Identifying third and fourth degree perineal tears

Quality statement 4

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.

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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.

For women

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.

For clinicians

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.

Box 4: Classification of perineal tears

The Royal College of Obstetricians and Gynaecologists (RCOG) classifies perineal tears as follows:

  • First degree tear: injury to perineal skin and/or vaginal mucosa
  • Second degree tear: injury to perineum involving perineal muscles but not involving the anal sphincter
  • Third degree tear: injury to perineum involving the anal sphincter complex
  • Grade 3a tear – less than 50% of external anal sphincter (EAS) thickness torn
  • Grade 3b tear – more than 50% of EAS thickness torn
  • Grade 3c tear – both EAS and internal anal sphincter (IAS) torn
  • Fourth degree tear: injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.

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.

 

For health service organisations

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.

For women

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.

For clinicians

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.

Box 4: Classification of perineal tears

The Royal College of Obstetricians and Gynaecologists (RCOG) classifies perineal tears as follows:

  • First degree tear: injury to perineal skin and/or vaginal mucosa
  • Second degree tear: injury to perineum involving perineal muscles but not involving the anal sphincter
  • Third degree tear: injury to perineum involving the anal sphincter complex
  • Grade 3a tear – less than 50% of external anal sphincter (EAS) thickness torn
  • Grade 3b tear – more than 50% of EAS thickness torn
  • Grade 3c tear – both EAS and internal anal sphincter (IAS) torn
  • Fourth degree tear: injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.

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.

 

For health service organisations

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.

Read quality statement 5 - Repairing third and fourth degree perineal tears
 

Related links
Third and Fourth Degree Perineal Tears Clinical Care Standard
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Clinical Care Standards
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