Reducing risk during pregnancy, labour and birth

Quality statement 2

A woman choosing a vaginal birth is offered evidence-based care to reduce her risk of a third or fourth degree perineal tear.

Purpose

To ensure that women are appropriately assessed and provided evidence-based care during pregnancy, labour and birth to reduce the likelihood of a third or fourth degree perineal tear.

For women

There are ways to reduce the likelihood of a third or fourth degree perineal tear. You will have the opportunity to talk to your healthcare team about these options.

During pregnancy:

  • Perineal self-massage (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third and fourth degree perineal tears.
  • Pelvic floor muscle training may help prepare you for labour and birth and reduce the possibility of a third or fourth degree perineal tear.

During a vaginal birth:

  • Applying warm compresses to the perineum during the second stage of labour can significantly reduce the risk of a third or fourth degree perineal tear
  • Slowing the rate at which the baby’s head and shoulders emerge, with the help of your birth attendants, may help prevent perineal injuries
  • Perineal massage performed by your healthcare professional during the second stage of labour may reduce the risk of third and fourth degree perineal tears. However some women may not feel comfortable with this option and it is not recommended for everyone.

If there is a clinical need, a member of your healthcare team may suggest an episiotomy where a cut is made in the vaginal opening to help make more space. After the birth, the cut will be repaired with stitches. If you consent to an episiotomy, the cut should be made at the correct angle to reduce the risk of a perineal tear.

Discussing these options with your healthcare team during pregnancy can prepare you to make informed decisions during labour and birth. You will always be asked for your preferences and consent for the care offered to you.

For clinicians

During pregnancy, advise the woman about evidence-based options that may reduce the risk of a third or fourth degree perineal tear, as follows:

During pregnancy:

  • Perineal self-massage (or by her partner) after 34 weeks of pregnancy can reduce the risk of third and fourth degree perineal tears
  • Pelvic floor muscle training may help women prepare for labour and birth and reduce the risk of third and fourth degree perineal tears. Ensure that the woman understands the correct technique to use and refer her to an appropriate clinician for training, if needed.

During a vaginal birth:

  • Applying warm compresses on perineal distention can significantly reduce risk (moderate grade evidence)
  • Slowing the fetal head at crowning and the birth of the shoulders may reduce risk (low to moderate grade evidence)
  • Perineal massage during the second stage of labour may reduce risk, however, the acceptability of this practice to women has not been established (low to moderate grade evidence).

Before birth, the possibility of an episiotomy, forceps, vacuum or an unplanned caesarean section should be explained so that the woman is aware of the risks and benefits, and has the opportunity to ask questions.

The selective use of episiotomy (see Box 2) may result in fewer women experiencing a third or fourth degree perineal tear (low to moderate grade evidence). If an episiotomy is performed, a medio-lateral technique with the incision angle 60° from the midline is recommended.

Medio-lateral episiotomy should be offered in instrumental vaginal birth, especially for nulliparous women.


Box 2: Indications for consideration of episiotomy

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists note that episiotomy should be considered in the following circumstances:

  • A high likelihood of a third or fourth degree perineal tear
  • Shoulder dystocia
  • A need for accelerated birth of a compromised fetus
  • A history of female genital mutilation.

Perineal tear outcome data should be collected and reviewed regularly at clinical review meetings.

For health service organisations

Ensure that policies, procedures and protocols detail evidence-based care to reduce the risk of third and fourth degree perineal tears. Ensure relevant clinicians act in accordance with policies and evidence-based guidelines.

Ensure that relevant clinicians are appropriately trained and skilled in assessment and classification of perineal tears.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, and respond to risk, as per Action 1.28 in the NSQHS Standards (2nd ed.).

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

For women

There are ways to reduce the likelihood of a third or fourth degree perineal tear. You will have the opportunity to talk to your healthcare team about these options.

During pregnancy:

  • Perineal self-massage (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third and fourth degree perineal tears.
  • Pelvic floor muscle training may help prepare you for labour and birth and reduce the possibility of a third or fourth degree perineal tear.

During a vaginal birth:

  • Applying warm compresses to the perineum during the second stage of labour can significantly reduce the risk of a third or fourth degree perineal tear
  • Slowing the rate at which the baby’s head and shoulders emerge, with the help of your birth attendants, may help prevent perineal injuries
  • Perineal massage performed by your healthcare professional during the second stage of labour may reduce the risk of third and fourth degree perineal tears. However some women may not feel comfortable with this option and it is not recommended for everyone.

If there is a clinical need, a member of your healthcare team may suggest an episiotomy where a cut is made in the vaginal opening to help make more space. After the birth, the cut will be repaired with stitches. If you consent to an episiotomy, the cut should be made at the correct angle to reduce the risk of a perineal tear.

Discussing these options with your healthcare team during pregnancy can prepare you to make informed decisions during labour and birth. You will always be asked for your preferences and consent for the care offered to you.

For clinicians

During pregnancy, advise the woman about evidence-based options that may reduce the risk of a third or fourth degree perineal tear, as follows:

During pregnancy:

  • Perineal self-massage (or by her partner) after 34 weeks of pregnancy can reduce the risk of third and fourth degree perineal tears
  • Pelvic floor muscle training may help women prepare for labour and birth and reduce the risk of third and fourth degree perineal tears. Ensure that the woman understands the correct technique to use and refer her to an appropriate clinician for training, if needed.

During a vaginal birth:

  • Applying warm compresses on perineal distention can significantly reduce risk (moderate grade evidence)
  • Slowing the fetal head at crowning and the birth of the shoulders may reduce risk (low to moderate grade evidence)
  • Perineal massage during the second stage of labour may reduce risk, however, the acceptability of this practice to women has not been established (low to moderate grade evidence).

Before birth, the possibility of an episiotomy, forceps, vacuum or an unplanned caesarean section should be explained so that the woman is aware of the risks and benefits, and has the opportunity to ask questions.

The selective use of episiotomy (see Box 2) may result in fewer women experiencing a third or fourth degree perineal tear (low to moderate grade evidence). If an episiotomy is performed, a medio-lateral technique with the incision angle 60° from the midline is recommended.

Medio-lateral episiotomy should be offered in instrumental vaginal birth, especially for nulliparous women.


Box 2: Indications for consideration of episiotomy

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists note that episiotomy should be considered in the following circumstances:

  • A high likelihood of a third or fourth degree perineal tear
  • Shoulder dystocia
  • A need for accelerated birth of a compromised fetus
  • A history of female genital mutilation.

Perineal tear outcome data should be collected and reviewed regularly at clinical review meetings.

For health service organisations

Ensure that policies, procedures and protocols detail evidence-based care to reduce the risk of third and fourth degree perineal tears. Ensure relevant clinicians act in accordance with policies and evidence-based guidelines.

Ensure that relevant clinicians are appropriately trained and skilled in assessment and classification of perineal tears.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, and respond to risk, as per Action 1.28 in the NSQHS Standards (2nd ed.).

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

Read quality statement 3 - Instrumental vaginal birth