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SDMS ID: P2010/0308-0013.8-07WACS

Title:  Management of Third and Fourth Degree Tears 

Replaces:  New PolicyDescription: Management of third and fourth degree perineal tearsTarget Audience: Midwifery and Medical Staff, Queen Victoria Maternity Unit Key Words: Third degree tear, fourth degree tear 

Policy Supported:

Purpose:

To correctly recognise and classify third and fourth degree perineal trauma, provideinformation to prevent infection, ensure adequate pain relief and postnatal follow up after discharge.

Definition:Third degree tear involves the external anal sphincter (EAS) and internal anal sphincter (IAS).

3a: less than 50% of EAS thickness torn3b: more than 50% of EAS thickness torn3c: IAS torn

Fourth degree tear involves the anal sphincter (EAS and IAS) and rectal mucosa.

Risk Factors

First vaginal birth

Prolonged second stage

 Assisted vaginal delivery

Birthweight > 4kg

Midline episiotomy

Management

 All women having a vaginal birth should have a systematic examination of theperineum, vagina and rectum to assess the severity of damage prior to suturing.

 An appropriately skilled operator should carry out repair of extensive tears in theoperating theatre under regional or general anaesthesia.

Post Repair Management

Ice therapy to decrease swelling for the first 48 hours. Apply an ice pack in asanitary pad to perineum for 20 minutes every 3 to 4 hours.

Positioning to reduce oedema – encourage horizontal position 24 to 48 hours postrepair.

 Adequate analgesia such as non-steroidal anti-inflammatory agents andparacetamol. Avoid analgesia containing codeine.

Rectal analgesia should be avoided.Consider the use of broad-spectrum prophylactic antibiotics for 3 to 5 days.

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Stool softeners (Lactulose) or bulking agents (Fybogel) should be used for at least 7to 10 days, as constipation must be avoided.

Inpatient physiotherapist review – pelvic floor contraction should be delayed until 3 to4 weeks for tissue healing.

Monitor bladder sensation - risk of urinary retention

Information sheet to be distributed to woman.

Education on measures to promote healing.

Debriefing and planning for next birth.

Discharge planning

Postnatal follow up appointment in six weeks in gynaecology clinic.

Outpatient appointment with physiotherapist.

Vaginal Birth Following Previous Third and Fourth Degree Tears

Women with previous third and fourth degree tears should be informed that their riskof severe perineal trauma is not increased in a subsequent birth, compared towomen having their first baby.

In order for women to make an informed choice regarding previous significant

perineal injury or trauma, a plan of management should be discussed anddocumented in the antenatal period. This discussion should address:o current continence symptoms o the degree of previous trauma o risk of recurrence o the success of the previous repair  o the psychological effect of the previous trauma o management of labour. 

Episiotomy should not be routinely offered at vaginal birth following previous third or fourth degree trauma.

Attachments Attachment 1  Background Information

 Attachment 2  References

Performance Indicators: Evaluation of compliance with guideline to be achieved throughmedical record audit annually by clinical Quality improvementMidwife WACS

Review Date:   Annually verified for currency or as changes occur, andreviewed every 3 years via Policy and Procedure working

group coordinated by the Clinical and Quality improvementmidwife. November 2009

Stakeholders: Midwives and medical staff WACS

Developed by:  Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Women’s & Children’s Services

Dr A Dennis  Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)

Women’s & Children’s Services  Women’s & Children’s Services 

Date: _________________________ 

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APPENDIX 1

Background Information:Clinically detectable anal sphincter lacerations are identified in less than 0.5  – 3% of vaginal births. With the use and availability of endoanal ultrasound, occult damage to theanal sphincter has been identified in up to 36% of women.

 A previous third degree tear poses a small increased risk of a repeat third degree tear in asubsequent vaginal birth. However the small number of studies available limits thisinformation. If a third degree tear has resulted in some residual sphincter defect or dysfunction, then a subsequent vaginal birth appears to cause a worsening of symptoms.Currently there is no consistent evidence that women whose tears have fully healed andwho have no symptoms of anal dysfunction are at increased risk of long-term incontinenceif they have a subsequent vaginal birth.

In subsequent births fourth degree tears are associated with a higher incidence of bowelincontinence then third degree tears. Women experiencing ongoing anal symptoms

following repair of third and fourth degree tears range from 25 to 57%. Leakage of faecesoccurs in 8% of women and incontinence of flatus in 30%.

Postnatal AssessmentPostnatal assessment by a colorectal surgeon is recommended for assessment of symptoms, endoanal ultrasound and manometry. The results of this assessment can bethen be assessed in planning for future births.

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APPENDIX 2REFERENCES

King Edward Memorial Hospital Clinical Guidelines 2006 Management of third and fourthdegree perineal trauma. Online:http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm 

Royal College of Obstetricians and Gynaecologist Guideline No 29 2001 Management of third- and fourth-degree perineal tears following vaginal delivery. Online:http://www.rcog.org.uk/index.asp?PageID=532 

Royal Women’s Hospital Clinical Practice Guidelines 2005 Management of third and fourthdegree tears. Online: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3650