Repairing third and fourth degree perineal tears

Quality statement 5

When a woman has a third or fourth degree perineal tear, it is promptly repaired by an appropriately trained and experienced clinician, in a suitable environment.

Purpose

To ensure that third and fourth degree perineal tears are repaired by an appropriately trained clinician and in accordance with evidence-based guidelines.

For women

If you have a third or fourth degree perineal tear, your doctor will discuss with you the nature of your injury, the method of repair, any risks involved and the need for follow-up care.

Third and fourth degree perineal tears require surgical repair. The doctor carrying out the repair needs access to appropriate equipment, lighting and support staff, to achieve the best outcome for you. Usually, the repair will take place in an operating theatre.

Only doctors who are trained to do this type of surgery, such as an obstetrician, GP obstetrician or a colorectal surgeon, should carry out the repair.

You will need a local or general anaesthetic for the repair. A urinary catheter may be needed for a short time after surgery to remove urine while you are recovering, and is usually inserted before the repair.  A rectal examination will be conducted with your consent at the end of surgery to check the repair.

If possible, the health service organisation will try to arrange for your baby and support person to stay with you during surgery, if that is your wish.

For clinicians

Accurate identification and prompt repair of severe perineal tears are important to minimise the risk of infection, blood loss, pain and incontinence, as well as long-term physical, emotional and sexual health consequences for women.

Discuss with the woman, the nature of her injury, the procedure for repair and any risks involved. Provide reassurance regarding her recovery and the expected outcome of the repair. Clinicians who respond in a respectful and dignified manner can improve the woman’s experience of care.

Surgical repair should be conducted as soon as possible to minimise the risk of infection and blood loss.

The repair should be performed in a suitable environment with good lighting, sterile conditions and access to appropriate equipment and clinical support. In most cases the repair should be conducted in an operating theatre. If the labour ward replicates the environmental conditions of an operating theatre, a risk assessment should be conducted to determine whether this is a suitable environment.

The repair should be conducted under adequate anaesthesia, using surgical techniques and materials that are consistent with evidence-based guidelines. A rectal examination should be performed after repair to ensure that sutures have not been inadvertently inserted through the anorectal mucosa.

Only appropriately trained and experienced clinicians should repair a third or fourth degree perineal tear. Refer women to an appropriately qualified clinician if required. Registrars should be supervised by a senior clinician, unless they have completed their Assessment of Procedural and Surgical Skills or the equivalent level of credentialing or training for the repair of third or fourth degree perineal tears.

Some women may decline surgical treatment because they do not want to be separated from their baby. Advise the woman whether it is possible for her baby and support person to be present during repair and support her to maintain uninterrupted skin-to-skin contact and breastfeed during the procedure, whenever possible.

The decision to use prophylactic antibiotics should be made on a case-by-case basis, following recommendations in the current Therapeutic Guidelines: Antibiotic. Although evidence is limited, prophylactic antibiotics for third and fourth degree perineal tears are recommended or considered reasonable in most clinical practice guidelines.

For health service organisations

Ensure that policies, procedures and protocols for the repair of third and fourth degree perineal tears are consistent with current evidence-based guidelines.

Ensure that clinicians undertaking repairs are trained and credentialed in accordance with professional standards, and are working within their scope of clinical practice.

Ensure that operating theatre policies and protocols enable timely repair of third and fourth degree perineal tears or timely transfer to an appropriate facility and allow for the woman’s baby and support person to be present during the repair whenever possible.

For women

If you have a third or fourth degree perineal tear, your doctor will discuss with you the nature of your injury, the method of repair, any risks involved and the need for follow-up care.

Third and fourth degree perineal tears require surgical repair. The doctor carrying out the repair needs access to appropriate equipment, lighting and support staff, to achieve the best outcome for you. Usually, the repair will take place in an operating theatre.

Only doctors who are trained to do this type of surgery, such as an obstetrician, GP obstetrician or a colorectal surgeon, should carry out the repair.

You will need a local or general anaesthetic for the repair. A urinary catheter may be needed for a short time after surgery to remove urine while you are recovering, and is usually inserted before the repair.  A rectal examination will be conducted with your consent at the end of surgery to check the repair.

If possible, the health service organisation will try to arrange for your baby and support person to stay with you during surgery, if that is your wish.

For clinicians

Accurate identification and prompt repair of severe perineal tears are important to minimise the risk of infection, blood loss, pain and incontinence, as well as long-term physical, emotional and sexual health consequences for women.

Discuss with the woman, the nature of her injury, the procedure for repair and any risks involved. Provide reassurance regarding her recovery and the expected outcome of the repair. Clinicians who respond in a respectful and dignified manner can improve the woman’s experience of care.

Surgical repair should be conducted as soon as possible to minimise the risk of infection and blood loss.

The repair should be performed in a suitable environment with good lighting, sterile conditions and access to appropriate equipment and clinical support. In most cases the repair should be conducted in an operating theatre. If the labour ward replicates the environmental conditions of an operating theatre, a risk assessment should be conducted to determine whether this is a suitable environment.

The repair should be conducted under adequate anaesthesia, using surgical techniques and materials that are consistent with evidence-based guidelines. A rectal examination should be performed after repair to ensure that sutures have not been inadvertently inserted through the anorectal mucosa.

Only appropriately trained and experienced clinicians should repair a third or fourth degree perineal tear. Refer women to an appropriately qualified clinician if required. Registrars should be supervised by a senior clinician, unless they have completed their Assessment of Procedural and Surgical Skills or the equivalent level of credentialing or training for the repair of third or fourth degree perineal tears.

Some women may decline surgical treatment because they do not want to be separated from their baby. Advise the woman whether it is possible for her baby and support person to be present during repair and support her to maintain uninterrupted skin-to-skin contact and breastfeed during the procedure, whenever possible.

The decision to use prophylactic antibiotics should be made on a case-by-case basis, following recommendations in the current Therapeutic Guidelines: Antibiotic. Although evidence is limited, prophylactic antibiotics for third and fourth degree perineal tears are recommended or considered reasonable in most clinical practice guidelines.

For health service organisations

Ensure that policies, procedures and protocols for the repair of third and fourth degree perineal tears are consistent with current evidence-based guidelines.

Ensure that clinicians undertaking repairs are trained and credentialed in accordance with professional standards, and are working within their scope of clinical practice.

Ensure that operating theatre policies and protocols enable timely repair of third and fourth degree perineal tears or timely transfer to an appropriate facility and allow for the woman’s baby and support person to be present during the repair whenever possible.

Read quality statement 6 - Postoperative care