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RCOG release: Updated guidance on the diagnosis, management and treatment of third- and fourth- degree perineal tears

News 12 June 2015

Early identification and appropriate repair of severe perineal tearing is vital in reducing the physical and mental impact of these injuries, according to updated guidelines published today by the Royal College of Obstetricians and Gynaecologists (RCOG).

Approximately 90% of women tear to some extent during childbirth, however, in some women the tear may be more extensive. A third-degree tear extends downwards from the vaginal wall and perineum to the anal sphincter, (the muscle that controls the bowel opening) and a fourth-degree tear extends to the lining of the anal canal.

In England, the rate of reported severe perineal tears has tripled from 1.8% to 5.9% between 2000 and 2012.The overall incidence in the UK is 2.9% and 6.1% in first time mothers compared to 1.7% in women who have previously given birth.

This trend towards an increasing incidence of third or fourth degree perineal tears does not necessarily indicate poor-quality care. Tearing is a complex issue which could be influenced by a range of factors including; advanced maternal age at first birth, larger maternal BMI and birth weight of the baby, instrumental delivery and better detection and reporting.

This guideline provides evidence-based advice for healthcare professionals on the diagnosis, management and treatment of third- and fourth- degree perineal tears. RCOG Patient Information on the topic has also been published today.

The guideline emphasises that clinicians must be aware of the risk factors for severe tearing which include; Asian ethnicity, first time motherhood, large birth weight, shoulder dystocia, prolonged labour and instrumental delivery.

However, these risk factors do not always allow the accurate prediction of severe tearing. There is therefore a need for early recognition of anal sphincter damage among clinicians as well as appropriate training in repair methods as a poor technique or poor selection of materials may cause a repair to be unsuccessful.

Additionally, women who have suffered a third- or fourth- degree perineal tear in a previous pregnancy should be counselled about the risks of further tearing in a subsequent delivery and the option of elective caesarean section should be discussed.

Dr Manish Gupta, Co-Chair of the RCOG Guideline Committee said:

“With increased awareness and training, there appears to be an increase in detection of more extensive tearing, it does not mean women are receiving substandard quality of care.

“Obstetricians who are appropriately trained are more likely to provide a consistent, high standard of repair and contribute to reducing the extent of morbidity associated with such injuries.”

Mr Ruwan Fernando, lead author of the guideline said:

“Severe tearing can affect many aspects of a woman’s life longer term, including her physical and mental health, as well as future pregnancies.

“Currently, there is a need for further research regarding the optimal mode of delivery following third- or fourth- degree perineal tears in a subsequent pregnancy. Clear documentation, including drawings, together with providing women with a clear explanation of the possible delivery options and associated risks are therefore extremely important.”


For further information, please contact the RCOG Media and PR team on +44 20 7772 6300 or email

This is the third edition of this guideline, which was previously published in July 2001 and March 2007.