Third and Fourth Degree Perineal Tears

Third and fourth degree perineal tears, if not appropriately managed, can have serious long-term consequences for women.  

About the Third and Fourth Degree Perineal Tears Clinical Care Standard

The Commission is developing a clinical care standard on third and fourth degree perineal tears, following a recommendation in the Second Australian Atlas of Healthcare Variation. The clinical care standard aims to improve the care provided to women to reduce the risk of a third or fourth degree perineal tear, and, to improve the care provided to women who experience one of these tears.

A draft clinical care standard was released for public consultation in October 2019 and feedback has been incorporated into the final version, which is due for release early in 2021. 

Third and Fourth Degree Perineal Tear

A perineal tear is an injury to the perineum, which is the area between the vagina and anus. Perineal tears are common during vaginal births, but most do not cause significant injury.

Third and fourth degree perineal tears are more serious tears - they extend from the perineum to the anus or rectum and include the muscle that controls the opening and closing of the anus (anal sphincter).1

First and second degree tears may need stitches, but women tend to recover within a few weeks or months. 2,3 Third and fourth degree perineal tears need surgical repair and may be associated with short- and long-term complications for women, affecting their physical, psychological and sexual wellbeing.

Third or fourth degree perineal tears affect:

  • Around 3 out of 100 women giving birth vaginally
  • Around 5 out of 100 women giving birth vaginally for the first time.

Most women who sustain a third or fourth degree perineal tear recover well with appropriate treatment and support, although some will need specialised care to optimise their recovery

While not all third and fourth degree perineal tears can be prevented, it is possible to reduce the risk of their occurrence.

Literature review

The Commission engaged the Burnet Institute, to carry out a literature review on third and fourth degree perineal tears based on 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 in rates of third and fourth degree perineal tears, and a 2.9 fold variation, after excluding the highest and lowest 10% of results.

2018
Publication, report or update

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 this work in the development of the clinical care standard. 

References

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.