Perineal tears

The RCOG have released new guidelines on the management of severe perineal tearing.  Approximately 90% of women tear to some extent during childbirth, severe tearing is described as third-degree (extends downwards from the vaginal wall and perineum to the anal sphincter) or fourth-degree (extends to the lining of the anal canal).  In England, the rate of reported severe perineal tears has tripled from 1.8% to 5.9% between 2000 and 2012.

The RCOG are keen to clarify that this increasing incidence does not necessarily indicate poor quality care. They acknowledge that tearing is a complex issue and the increase could be influenced by a range of factors including; advanced maternal age at first birth, larger maternal BMI and birth weight of the baby, instrumental delivery and better detection and reporting.

Key recommendations from the guidance are:

Clinicians must be aware of the risk factors for severe tearing (Asian ethnicity, first time motherhood, large birth weight, shoulder dystocia, prolonged labour and instrumental delivery).

Early recognition of anal sphincter damage should be a priority.

Clinicians should be appropriately trained in repair methods.

Women who have suffered a third- or fourth- degree perineal tear in a previous pregnancy should be counselled about the risks of further tearing in a subsequent delivery and the option of elective caesarean section should be discussed.

Lead author of the guideline Ruwan Fernando said: ‘Severe tearing can affect many aspects of a woman’s life longer term, including her physical and mental health, as well as future pregnancies.  Currently, there is a need for further research regarding the optimal mode of delivery following third- or fourth-degree perineal tears in a subsequent pregnancy.  Clear documentation, including drawings, together with providing women with a clear explanation of the possible delivery options and associated risks are therefore extremely important.’

Read the guidelines here

RCOG summary can be found here