Reducing avoidable third and fourth degree tears

Childbirth is a wonderful experience for mothers, fathers, support partners and families. Sometimes though it can result in some ongoing issues for the mum and one of these is perineal tearing—tearing of the area between the vagina and anus. These tears can range from being small abrasions to deep lacerations that affect the pelvic floor muscles. Most often, though a tear will simply be an abrasion needing to be stitched and will heal well. But some tears are worse than others and affect the pelvic floor muscles which can affect a mother’s broader health sometimes even having a lifelong impact on physical, psychological & social health and wellbeing.

The Women’s Healthcare Australasia (WHA) has worked collaboratively with Mater Mothers’ Hospitals and several other Australian maternity hospitals to develop ways to avoid or minimize a third or fourth degree tear from occurring. The collaboration is committed to reducing the harm caused by third and fourth degree tears because while only 4% of women sustain a third or fourth degree tear they can have continuing bowel, bladder and sexual problems for varying amounts of time but sometimes even permanently. These lasting effects can be minimised with timely, accurate diagnosis and follow up.

The following information has been developed by the WHA Collaborative.

What are perineal tears? 

• Perineal tears affect the skin and muscles of your perineum, between your vagina and anus
• First and second degree tears are quite common and usually heal without difficulty
• These tears may need stitches and follow up with your local doctor.

What are third and fourth degree tears? 

• Third degree tears go through the muscles that control the anus (back passage)
• Fourth degree tears extend into the lining of the anus or rectum. Third and fourth degree tears usually require repair in an operating theatre.

Could this happen to me?

Approximately 4 out of every 100 women having a vaginal birth experience a third or fourth degree tear.

Your chance of a third or fourth degree tear is increased if:

• This is your first baby
• You are of Southeast Asian background
• You have previously had a third or fourth degree perineal tear
• Your baby weighs more than 4kg (9lb) or is in a position with their back against your back (posterior)
• Your baby’s shoulders become stuck during birth
• You require forceps or other instruments to assist your birth. 

What does this mean for my care?

As part of our commitment to reducing avoidable third and fourth degree tears, women having vaginal births will be offered the following care:

• Application of a warm washcloth (compress) to your perineum when your baby’s head is crowning. This helps the muscles in your perineum stretch naturally
• Encouraging you to move and to adopt birthing positions that control your birth during the second stage of your labour (e. g. on hands and knees)
• Helping you to have a slow, controlled birth through breathing techniques, and without directed pushing
• Using hands to gently support your perineum during the birth of your baby’s head.

For births that require instrumental assistance 

Sometimes instruments, such as forceps or a vacuum (Ventouse) are needed to assist with the birth of your baby. Forceps and Ventouse are instruments that enable your obstetrician to pull, in time with your contractions, to assist with the birth of your baby.

Which instrument is used depends on how your birth is progressing and the position your baby is in. These instruments can help the mother and baby achieve a safe vaginal birth.

If this is your first birth and you require assistance by forceps or Ventouse we will recommend an episiotomy. An episiotomy is a cut made with scissors at the entrance to your vagina into the perineum.

An episiotomy can help to reduce third and fourth degree perineal tears.

We will ask for your permission to cut an episiotomy and pain relief will be provided.

How will I know if I have a third or fourth degree perineal tear?

After the birth of your baby we will examine your perineal and anal area to see if you have a perineal tear. To ensure a tear is not missed we recommend a rectal examination for all women.

This examination can detect internal tears, and ensures we are able to offer appropriate treatment and follow up.

We will ask for your consent before we conduct this examination, and you can withdraw your consent for the examination at any time.

What happens if I get a third or fourth degree tear?

The tear will need to be repaired, usually in an operating theatre. Your baby will be looked after by your partner, a family member or a midwife. Support will be provided to them.

You should be provided with pain relief and information on what you can do to help the tear heal.

An appointment will be made to see a health professional after you go home. Follow up with an experienced women’s health physiotherapist is also recommended.

Further information

Please speak to your midwife or obstetrician if you have questions about this information, or what you can do to reduce your chance of a third of fourth degree tear e.g. perineal massage.

You can read our information brochure on MMH Perineal massage

 For further information about the care of a third or fourth degree tear after the birth of your baby, please read this brochure:

MMH Care of third and fourth degree tears

MMPB Care of third and fourth degree tears

MMPR Care of third and fourth degree tears

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