SDMS ID: P2010/0308-001 3.

8-07WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: To correctly recognise and classify third and fourth degree perineal trauma, provide information to prevent infection, ensure adequate pain relief and postnatal follow up after discharge. Definition: Third degree tear involves the external anal sphincter (EAS) and internal anal sphincter (IAS). 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn Fourth degree tear involves the anal sphincter (EAS and IAS) and rectal mucosa. Risk Factors First vaginal birth Prolonged second stage Assisted vaginal delivery Birthweight > 4kg Midline episiotomy Management All women having a vaginal birth should have a systematic examination of the perineum, vagina and rectum to assess the severity of damage prior to suturing. An appropriately skilled operator should carry out repair of extensive tears in the operating theatre under regional or general anaesthesia. Post Repair Management Ice therapy to decrease swelling for the first 48 hours. Apply an ice pack in a sanitary pad to perineum for 20 minutes every 3 to 4 hours. Positioning to reduce oedema encourage horizontal position 24 to 48 hours post repair. Adequate analgesia such as non-steroidal anti-inflammatory agents and paracetamol. Avoid analgesia containing codeine. Rectal analgesia should be avoided. Consider the use of broad-spectrum prophylactic antibiotics for 3 to 5 days.
Third and Fourth Degree Tears May-11 Page 1 WACS Clinproc3.8

Management of Third and Fourth Degree Tears

New Policy Management of third and fourth degree perineal tears Midwifery and Medical Staff, Queen Victoria Maternity Unit Third degree tear, fourth degree tear

Stool softeners (Lactulose) or bulking agents (Fybogel) should be used for at least 7 to 10 days, as constipation must be avoided. Inpatient physiotherapist review pelvic floor contraction should be delayed until 3 to 4 weeks for tissue healing. Monitor bladder sensation - risk of urinary retention Information sheet to be distributed to woman. Education on measures to promote healing. Debriefing and planning for next birth. Discharge planning Postnatal follow up appointment in six weeks in gynaecology clinic. Outpatient appointment with physiotherapist. Vaginal Birth Following Previous Third and Fourth Degree Tears Women with previous third and fourth degree tears should be informed that their risk of severe perineal trauma is not increased in a subsequent birth, compared to women having their first baby. In order for women to make an informed choice regarding previous significant perineal injury or trauma, a plan of management should be discussed and documented in the antenatal period. This discussion should address: o current continence symptoms o the degree of previous trauma o risk of recurrence o the success of the previous repair o the psychological effect of the previous trauma o management of labour. Episiotomy should not be routinely offered at vaginal birth following previous third or fourth degree trauma. Attachments
Attachment 1 Attachment 2 Background Information References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services Date: _________________________

Third and Fourth Degree Tears May-11 Page 2

WACS Clinproc3.8

APPENDIX 1 Background Information: Clinically detectable anal sphincter lacerations are identified in less than 0.5 3% of vaginal births. With the use and availability of endoanal ultrasound, occult damage to the anal sphincter has been identified in up to 36% of women. A previous third degree tear poses a small increased risk of a repeat third degree tear in a subsequent vaginal birth. However the small number of studies available limits this information. If a third degree tear has resulted in some residual sphincter defect or dysfunction, then a subsequent vaginal birth appears to cause a worsening of symptoms. Currently there is no consistent evidence that women whose tears have fully healed and who have no symptoms of anal dysfunction are at increased risk of long-term incontinence if they have a subsequent vaginal birth. In subsequent births fourth degree tears are associated with a higher incidence of bowel incontinence then third degree tears. Women experiencing ongoing anal symptoms following repair of third and fourth degree tears range from 25 to 57%. Leakage of faeces occurs in 8% of women and incontinence of flatus in 30%. Postnatal Assessment Postnatal assessment by a colorectal surgeon is recommended for assessment of symptoms, endoanal ultrasound and manometry. The results of this assessment can be then be assessed in planning for future births.

Third and Fourth Degree Tears May-11

Page 1

WACS Clinproc3.8

APPENDIX 2 REFERENCES King Edward Memorial Hospital Clinical Guidelines 2006 Management of third and fourth degree perineal trauma. Online: http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm Royal College of Obstetricians and Gynaecologist Guideline No 29 2001 Management of third- and fourth-degree perineal tears following vaginal delivery. Online: http://www.rcog.org.uk/index.asp?PageID=532 Royal Womens Hospital Clinical Practice Guidelines 2005 Management of third and fourth degree tears. Online: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3650

Third and Fourth Degree Tears May-11

Page 1

WACS Clinproc3.8