Index

Recent
{{a.title}}

Perineal Tears

RCOG Green-top Guideline No.29 The Management of Third- and Fourth-Degree Perineal Tears. Jun 2015.

Background Information

Classification system adopted by the RCOG and International Consultation on Incontinence:

Degree of Tear	Definition (involved structure in injury)
1st	Perineal skin and/or vaginal mucosa
2nd	Perineal muscle ONLY (not anal sphincter)
3rd	Anal sphincter complex ONLY 3a: <50% of EASExternal anal sphincter thickness torn 3b: >50% of EASExternal anal sphincter thickness torn 3c: both EASExternal anal sphincter and IASInternal anal sphincter torn
4th	Anal sphincter complex (EASExternal anal sphincter + IASInternal anal sphincter) and anorectal mucosa

Obstetric anal sphincter injuries (OASIS): encompass both 3rd and 4th degree perineal tears

Risk factors outlined by the RCOG guidelines:

Asian ethnicity
Nulliparity
Birthweight >4 kg
Shoulder dystocia
Occipito-posterior position
Prolonged secondary stage of labour
Instrumental delivery (esp. without episiotomy)

Guidelines

RCOG recommends the following points to prevent :

If episiotomy indicated → mediolateral technique (60 degrees away from midline)
Instrumental deliveries → consider mediolateral episiotomy

Interventions at stage 2 labour:
- Perineal protection at crowning
- Warm compression

RCOG recommends that all women having a vaginal delivery should be examined systemically, including a digital rectal examination, as they are at risk of OASIS or isolated rectal buttonhole tears.

3rd and 4th degree tears (OASIS) should be repaired in operating theratre (under GA / LA) by a trained clinician.

Other points:

If there is excessive bleeding → vaginal packing and take to theatre ASAP

Perform digital rectal examination after the repair to ensure sutures have not been inserted through the anorectal mucosa
Broad spectrum antibiotics (to reduce risk of infection and wound dehiscence)
Laxatives (to reduce risk of wound dehiscence)
- Do not routinely give bulking agents with laxatives
Review 6-12 weeks postpartum + physiotherapy

References

Author: Adams Lau
Reviewer:
Last Edited: 03/03/25

1. By accessing or using this website, you agree to comply with and be bound by these terms and conditions. If you do not agree with any part of these terms and conditions, you must not use this website.

2. Use of the website: This website is for informational and educational purposes only and is intended for medical professionals. You agree to use the website in a lawful manner and to refrain from activities that may disrupt its functionality or compromise its security.

3. Intellectual property: All content on this website, including but not limited to text, graphics, logos, images, and code, is the property of Guideline Genius LTD unless otherwise stated. Unauthorised reproduction, distribution, or use of the website's content is strictly prohibited without prior written consent.

4. Subscriptions and payments: Certain sections of the website may require a subscription for access. By subscribing, you agree to pay any fees specified during the subscription process. All fees are non-refundable unless otherwise specified.

5. Accuracy and updates: While we strive to ensure the accuracy of the information on this website, we do not guarantee that the content is error-free or up-to-date. Guideline Genius LTD reserves the right to modify or update the content of this website at any time without prior notice.

6. Third-party links: This website may contain links to third-party websites for your convenience. Guideline Genius LTD is not responsible for the content, accuracy, or availability of these external sites.

7. Disclaimer of liability: Guideline Genius LTD disclaims any liability for damages resulting from the use of or reliance on this website or its content. Your use of the website is at your own risk, and we shall not be held liable for any direct, indirect, or consequential damages.

8. Termination: We reserve the right to terminate your access to the website at our discretion, without notice, for any breach of these terms.

9. Governing law: These terms and conditions shall be governed by and construed in accordance with the laws of England and Wales.

Medical disclaimer

1. No advocacy or endorsement: Guideline Genius LTD does not advocate or endorse the use of any specific drug, therapy, medical intervention, or any other content mentioned on this website, including but not limited to diagnostic tools, procedures, or treatment recommendations. All content is for informational and educational purposes only and does not constitute medical advice or diagnosis.

2. Professional responsibility: As a medical professional, you retain full responsibility for the care and treatment of your patients. You should use your own clinical judgment, expertise, and knowledge of local regulations when interpreting and applying the information provided on this website.

3. Scope of information: This content does not aim to cover all possible diagnostic methods, treatments, follow-up protocols, drugs, contraindications, or side effects. Medical standards and practices evolve as new data become available, and we strongly recommend consulting multiple reputable sources to validate the information provided.

4. Verification of information: You are advised to independently verify all diagnoses, treatments, and follow-up plans to ensure they are appropriate for your patient and compliant with the regulations in your region. When dealing with prescription medication, always consult the product information sheet and the British National Formulary to verify conditions of use, dosage schedules, indications, forms of administration, adverse effects, contraindications, cautions, and any circumstances under which the medication should be avoided.

5. Accuracy and updates: Information on this website is provided on an "as is" basis without representations, warranties, or conditions regarding its accuracy, completeness, or timeliness. While we strive to provide up-to-date content, Guideline Genius LTD and its contributors do not guarantee the information will always reflect the latest medical standards or practices.

6. Liability disclaimer: To the fullest extent permitted by law, Guideline Genius LTD disclaims all liability for any loss, injury, or damage arising from the use of this website's content. All implied warranties and conditions, including those of satisfactory quality, fitness for a particular purpose, and use of reasonable care and skill, are excluded.

7. Local guidelines: Where regional or local guidelines are applicable, users should refer to those resources for contextually relevant information. Guideline Genius LTD disclaims all liability for reliance on content not specifically aligned with your local medical guidelines or practices.

8. Emergency situations: In case of a medical emergency, contact your local emergency services or healthcare provider immediately.