Until recently, perineal tears were a taboo subject and women often suffered in silence after they experienced a severe tear. This is despite 3% of all Australian women giving birth, and 5% of women having their first vaginal birth, being affected by a third or fourth degree perineal tear.[i]
The release of the first national Third and Fourth Degree Perineal Tears Clinical Care Standard by the Australian Commission on Safety and Quality in Health Care (the Commission) will help to ensure that women receive appropriate treatment and support throughout their childbirth experience.
Professor Anne Duggan, Commission Clinical Director, said that both health professionals and women need to feel comfortable talking about perineal tears, since the risk of a third or fourth degree tear can potentially be reduced with evidence-based, woman-centred care.
“Minor perineal tears are common during vaginal births and most heal well, but some women experience a more serious tear that requires surgical repair,” said Professor Duggan.
“With third and fourth degree tears, there may be short and long-term complications affecting a woman’s physical, psychological and sexual wellbeing. We want women to understand that they can talk to their healthcare team to prepare for childbirth, and to know that if a serious tear occurs, high quality care is available to help them recover well, and reduce the likelihood of long-term impacts.”
The rate of perineal tears among women in Australia is above the reported average in the OECD. In 2017, 2.5% of vaginal deliveries without instruments* in Australia resulted in a third or fourth degree tear, whereas across the OECD the figure was 1.4%.[ii]
While not all third and fourth degree perineal tears are preventable, it is possible to reduce the risk of a third or fourth degree tear occurring with appropriate interventions during labour.
“During pregnancy, women may be feeling overwhelmed with making decisions about their health care. This standard aims to ensure they are well informed and prepared for what they may experience with childbirth,” said Professor Duggan.
“Making sure that women get the information they need before they go into labour is one thing we can do to improve the quality of care we offer to mothers, particularly in relation to perineal tearing where we don’t do as well as comparable countries in the OECD.
“The new standard will also improve the care, and ensure the best chance of recovery, for women who do experience such tears. When they occur, it is important that they are identified early and are surgically repaired soon after birth to help prevent long-term problems,” Professor Duggan explained.
Concerning findings in the Second Australian Atlas of Healthcare Variation, which examined the occurrence of perineal tears across the country, led to the development of the Third and Fourth Degree Perineal Tears Clinical Care Standard.
The Atlas found that in 2012–14, there was significant variation in the number of Australian women who had a third or fourth degree perineal tear depending on where they lived. Data revealed a 12-fold difference across Australia – in some areas the rate was as low as 6 per 1,000 vaginal births, while in others it was as high as 71 per 1,000 vaginal births.[iii]
Empowering pregnant women with knowledge
For Professor Hannah Dahlen AM, Professor of Midwifery at Western Sydney University, reducing perineal trauma during childbirth has long been her passion – as a researcher, a midwife and a woman.
“I am so pleased to see this important area of women’s health being given the considered attention that it needs with the release of a national standard of care to support both women and healthcare professionals working in maternity care,” she said.
“We need healthcare providers to talk to women sensitively about this important health issue during pregnancy, so they can be empowered with knowledge and helpful strategies as they approach one of the most powerful moments of their lives.”
Sydney-based Obstetrician and Urogynaecologist, Associate Professor Emmanuel Karantanis, established one of the first clinics in Australia for women experiencing third and fourth degree tears during childbirth, and works with culturally diverse communities.
“The clinical care standard on third and fourth degree tears is an important guide for both women and health workers,” he said. “It brings to our attention a subject which until recently was taboo, but which can cause lifetime problems and embarrassment for women who suffer in silence all too often.
“Women deserve to know more about the factors leading to third and fourth degree tears. More effort is required to check for these tears immediately after childbirth. Women who sustain these tears deserve early diagnosis, prompt explanation, effective treatment, and ongoing physical and psychological support. The evidence shows that such interventions can improve women’s quality of life.”
Associate Professor Karantanis added: “Third and fourth degree tears are more common than previously thought – they can no longer be ignored.”
The new standard will be launched today via a live-streamed event. The panel discussion will include: the Commission’s Professor Anne Duggan; obstetrician and urogynaecologist Associate Professor Emmanuel Karantanis; leading midwife and researcher Professor Hannah Dahlen; physiotherapist at Macquarie Women's Health Dubbo, Natalie McConochie; and a woman with personal experience of a third degree perineal tear, Janelle Gullan.
The new clinical care standard has been endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Australian College of Midwives (ACM), the Australian Physiotherapy Association (APA) and other professional bodies.
* The risk of a perineal tear is higher when instruments (forceps or vacuum extraction) are used.
[i] Australian Institute of Health and Welfare. National Core Maternity Indicators. Canberra: AIHW; 2018.
[ii] OECD (2019), Health at a Glance 2019: OECD Indicators (Summary), OECD Publishing, Paris,.
[iii] Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The Second Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2017
