​ Third and fourth degree tears during labour

August 12, 2017

90% of women sustain a perineal tear during labour.  The perineum is the area separating the vagina from the anus.  Tearing is normal, but the consequences that some women suffer from an undiagnosed and untreated tear can be catastrophic such as incontinence, pain and painful intercourse. Many women, and especially first time mothers, do not realise that the symptoms that they are suffering are due to a missed or incorrectly repaired tear.  They are told that their symptoms are just a normal consequence of child birth.

Types of perineal tear:

First-degree tear: this is a simple tear of the skin and tissue of the vagina.

Second-degree tear: A tear that goes beyond the skin and tissue of the vagina into the muscle but not into the anal sphincter.

Third-degree tear: This is a tear to the skin, muscles and anal sphincter.  These tears are further categorised as:

3a: partial tear of the external anal sphincter involving less than 50% thickness

3b: greater than 50% tear of the external anal sphincter

3c: internal sphincter is torn

Fourth-degree tear: perineal skin, vaginal tissue, muscles, anal sphincter, and rectal tissue are torn

Rectal buttonhole tear: Where the tear involves the rectal tissue with an intact anal sphincter. If not recognised and repaired, this type of tear may lead to a rectovaginal fistula (a hole between the rectum and the vagina).

Can tears be predicted? What should be done following your birth to detect a tear and how should it be repaired?

New Green top guidance was issued by the Royal College of Obstetricians and Gynaecologists in June 2015, for the prediction, diagnosis, treatment and management of 3rd and 4th degree tears.

The following risk factors have been identified, in relation to the risk of sustaining 3rd or 4th degree tears:-

Being of Asian ethnicity; Being a First time mum; Child having a birthweight greater than 4 kgs; Births involving shoulder dystocia (baby’s shoulder getting stuck in birth canal); Births involving the occipito-posterior position (baby’s head facing mum’s spine); a prolonged second stage of labour; a birth involving the use of forceps or ventous (suction cup); a delivery with or without episiotomy (being cut).

If these risks are present then the guidance suggests that, with consent, a visual and digital examination should take place, exploring both the vagina and the anus to assess the extent of the damage.

If a 3rd or 4th degree tear is present surgery should take place soon after to repair it.  This is what is known as a primary repair.  Primary repairs have a good prognosis and it is likely that in the longer term you will not suffer from incontinence.

If the tear is not diagnosed and treated soon after it has occurred, usually within 2 weeks, it will not heal as well as it would if primary repair has taken place. You may be encouraged to have what is called  a secondary repair, the success rates for which are much lower than for a primary repair and usually result in long term incontinence of faeces and flatus.  You may alternatively be treated by way of sacral nerve stimulation which promotes continence, but has other drawbacks.

If you feel that you have suffered from a misdiagnosed tear or that your tear should have been treated more quickly, please get in touch with us for a considerate, discrete and sensitive appraisal of your claim. Here at Metcalfes we deal with all areas of medical negligence, including maternal birth injuries. If you think that you or a loved one has suffered as a result of medical negligence or are concerned with the quality of care and treatment they are now receiving, we may be able to help. Please contact us on 0117 239 8012.  Alternatively, you can email us by using our online contact form and we will be happy to discuss your potential claim with you.

Further Reading:

Website content note: This is not legal advice; it is intended to provide information of general interest about current legal issues.

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​  Third and fourth degree tears during labour

Gillian Clark

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