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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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Third and fourth degree tear management 
 
 

Table I: Complications associated with 3rd and 4th degree tears1 

Serious risks 
&gt; Incontinence of faeces / flatus Common 
&gt; Need for LSCS in future pregnancies due to 

persistent symptoms of incontinence or 
abnormal anal sphincter structure or function 

Uncommon 
 

&gt; Haematoma Rare 
&gt; Consequences of failure of the repair requiring 

the need for further interventions e.g. 
secondary repair or sacral nerve stimulation  

Rare 
 

&gt; Rectovaginal fistula Very rare 

Frequent risks 
&gt; Fear, difficulty and discomfort in passing stools 

in the immediate postpartum period 
&gt; Migration of suture material requiring removal 
&gt; Granulation tissue formation 

 

&gt; Faecal urgency 26/100  Very common 
&gt; Perineal pain and dyspareunia 9/100   Common 
&gt; Wound infection 8/100    Common  
&gt; 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 
&gt; Obstetric anal sphincter injury encompasses both third and fourth degree perineal tears and 

can occur with an intact perineum 
&gt; In South Australia in 2010, third and fourth degree tears occurred in 3.4 % (n=450) of 

vaginal births3   
&gt; 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     

&gt; 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  

&gt; Damage to the innervation of the sphincter muscles and pelvic floor may be related to 
pudendal nerve damage4,7 

Classification of tears 
First Degree: 
&gt; Injury to the perineal skin only 

Second Degree: 
&gt; Injury to the perineum extending into the perineal muscles but not the anal sphincter (either 

external [EAS] or internal anal sphincter[IAS]) 

Third degree: 
&gt; Injury to the perineum involving the anal sphincter complex: 

&gt; 3a:  Less than 50 % of EAS thickness torn 

&gt; 3b: More than 50 % of EAS thickness torn 

&gt; 3c:  Both EAS and IAS torn4  

Fourth Degree: 
&gt; 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 
&gt; First vaginal birth 
&gt; Instrumental delivery 
&gt; Prolonged second stage 
&gt; Macrosomia &gt; 4 kg 
&gt; Midline episiotomy 
&gt; Occipitoposterior position at delivery  
&gt; Induction of labour 
&gt; Epidural analgesia 
&gt; Shoulder dystocia 
&gt; Most of the above risk factors cannot readily be used to prevent or predict the occurrence of 

a third or fourth degree tear9  
&gt; Damage to the pudendal nerves is cumulative in successive vaginal births7,10,11   

 

 
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Management of Repair 
&gt; All women should be examined following vaginal birth to assess the degree of vaginal, 

perineal or rectal injury 
&gt; All sphincter damage must be identified, documented and treated appropriately 
&gt; This includes:  

&gt; partial sphincter tears 

&gt; sphincter damage with an intact perineum 

&gt;  buttonhole  rectal mucosa tears 
&gt; 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: 
&gt; Informed verbal consent explaining the need for thorough examination of the vagina, vulva 

and perineum and why a per rectum examination may be required 
&gt; Good exposure and good lighting 
&gt; Good analgesia 
&gt; Vulval and vaginal examination 
&gt; The normal pattern of peri-anal rugae confirmed 
&gt; Rectal examination for all episiotomies or if tear extending to anal verge  
&gt; Direct visualisation of sphincter with digit in rectum 
&gt; Palpation of sphincter with digit in rectum and pill rolling action with thumb on sphincter 

Recommended method for repair 
&gt; 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 
&gt; 3a tears may be repaired in labour and delivery if there is adequate analgesia 
&gt; 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 
&gt; Perform a repeat detailed assessment of the degree of vaginal / perineal / rectal injury 

under anaesthesia 
&gt; Ends of EAS should be mobilised by sharp and blunt dissection to facilitate a tension free 

repair 
&gt; When repairing the EAS, use either monofilament sutures such as 2-0 polydioxanone (PDS 

or Maxon) (DON T USE Vicryl) 
&gt; 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  

&gt; 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) 

&gt; 3a tears can only be repaired using an end-to-end repair 
&gt; Bury surgical knots beneath the superficial perineal muscles by performing a standard 

perineal repair to prevent knot migration to the skin  
&gt; Perform a rectal examination on completion to ensure the repair is intact 
&gt; Document the procedure in case notes and arrange postpartum follow up  

 

 
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Recommended antibiotic cover 
&gt; Give single IV doses of both cephazolin 2 g and metronidazole 500 mg 

Allergy to penicillin 
&gt; Single IV doses of clindamycin 450 mg, AND gentamicin 5 mg / kg  

Role of colostomy 
&gt; There is no clear consensus amongst colorectal surgeons on who requires Colostomy and 

no reliable data to base a decision on 
&gt; A Colostomy is not required for management of 3a, 3b and straightforward 3c tears 
&gt; 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  
&gt; Consult with a colorectal surgeon regarding the need for a colostomy 

Postpartum Management  
Bladder management 
&gt; On average, bladder sensation takes between 6 to 7 hours to return after a vaginal birth 

with regional anaesthesia12   
&gt; 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  
&gt; 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 
&gt; The use of broad-spectrum antibiotic cover is recommended after obstetric anal sphincter 

repair to reduce the incidence of postoperative infections and wound dehiscence6 
&gt; Commence oral Augmentin Duo Forte  (amoxicillin 875 mg and clavulanic acid 125 mg)    

12 hourly with meals for 5 days 
&gt; If allergic to penicillin, use both  

&gt; oral ciprofloxacin 500 mg 12 hourly for 5 days  

 plus 

&gt; oral clindamycin 450 mg 8 hourly for 5 days  
Breastfeeding: All these drugs are acceptable  

Analgesia and other measures 
&gt; Use a multimodal approach to minimise the use of opioid medication, i.e. oxycodone and 

codeine containing analgesics, as they may cause constipation 
&gt; Administer oral paracetamol 1 g every 6 hours as required 
&gt; 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 

&gt; 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) 

&gt; 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 

&gt; 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 

&gt; 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)  
&gt; 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 

&gt; Establish the following: 

&gt; Control of bowel motions 

&gt; Control of flatus 

&gt; Faecal urgency 

&gt; Offensive vaginal discharge (this may suggest a fistula) 

&gt; Confirm urinary continence  

&gt; Assess pelvic floor muscles 

&gt; Assess ongoing perineal discomfort 

&gt; The mode of subsequent delivery should be discussed in the context of current symptoms 
or findings of postpartum sonography 

Recommendations about future pregnancies  
&gt; Women who are asymptomatic may consider a vaginal birth 
&gt; Advise the woman that there is no evidence to support the role of prophylactic episiotomy in 

subsequent pregnancies 
&gt; Recommend LSCS: 

&gt; Symptomatic 

&gt; Previous 4th degree tear 

&gt; Delayed surgical correction of sphincter damage 

&gt; Other risk factor for sphincter damage (e.g. big baby, occipito posterior 
position) 

&gt; Woman s request 
&gt; 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  &amp; 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 &amp; 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 
&gt; 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/  

&gt; 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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Third and fourth degree tear management 
 
 

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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Third and fourth degree tear management 
 
 

Document Ownership &amp; History 
Developed by: SA Maternal, Neonatal &amp; 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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