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South Australian Perinatal Practice Guideline
Third and fourth degree
tear management
Department for Health and Wellbeing, Government of South Australia. All rights reserved.
Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
The use of interpreter services where necessary,
Advising consumers of their choice and ensuring informed consent is obtained,
Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal
culture. The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts
a pregnant women. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the
document symbolises a footprint and demonstrates the need to move forward together in unison.
Purpose and Scope of PPG
This guideline provides clinicians with information on the management of third and fourth
degree tears. It includes details on risk factors, diagnosis and classification, repair technique
and postnatal care and follow-up.
Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectively manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.
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Table I: Complications associated with 3rd and 4th degree tears1
Serious risks
> Incontinence of faeces / flatus Common
> Need for LSCS in future pregnancies due to
persistent symptoms of incontinence or
abnormal anal sphincter structure or function
Uncommon
> Haematoma Rare
> Consequences of failure of the repair requiring
the need for further interventions e.g.
secondary repair or sacral nerve stimulation
Rare
> Rectovaginal fistula Very rare
Frequent risks
> Fear, difficulty and discomfort in passing stools
in the immediate postpartum period
> Migration of suture material requiring removal
> Granulation tissue formation
> Faecal urgency 26/100 Very common
> Perineal pain and dyspareunia 9/100 Common
> Wound infection 8/100 Common
> Urinary infection
Adapted from RCOG Consent advice No. 9, repair of third and fourth degree perineal tears
following childbirth14
RCOG: Presenting information on risk2
Term Equivalent numerical ratio
Very common 1/1 to 1/10
Common 1/10 to 1/100
Uncommon 1/100 to 1/1,000
Rare 1/1,000 to 1/10,000
Very rare Less than 1/10,000
Based on the RCOG Clinical Governance Advice, Presenting information on Risk15
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Table of Contents
Purpose and Scope of PPG
Table I: Complications associated with 3rd and 4th degree tears
Summary of Practice Recommendations
Abbreviations
Literature review
Classification of tears
Risk factors
Management of repairs
Diagnosis of third and fourth degree tear
Recommended method for repair
Repair technique
Recommended antibiotic cover
Role of colostomy
Postpartum Management
Bladder management
Antibiotics
Analgesia and other measures
Follow-up (at 6 weeks)
Recommendations about future pregnancies
References
Acknowledgements
Summary of Practice Recommendations
Careful inspection of the perineum, vulva and vagina following birth is essential
Rectal examination prior to suturing is required when the woman has undergone episiotomy
or if the tear is extends to the anal verge to determine classification of tear
Repair of 3b, 3c and fourth degree tears should be undertaken in theatre with adequate
analgesia
Consult a colorectal surgeon if a large fourth degree tear is diagnosed
Antibiotic cover is required for all third and fourth degree tears
Postnatal bladder management requires specific attention
Postnatal follow-up needs to be individualised
Recommendations for subsequent births is based on presence of symptoms and the woman s
preference
Abbreviations
et al. And others
EAS External anal sphincter
e.g. For example
g Gram(s)
IAS Internal anal sphincter
IV Intravenous
mg Milligrams
n Number
% Percent
Registered trademark
RCOG Royal College of Obstetricians and Gynaecologists
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Literature review
> Obstetric anal sphincter injury encompasses both third and fourth degree perineal tears and
can occur with an intact perineum
> In South Australia in 2010, third and fourth degree tears occurred in 3.4 % (n=450) of
vaginal births3
> Prospective studies using postpartum anal endoanal sonography suggest that almost one
third of primiparous women may sustain occult anal sphincter injury following vaginal
birth4,5,6
> Recent randomised controlled studies of external anal sphincter (EAS) repair have reported
low incidences of anal incontinence symptoms (e.g. loss of control over flatus, faecal
urgency and staining) with 60 80 % of women asymptomatic at 12 months5
> Damage to the innervation of the sphincter muscles and pelvic floor may be related to
pudendal nerve damage4,7
Classification of tears
First Degree:
> Injury to the perineal skin only
Second Degree:
> Injury to the perineum extending into the perineal muscles but not the anal sphincter (either
external [EAS] or internal anal sphincter[IAS])
Third degree:
> Injury to the perineum involving the anal sphincter complex:
> 3a: Less than 50 % of EAS thickness torn
> 3b: More than 50 % of EAS thickness torn
> 3c: Both EAS and IAS torn4
Fourth Degree:
> Disruption of the anal sphincter complex (EAS and IAS) and anal epithelium5. Occasionally
there can be an anal or rectal mucosa tear behind an intact sphincter. Rectal examination
before repair is recommended8
Risk factors
> First vaginal birth
> Instrumental delivery
> Prolonged second stage
> Macrosomia > 4 kg
> Midline episiotomy
> Occipitoposterior position at delivery
> Induction of labour
> Epidural analgesia
> Shoulder dystocia
> Most of the above risk factors cannot readily be used to prevent or predict the occurrence of
a third or fourth degree tear9
> Damage to the pudendal nerves is cumulative in successive vaginal births7,10,11
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Management of Repair
> All women should be examined following vaginal birth to assess the degree of vaginal,
perineal or rectal injury
> All sphincter damage must be identified, documented and treated appropriately
> This includes:
> partial sphincter tears
> sphincter damage with an intact perineum
> buttonhole rectal mucosa tears
> Accurate diagnosis will mean that these women will have the best chance of normal anal
function in years to come
Diagnosis of third and fourth degree tear
All women delivering vaginally should have:
> Informed verbal consent explaining the need for thorough examination of the vagina, vulva
and perineum and why a per rectum examination may be required
> Good exposure and good lighting
> Good analgesia
> Vulval and vaginal examination
> The normal pattern of peri-anal rugae confirmed
> Rectal examination for all episiotomies or if tear extending to anal verge
> Direct visualisation of sphincter with digit in rectum
> Palpation of sphincter with digit in rectum and pill rolling action with thumb on sphincter
Recommended method for repair
> Third and fourth degree repairs should be undertaken by an obstetrician or a registrar
trained to repair third and fourth degree tears after discussion with a consultant
> 3a tears may be repaired in labour and delivery if there is adequate analgesia
> All 3 b and c and fourth degree tear repairs should be carried out in theatre with adequate
regional anaesthesia to facilitate adequate analgesia, good visualisation and relaxation of
sphincter muscles
Repair technique
> Perform a repeat detailed assessment of the degree of vaginal / perineal / rectal injury
under anaesthesia
> Ends of EAS should be mobilised by sharp and blunt dissection to facilitate a tension free
repair
> When repairing the EAS, use either monofilament sutures such as 2-0 polydioxanone (PDS
or Maxon) (DON T USE Vicryl)
> For repair of complete tear of the EAS, either an overlapping or end-to-end (approximation)
method can be used. Overlapping repair is preferred by most Obstetric Consultants
specialising in the management of anal sphincter injury and Colorectal Surgeons; however,
there is no level I evidence to support this6
> Where the IAS can be identified, it is advisable to repair separately with interrupted sutures.
When repairing the IAS, use fine suture size such as 3-0 PDS and 2-0 Vicryl (associated
with less irritation and discomfort)
> 3a tears can only be repaired using an end-to-end repair
> Bury surgical knots beneath the superficial perineal muscles by performing a standard
perineal repair to prevent knot migration to the skin
> Perform a rectal examination on completion to ensure the repair is intact
> Document the procedure in case notes and arrange postpartum follow up
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Recommended antibiotic cover
> Give single IV doses of both cephazolin 2 g and metronidazole 500 mg
Allergy to penicillin
> Single IV doses of clindamycin 450 mg, AND gentamicin 5 mg / kg
Role of colostomy
> There is no clear consensus amongst colorectal surgeons on who requires Colostomy and
no reliable data to base a decision on
> A Colostomy is not required for management of 3a, 3b and straightforward 3c tears
> A Colostomy is usually indicated with large 4th degree tears, especially when the tear
extends above the levator muscles, or where other risk factors for fistula exist
> Consult with a colorectal surgeon regarding the need for a colostomy
Postpartum Management
Bladder management
> On average, bladder sensation takes between 6 to 7 hours to return after a vaginal birth
with regional anaesthesia12
> In cases of 3rd or 4th degree tear, severe perineal discomfort is known to cause urinary
retention with a delay of up to 12 hours before bladder sensation returns13
> Urinary catheterisation should occur following 3rd and 4th degree repair in the immediate
postpartum period to minimise urinary retention. The optimum time for catheterisation after
birth is uncertain. Careful attention should be paid to voiding after removal of the catheter,
particularly in the first six hours after catheter removal (see Bladder Management for
Intrapartum and Postnatal Women PPG available at www.sahealth.sa.gov.au/perinatal)
Antibiotics
> The use of broad-spectrum antibiotic cover is recommended after obstetric anal sphincter
repair to reduce the incidence of postoperative infections and wound dehiscence6
> Commence oral Augmentin Duo Forte (amoxicillin 875 mg and clavulanic acid 125 mg)
12 hourly with meals for 5 days
> If allergic to penicillin, use both
> oral ciprofloxacin 500 mg 12 hourly for 5 days
plus
> oral clindamycin 450 mg 8 hourly for 5 days
Breastfeeding: All these drugs are acceptable
Analgesia and other measures
> Use a multimodal approach to minimise the use of opioid medication, i.e. oxycodone and
codeine containing analgesics, as they may cause constipation
> Administer oral paracetamol 1 g every 6 hours as required
> If there are no contra-indications, administer diclofenac (Voltaren ) 100 mg suppository per
rectum at the end of the procedure while the patient is in the lithotomy position. Subsequent
doses can be administered orally (i.e. 50 mg TDS), commencing no sooner than ten hours
after administration of the intra-operative dose
> Ice packs and resting supine / prone for 10 - 20 minutes every 2 3 hours over the first
week may decrease symptoms of pelvic floor fatigue (e.g. swelling, pain and perineal
descent)
> Bulking agents and stool softeners (e.g. Fybogel 1 sachet three times a day, Lactulose 20
mL twice daily, and Coloxyl 120 mg 1-2 nocte in addition as required) are recommended.
Commence after 24 hours and continue for two weeks before weaning off. Educate the
woman about the need for adequate fluid intake when using bulking agents
> In-patient referral to a continence health professional (e.g. continence nurse advisor /
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practitioner or physiotherapist) for advice about defecation techniques, pelvic floor care and
ongoing support
> Before discharge, the woman must be fully informed about the nature of her injury,
associated risks (see Table 1) and benefits of follow-up
Follow up (at 6 weeks)
> A third or fourth degree tear is a significant peripartum event. Postpartum follow-up by a
consultant with an interest in management of third and fourth degree tears and a continence
health professional referral is required. If the woman is experiencing incontinence or pain at
follow-up, a colorectal opinion and investigation (endoanal ultrasound) may be necessary
> Establish the following:
> Control of bowel motions
> Control of flatus
> Faecal urgency
> Offensive vaginal discharge (this may suggest a fistula)
> Confirm urinary continence
> Assess pelvic floor muscles
> Assess ongoing perineal discomfort
> The mode of subsequent delivery should be discussed in the context of current symptoms
or findings of postpartum sonography
Recommendations about future pregnancies
> Women who are asymptomatic may consider a vaginal birth
> Advise the woman that there is no evidence to support the role of prophylactic episiotomy in
subsequent pregnancies
> Recommend LSCS:
> Symptomatic
> Previous 4th degree tear
> Delayed surgical correction of sphincter damage
> Other risk factor for sphincter damage (e.g. big baby, occipito posterior
position)
> Woman s request
> It is appropriate to warn women that the cumulative effect of ageing, menopause and
progression of neuropathy on long term sphincter weakness by the fifth and sixth decade
may result in the new onset of symptoms for which treatment is available5
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References
1. Royal College of Obstetricians and Gynaecologists. Repair of third and fourth degree
perineal tears following childbirth. Consent advice No 9. June 2010. Available from URL:
http://www.rcog.org.uk/repair-third-and-fourth-degree-perineal-tears-following-childbirth
2. Royal College of Obstetricians and Gynaecologists. Presenting information on risk.
Clinical Governance advice No. 7. London: RCOG; 2008. Available from URL:
http://www.rcog.org.uk/files/rcog-corp/CGA7-15072010.pdf
3. Scheil W, Scott J, Catcheside B & Sage L. Pregnancy Outcome in South Australia 2010.
Adelaide: Pregnancy Outcome Unit, SA Health, Government of South Australia, 2012.
4. Sultan AH, Kamm MA, Hudson CN, Chir M, Thomas JM, Bartram CI. Anal-Sphincter
disruption during vaginal delivery. N Engl J Med 1993; 329: 1905-11 (Level III).
5. Royal College of Obstetricians and Gynaecologists (RCOG). Management of third and
fourth-degree perineal tears following vaginal delivery, Guideline No. 29. London: RCOG
Press; 2007.
6. Thakar R, Sultan AH. Management of obstetric anal sphincter injury. The Obstetrician
and Gynaecologist 2003; 5: 72-8.
7. Fitzpatrick M, O Herlihy C. The effects of labour and delivery on the pelvic floor. Best
Practice & Research Clinical Obstet Gynaecol 2001; 15: 63 79.
8. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal
incontinence: Retrospective cohort study. Br Med J 2000; 320: 86 91 (Level III-2).
9. Rieger N, Perera S, Stephens J, Coates D, Po D. Anal sphincter function and integrity
after primary repair of third-degree tear: a prospective analysis. ANZ J of Surg 2004; 74
122 4 (Level III-3).
10. Fynes M, Donnelly V, Behan M, O Connell PR, O Herlihy C. Effect of second vaginal
delivery on anorectal physiology and faecal continence: a prospective study. The Lancet
1999; 354:983-86 (Level III).
11. Fynes M. Childbirth and faecal incontinence. Aust Continence Journal 2001; 7: 2-6
(Level III).
12. Foona R, Toozs-Hobsonb P, Millnsb P, Kilbyb M. The impact of anesthesia and mode of
delivery on the urinary bladder in the postdelivery period. Int J Gyn Obst 2010; 110: 114-
117.
13. Sultan AH, Thakar R, Fenner DE, editors. Perineal and anal sphincter trauma. London:
Springer; 2009.
Useful resources
> Royal College of Obstetrics and Gynaecology Patient information Third and fourth degree
tears. Available from URL:
https://www.rcog.org.uk/en/patients/patient-leaflets/third--or-fourth-degree-tear-during-
childbirth/
> Royal Women s Hospital. Consumer information. Anal sphincter tears in childbirth.
Available from URL:
https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Perineal-tears-third-and-fourth-
degree.pdf
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Acknowledgements
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development
process particularly:
Write Group Lead
Dr Steven Scroggs
Write Group Members
Allison Rogers
Dr Brian Peat
Dr Elinor Atkinson
Prof Gus Dekker
Other major contributors
J Phelps
J Turnidge
N Rieger
SAPPG Work Group 2004-2014
SAPPG Management Group Members
Sonia Angus
Dr Kris Bascomb
Lyn Bastian
Elizabeth Bennett
Dr Feisal Chenia
John Coomblas
A/Prof Rosalie Grivell
Dr Sue Kennedy-Andrews
Jackie Kitschke
Catherine Leggett
Dr Anupam Parange
Dr Andrew McPhee
Rebecca Smith
A/Prof John Svigos
Dr Laura Willington
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Document Ownership & History
Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Endorsed by: SA Safety and Quality Strategic Governance Committee
Next review due: 17 June 2019
ISBN number: 978-1-74243-162-8
PDS reference: CG143
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? V5
Does this policy replace another policy with a different title? N
If so, which policy (title)?
Approval
Date Version
Who approved New/Revised
Version Reason for Change
15 June 2018 V5.1 SA Health Safety and Quality Strategic Governance Committee
Review date extended to 5 years
following risk assessment. New
template.
17 June 2014 V5 SA Health Safety and Quality Strategic Governance Committee
Reviewed in line with scheduled
review date
20 Mar 2012 V4 Maternal and Neonatal Clinical Network
Reviewed in line with scheduled
review date
27 Oct 2009 V3 Maternal and Neonatal Clinical Network
Reviewed in line with scheduled
review date
25 Jan 2005 V2 Maternal and Neonatal Clinical
Network
Reviewed.
21 Jul 2004 V1 Maternal and Neonatal Clinical Network Original approved version.
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Recommendations about future pregnancies
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