the perineum involving the anal sphincter (muscle controlling the anus), and a fourth degree tear involves the anal sphincter and the anal mucosa (the lining of the anus or rectum).1
Occurrence and outcomes of perineal tears
Of all women who gave birth vaginally in Australia in 2014, 3% had a third or fourth degree perineal tear.2
Severe perineal trauma, if not recognised and repaired at the time, can have serious long-term consequences for women, including continued perineal pain, faecal and flatus incontinence, painful sexual intercourse, reduced quality of life and depression.1 There are also significant social and emotional implications for women which affect their psychological well-being and have impacts on the family.3
The development of a literature review on third and fourth degree perineal tears follows on from findings and recommendations made in the Second Australian Atlas of Healthcare Variation (2017). The Atlas found the Australian rate of third and fourth degree perineal tears is above the reported average for comparable countries in the Organisation for Economic Cooperation and Development (OECD) 4 and that there was significant variation in rates across the country.
In all women giving birth vaginally, the Atlas observed an overall 12-fold geographical variation across local areas in rates of third and fourth degree perineal tears and a 2.9 fold variation, after excluding the highest and lowest 10% of results.
The Atlas recommended that “the Commission work with Women’s Healthcare Australasia, and relevant colleges and specialist societies to develop a clinical care standard on perineal care during vaginal birth, to improve national consistency of best practice for the prevention, recognition and management of severe perineal trauma.”
As an initial step in this work, the Commission engaged Professor Caroline Homer and Dr Alyce Wilson, of the Burnet Institute, to carry out a literature review addressing the following questions:
- Which guidelines, policies and procedures and health policies/programs or strategy documents are available which are relevant to the prevention and treatment of perineal tears in Australia?
- What do current guidelines specifically recommendation for preventing and managing third- and fourth- degree perineal tears?
- What evidence is there regarding current clinical practice in Australia for preventing and managing severe perineal tears?
- What contributes to variations in rates of perineal tears? (including differences in clinical practice, service delivery/models of care, access to services, location, skills etc)
- What is the literature on interventions to reduce rates of, and morbidity from, perineal tears and the effectiveness of those interventions? This may include information on patient experience.
The evidence-based literature review was undertaken to better understand the current clinical environment for preventing and managing third and fourth degree perineal tears and to identify issues or gaps that may need to be addressed further.
Other work on perineal tears
Women’s Healthcare Australasia (WHA) is currently conducting a National Quality Improvement Collaborative (the Collaborative) with the aim of reducing harm to women from perineal tears.
The Commission will consider the recommendations from the literature review in the context of the work being done within the WHA Collaborative.
1. Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears (Green top 29). London: Royal College of Obstetricians and Gynaecologists, 2015.
2. Australian Institute of Health and Welfare. Mothers and Babies Report. In: Australian Institute of Health and Welfare, ed. Canberra: Australian Government, 2018.
3. Priddis H, Dahlen H, Schmied V. Women's experiences following severe perineal trauma: a meta‐ethnographic synthesis. Journal of advanced nursing 2013;69(4):748-59.
4. Organisation for Economic Co-operation and Development. Obstetric trauma. In: Health at a glance 2015: OECD indicators. Paris: OECD Publishing; 2015.