Information for health service organisations – Third and Fourth Degree Perineal Tears Clinical Care Standard

What the standard says

During the antenatal period, a woman is informed about the risk of a third or fourth degree perineal tear. Throughout pregnancy, labour and birth, she is supported to make decisions and provide informed consent for the care she receives.

What the quality statement means for health service organisations

Ensure that policies, procedures and protocols are in place to support information provision, shared decision making and informed consent, consistent with the requirements of the NSQHS Standards.

Ensure that information about third and fourth degree perineal tears and their management is consistent with current evidence and meets the woman’s health literacy and cultural needs. Information should be easy to use and accessible.

Ensure that healthcare professionals are appropriately trained and skilled to undertake clinical assessment of the risk of third and fourth degree tears and to communicate with women regarding risks, as part of shared decision making, and to obtain informed consent.

Ensure that systems are in place to record the key outcomes of discussions and assessments to enable appropriate clinical communication between clinicians. This is especially important when care is provided by a multidisciplinary team, a shared-care model is used, or women are referred to another clinician or transferred to a different care setting.

What the standard says

A woman choosing a vaginal birth is offered evidence-based care to reduce her risk of a third or fourth degree perineal tear.

What the quality statement means for health service organisations

Ensure that policies, procedures and protocols detail evidence-based care to reduce the risk of third and fourth degree perineal tears. Ensure relevant clinicians act in accordance with policies and evidence-based guidelines.

Ensure that relevant clinicians are appropriately trained and skilled in assessment and classification of perineal tears.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, and respond to risk, as per Action 1.28 in the NSQHS Standards (2nd ed.).²²

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

What the standard says

When intervention is indicated in a vaginal birth, the choice of intervention is based on the clinical situation, the benefits and risks of each option and discussion with the woman.

What the quality statement means for health service organisations

Ensure that policies, procedures and protocols include the management of instrumental vaginal birth, discussion with the woman about the possible benefits and risks associated with the available options and informed consent.

Ensure that conditions for a safe instrumental vaginal birth, as described in relevant clinical guidelines, are met within the facility, particularly with regard to availability of senior staff, facilities and back-up plans in case an instrumental birth is not successful.

Ensure that clinicians are appropriately trained and experienced to provide safe, high-quality care during an instrumental vaginal birth in accordance with professional standards, and are working within their scope of clinical practice. Ensure junior staff who do not have the requisite skills are supported by an experienced clinician.

Ensure that systems are in place to monitor variation in practice against expected health outcomes, as per Action 1.28 in the NSQHS Standards (2nd ed.), including rates of instrumental births and perineal trauma.

Provide timely feedback to clinicians on variation in practice and support them to review their clinical practice.

Record risks and the planned mitigation strategies in the risk management system.

What the standard says

After a vaginal birth, a woman is offered examination by an appropriately trained clinician to exclude the possibility of a third or fourth degree perineal tear. A tear is classified using the Royal College of Obstetricians and Gynaecologists classification and is documented in the woman’s healthcare record.

What the quality statement means for health service organisations

Ensure that policies, procedures and protocols for classifying and reporting perineal tears are consistent with current evidence-based guidelines such as the RCOG classification system, and incorporate respectful communication regarding the examination and the request for verbal consent.

Ensure that clinicians are appropriately trained in perineal anatomy and skilled in assessment and use of the RCOG classification system. Communication with the woman should be offered in a respectful manner and consent sought. Ensure junior staff who do not have the requisite skills are supported by an experienced clinician when a tear is being classified. If possible, a second, experienced clinician should be available during assessment to confirm the classification of the tear.

What the standard says

When a woman has a third or fourth degree perineal tear, it is promptly repaired by an appropriately trained and experienced clinician, in a suitable environment.

What the quality statement means for health service organisations

Ensure that policies, procedures and protocols for the repair of third and fourth degree perineal tears are consistent with current evidence-based guidelines.

Ensure that clinicians undertaking repairs are trained and credentialed in accordance with professional standards, and are working within their scope of clinical practice.

Ensure that operating theatre policies and protocols enable timely repair of third and fourth degree perineal tears or timely transfer to an appropriate facility and allow for the woman’s baby and support person to be present during the repair whenever possible.

What the standard says

After repair of a third or fourth degree perineal tear, a woman receives postoperative care that includes the opportunity for debriefing, physiotherapy and psychosocial support.

What the quality statements mean for health service organisations

Ensure that policies, procedures and protocols support clinicians to provide appropriate postoperative care including access to services such as debriefing, physiotherapy, and psychosocial support services.

Ensure discharge policies support appropriate follow-up post-discharge.

What the standard says

A woman with a third or fourth degree perineal tear receives individualised continuity of care and appropriate follow-up and referral to optimise her ongoing physical, emotional, psychological and sexual health.

What the quality statements mean for health service organisations

Ensure that policies, procedures, protocols and referral pathways promote comprehensive care, using a multidisciplinary team-based approach. This should include access to services appropriate for women with third and fourth degree perineal tears, including physiotherapy for pelvic floor rehabilitation, continence management, psychological support and surgical expertise, including in specialised multidisciplinary clinics. A discharge summary should be forwarded to the woman’s general practitioner, which details the follow-up care and referrals needed.