Third and Fourth Degree Perineal Tears Clinical Care Standard

This national standard describes best practice care for the prevention, recognition and management of third and fourth degree perineal tears.

Third and Fourth Degree Perineal Tears Clinical Care Standard

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.

Third and Fourth Degree Perineal Tears Clinical Care Standard (2021)

2021

Publication, report or update

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.

Contents of the standard and resources

The Third and Fourth Degree Perineal Tears Clinical Care Standard is made up of seven quality statements and a set of indicators for safe and appropriate care.

For women	The standard describes the care a woman should expect during pregnancy, labour and birth, to help them make informed decisions about their care. Find information about reducing risk and recovering from a third or fourth degree tear, a video based on women's experiences and other information for women
For clinicians	The standard provides guidance about providing high-quality, evidence-based care to women during pregnancy, labour and birth. Find out what the standard recommends, a video for clinicians talking about tears, and other information for clinicians
For health service organisations	The standard describes key components of care that health services can use to guide practice and monitor improvements in care Find out about implementing the standards, indicators to monitor quality improvement and other information for health service organisations

For women

The standard describes the care a woman should expect during pregnancy, labour and birth, to help them make informed decisions about their care.

Find information about reducing risk and recovering from a third or fourth degree tear, a video based on women's experiences and other information for women

For clinicians

The standard provides guidance about providing high-quality, evidence-based care to women during pregnancy, labour and birth.

Find out what the standard recommends, a video for clinicians talking about tears, and other information for clinicians

For health service organisations

The standard describes key components of care that health services can use to guide practice and monitor improvements in care

Find out about implementing the standards, indicators to monitor quality improvement and other information for health service organisations

Webcast recording and other videos

Webcast launch – video recording

The Commission hosted a webcast to launch the standard on 21 April 2021.

The launch and panel discussion hosted by Professor Anne Duggan, Acting Chief Medical Officer, provides an overview of the new standard, and discusses some of the evidence driving the need for change.

Expert panellists include obstetrician Associate Professor Emmanuel Karantanis, midwifery expert Professor Hannah Dahlen, physiotherapist Natalie McConochie, and Janelle Gullan, a woman who experienced a third-degree perineal tear.

Other videos available include Talking about tears - a video for clinicians and a video featuring women's experiences and advice to other women Third and fourth degree tears during labour and birth - a video for consumers.

Quality statements

Quality statement 1 - Information, shared decision making and informed consent

During the antenatal period, a woman is informed about the risk of a third or fourth degree perineal tear. Throughout pregnancy, labour and birth, she is supported to make decisions and provide informed consent for the care she receives.

Purpose

To ensure that women receive information during pregnancy about the potential of a third or fourth degree perineal tear, relevant risk factors and evidence-based care to reduce their risk. To support shared decision making and informed consent.

Quality statement 2 - Reducing risk during pregnancy, labour and birth

Quality statement 3 - Instrumental vaginal birth

When intervention is indicated in a vaginal birth, the choice of intervention is based on the clinical situation, the benefits and risks of each option and discussion with the woman.

Purpose

To ensure that decisions about an instrumental vaginal birth consider the individual clinical circumstances, and the benefits and risks of each option, including the risk of a third or fourth degree perineal tear, and the potential benefit of episiotomy.

Quality statement 4 - Identifying third and fourth degree perineal tears

After a vaginal birth, a woman is offered examination by an appropriately trained clinician to exclude the possibility of a third or fourth degree perineal tear. A tear is classified using the Royal College of Obstetricians and Gynaecologists classification and is documented in the woman’s healthcare record.

Purpose

To ensure that all women who give birth vaginally are offered an examination, in a respectful way, by a clinician trained to accurately identify and classify third and fourth degree perineal tears using the RCOG classification.⁶

6. Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears (Green-top Guideline No. 29). London: Royal College of Obstetricians and Gynaecologists; 2015.

Quality statement 5 - Repairing third and fourth degree perineal tears

Quality statement 6 - Post operative care

After repair of a third or fourth degree perineal tear, a woman receives postoperative care that includes the opportunity for debriefing, physiotherapy and psychosocial support.

Purpose

To ensure that a woman receives postoperative care during admission that optimises her recovery from a third or fourth degree perineal tear. To ensure that if it is not possible to provide this care before the woman leaves hospital, arrangements are made for her to obtain this care soon after discharge.

Quality statement 7 - Follow-up care post-discharge

A woman with a third or fourth degree perineal tear receives individualised continuity of care and appropriate follow-up and referral to optimise her ongoing physical, emotional, psychological and sexual health.

Purpose

To ensure that women who experience a third or fourth degree perineal tear receive appropriate follow-up care after leaving hospital, to optimise their physical, emotional, psychological and sexual health. To ensure that appropriate referral pathways are in place.

Background

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.

Consultation and endorsement

The standard was developed in collaboration with a topic working group of clinicians, researchers and consumers. Public consultation was conducted in December 2019.

The standard is endorsed by 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).

Perineal tears: A literature review

The Commission engaged the Burnet Institute to carry out a literature review on third and fourth degree perineal tears to support the development of the clinical care standard. Further information is available on the evidence base which underpins the Third and Fourth Degree Perineal Tears Clinical Care Standard.

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