Introduction by Croakey: Third and fourth degree perineal tears are an uncommon but potentially devastating complication of vaginal childbirth. While not all such tears can be prevented, many can.
When they do occur, early identification, surgical repair, and support are all key to recovery.
With the release this month of the Australian Commission on Safety and Quality in Health Care’s Third and Fourth Degree Perineal Tear Clinical Care Standard, experts are seeking to reduce the risk of these tears and to improve care for women who do experience them.
This article is published by Croakey Professional Services as sponsored content. It is funded by the Australian Commission on Safety and Quality in Health Care.
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“There is a lot of suffering in silence,” says Professor Hannah Dahlen of the small proportion of women in Australia who experience complications from third or fourth degree perineal tears during vaginal childbirth.
Some minor tearing of the perineum is common during childbirth. First and second degree tears may require suturing, but women tend to heal well within weeks.
Third degree tears, however, involve the anal sphincter complex, and fourth degree tears extend to the anorectal mucosa.
With appropriate treatment and support, women can recover well, but current gaps can mean some women miss out.
Dahlen, a Professor of Midwifery at Western Sydney University, said some women lived with complications, such as faecal incontinence, uncontrollable flatulence, and impaired sexual functioning, for “years and years”, unaware of the treatment options for the condition.
Professor Dahlen told Croakey:
Some women think it is just their ‘lot’. It is not just their lot; there are things that can be done.”
Professor Dahlen was a member of the Topic Working Group, formed by the Australian Commission on Safety and Quality in Health Care to develop the Third and Fourth Degree Perineal Tears Clinical Care Standard.
The standard aims to reduce the incidence of third and fourth degree tears and, when they do occur, to ensure women receive evidence-based care for the best chance of recovery.
Currently three percent of all women who give birth vaginally, and five percent of those having a first vaginal birth in Australia experience third or fourth degree tears.
‘A call to action’
The standard was developed in response to concerning findings in the Commission’s Australian Atlas of Healthcare Variation series, which noted that the incidence in Australia was higher than the average for similar Organisation for Economic Co-operation and Development (OECD) countries.
In 2012–14, the number of Australian women who had a third-or fourth-degree perineal tear ranged from six per 1,000 vaginal births in some geographical areas, to 71 per 1,000 vaginal births in other parts of Australia. This equated to a 12-fold variation between areas.
Professor Anne Duggan, Commission Clinical Director and Chair of the Topic Working Group, said this degree of variation suggested that prevention and management of perineal tears was inconsistent, and highlighted a need for action to identify the potential causes of variation and address them.
There are good practices that can reduce perineal tears overall, but maybe those practices aren’t as well embedded in some places as they are in others.”
Professor Duggan noted that rates of instrumental birth – using forceps or vacuum – and the experience of the clinician, are crucial factors to consider when looking at rates of third and fourth degree tears.
Other factors driving variation across Australia include: maternal and fetal risk factors; the rate or type of episiotomy; birth practices in the second stage of labour including those affecting the speed of the birth; recognition of third and fourth degree tears; and health services’ guidelines on perineal care.
The Commission convened experts from all relevant fields – midwifery, obstetrics, colorectal surgery and physiotherapy – as well as consumers, to develop the standard.
Said Professor Dahlen:
Consumers were always at the heart of the standard.”
The standard contains seven quality statements, covering:
- Information, shared decision making and informed consent
- Reducing risk during pregnancy, labour and birth
- Instrumental vaginal birth
- Identifying third and fourth degree perineal tears
- Repairing third and fourth degree perineal tears
- Postoperative care
- Follow-up care post discharge.
It also includes several indicators to help health services to provide care in line with these statements.
“Until recently, many people have not talked about [the risk of third and fourth degree perineal tears]. It’s been one of those too-hard subjects,” said Associate Professor Emmanuel Karantanis, an obstetrician and urogynaecologist and member of the Topic Working Group for the standard.
“A key part of the standard is the insistence on patient education becoming a routine part of antenatal care,” he told Croakey.
Professor Dahlen said she had heard “terrible stories” about misinformation given to women.
One pregnant woman, who experienced severe tearing and faecal leaking after her first birth, was anxious about the impact of a second vaginal birth.
“And a clinician said to her, ‘don’t eat as much in the next pregnancy and your baby won’t be as big – that will solve it’.”
Professor Duggan said she hoped the standard would encourage timely and evidence-based discussions about the benefits and risks of vaginal births but also of caesarean sections.
“We want to see that women have the opportunity to discuss birthing options,” she said.
With vaginal delivery, of course, the baby gets the life-long benefit of the vaginal flora, so we don’t want people to think, ‘I am so scared about a perineal tear, so I am not going to do a vaginal delivery after all’.”
If a woman wants a vaginal delivery, it is important to discuss the risks, benefits, and strategies to optimise her birth experience.”
During pregnancy, perineal self-massage (after week 34), and pelvic floor muscle training may help to reduce the risk of third and fourth degree tears during birth, according to the standard.
And during a vaginal birth, warm compresses applied to the perineum in the second stage of labour, as well as slowing the rate of birth, are recommended.
Professor Dahlen led a large, randomised control trial that found that applying warm packs to the perineum during labour not only reduced pain, but significantly reduced the rate of third and fourth degree tears.
“Good old warm water on your perineum is not only soothing, but it also reduces severe trauma, although we don’t know why,” Professor Dahlen said, adding that this was a simple and accessible prevention strategy.
We need to give women strategies that will empower them to help to reduce that trauma as well.”
The standard notes that the risk of a third or fourth degree tear is roughly doubled in instrument assisted births (using forceps or vacuum extraction).
“If we could eliminate forceps and vacuum from this picture, you would have very little perineal trauma,” Professor Dahlen said. “Let’s give women the greatest possible chance to let physiology work.”
Associate Professor Karantanis said the goal should always be to have fewer forceps and vacuum-assisted deliveries.
“But there’s a corollary to that; sometimes [avoiding instrumental deliveries] at the stage of labour when women are pushing, results in difficult and complicated caesarean sections and potentially sicker babies,” he said.
He added, however, that more research is needed on the use of forceps and vacuum.
“We need to better understand when to do it and for which patients,” Associate Professor Karantanis said. “It’s still an area in medicine that needs a lot more work.”
He welcomed the standard’s recommendation of the selective use of episiotomies when instrumental deliveries are unavoidable.
“Episiotomy is often considered as an invasive step, but in the context of using vacuums and forceps, we are already dealing with an abnormal situation and sometimes we have to take steps to help the woman in the long run,” Associate Professor Karantanis said, adding that episiotomy significantly reduced the risk of third and fourth degree tears during instrumental births.
Episiotomy incisions heal well, he said, are not painful at the time they are made, and do not impact on sexual functioning.
The standard states that during a first vaginal birth where instruments are used, medio-lateral episiotomy (with an incision angle of 60°) reduces the risk of a third or fourth degree tear.
Identification, repair, and support
The standard recommends that women are offered a rectal examination after a vaginal birth, particularly when there is evidence of injury to the perineal area.
“Identification is really important,” Associate Professor Karantanis said. “If we identify third and fourth degree tears, it gives us an opportunity to repair the injury and decreases a woman’s chance of having faecal incontinence.”
Associate Professor Karantanis said, where possible, a second clinician should be present at the rectal examination to ensure any significant tearing is detected and accurately classified. This would also help ensure the right surgical expertise is provided in the best location, such as an operating theatre.
Once a third and fourth degree tear has been surgically repaired, physiotherapy and psychological support are key to ensuring women have the best chance of a full recovery.
Follow up is crucial, Associate Professor Karantanis said, particularly with women from culturally and linguistically diverse communities who may be reluctant or unable to return for follow-up support and care.
The standard notes that women of south Asian ethnicity are at higher risk of tears.
Associate Professor Karantanis, who practises in an area with a high proportion of women of Asian, Indian and Arabic ethnicity, said language and cultural barriers may stand in the way of these women presenting for follow up.
They may also be asymptomatic and not think that it’s important to return to the clinic for review, or it could be that, with a new baby, they put themselves last,” he said. “But they could be left wondering why the tear happened, be concerned about future pregnancies or be unprepared for late onset symptoms.”
Professor Dahlen said innovative approaches are needed to be sure that no woman with a third or fourth degree perineal tear falls through the gaps in the system.
Every single woman with a third or fourth degree tear should have a physio appointment and a recovery plan.”
Debriefing allays fears
Associate Professor Karantanis has found that many new mothers experiencing third and fourth degree perineal tearing were fearful, pointing out the importance of debriefing with them after the birth.
“They have the fear of the pain of the recovery, the fear when it comes to intimacy, and the impact on their own self-image,” he said. “And the fear of not knowing if this is going to get better.”
He said perineal tears increase a woman’s risk of developing postnatal depression, emphasising the need for the woman’s healthcare team to be aware of this possibility and to put support in place.
Ultimately, this clinical care standard aims to support women and clinicians to ensure that women receive high quality, evidence based and women centred care, from the time they receive antenatal care right through to post-operative and longer term follow-up care.
In addition to the Clinical Care Standard, the Commission plans to release videos and fact sheets for clinicians and consumers to promote improved prevention and care.
The Australian Commission on Safety and Quality in Health Care’s new Third and Fourth Degree Perineal Tear Clinical Care Standard will be launched via webcast today at 1:00pm AEST.
This article was written by Nicole McKee and edited by Ruth Armstrong, on behalf of Croakey Professional Services. It was sponsored by The Australian Commission on Safety and Quality in Health Care, which had final say over the content.
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