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.
