Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2020 Apr;60(2):175-182.
doi: 10.1111/ajo.13127. Epub 2020 Feb 17.

Third- and fourth-degree tears: A review of the current evidence for prevention and management

Alyce N Wilson  1   2 , Caroline S E Homer  1   2   3   4
Affiliations
Review

Third- and fourth-degree tears: A review of the current evidence for prevention and management

Alyce N Wilson et al. Aust N Z J Obstet Gynaecol. 2020 Apr.

Abstract

Background: Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development.

Aims: We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres.

Materials and methods: We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic.

Results: Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births.

Conclusions: Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.

Keywords: child birth; obstetric labour complications; perineal tears; perineum; pregnancy.

PubMed Disclaimer

Comment in

References

    1. Australian Commission of Quality and Safety in Health Care (ACQSHC). Second Australian Atlas of Healthcare Variation. Sydney: Australian Commission of Quality and Safety in Health Care (ACQSHC), 2017.
    1. Organisation for Economic Co-operation and Development. Obstetric Trauma. Health at a Glance 2017: OECD Indicators. Paris: OECD Publishing, 2017.
    1. Basham E, Stock L, Lewicky-Gaupp C, Mitchell C, Gossett DR. Subsequent pregnancy outcomes after obstetric anal sphincter injuries (OASIS). Obstet Gynecol Surv 2014; 69(2): 78-79.
    1. Sultan AH. Obstetrical perineal injury and anal incontinence. AVMA Med Leg J 1999; 5(6): 193-196.
    1. Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears (Green top 29). London: Royal College of Obstetricians and Gynaecologists, 2015.