Information, shared decision making and informed consent

Quality statement 1

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.

For women

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.

For clinicians

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

 Risk factors

Individual risk factors (mother)

  • Women having their first vaginal birth
  • Women of south Asian ethnicity

Fetal risk factors

  • Infants with a higher birth weight*

Risks arising during labour and birth

  • Persistent occipito-posterior position
  • Shoulder dystocia
  • Prolonged second stage of labour
  • Instrumental vaginal birth
  • Epidural pain relief **
  • Midline episiotomy***

*      > 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.

 

For health service organisations

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.

For women

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.

For clinicians

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

 Risk factors

Individual risk factors (mother)

  • Women having their first vaginal birth
  • Women of south Asian ethnicity

Fetal risk factors

  • Infants with a higher birth weight*

Risks arising during labour and birth

  • Persistent occipito-posterior position
  • Shoulder dystocia
  • Prolonged second stage of labour
  • Instrumental vaginal birth
  • Epidural pain relief **
  • Midline episiotomy***

*      > 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.

 

For health service organisations

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.