Third and fourth degree tears
A perineal tear is the laceration of the skin and tissues that separate the vagina from the anus. Third or fourth degree tears are classified as severe trauma to the perineum and can occur spontaneously or as a result of obstetric intervention during vaginal birth. For more information, see Clinical commentary.
This indicator looks at the proportion of third and fourth degree tears among all women who gave birth vaginally, and among all vaginal first births.
- 4.5% of women giving birth for the first time and giving birth vaginally experienced a third or fourth degree tear
- 2.7% of all women giving birth vaginally experienced a third or fourth degree tear.
The proportion of third and fourth degree tears among women giving birth vaginally:
- has fluctuated around 5% between 2013 (5.2%) and 2021 (4.5%) for vaginal first births, and has remained fairly stable for all vaginal births during this time (3.0% in 2013 and 2.7% in 2021)
- was higher for women giving birth in public hospitals than private hospitals (5.0% compared with 2.5% for all vaginal first births in 2021)
- was highest in women aged 25–29 (3.1% in 2021) and lowest in women aged 40 and over (1.7% in 2021) for all vaginal births.
The interactive data visualisation (Figure 15) presents data on third and fourth degree tears for all vaginal births and all vaginal first births by selected maternal characteristics. Select the trend button to see how data have changed between 2013 and 2021.
Figure 15: Third and fourth degree tears
Third and fourth degree tears for all vaginal first births, 2013 to 2021.
This chart shows the proportion of third and fourth degree tears for all vaginal first births, for the current data 2021 and trend data from 2013 to 2021. The proportion of third and fourth degree tears for all vaginal first births, for all Australia, has fluctuated around 5% with 5.2% in 2013 and 4.5% in 2021. The chart also shows data for third and fourth degree tears for all vaginal births. The proportion of third and fourth degree tears for all vaginal births, in Australia, has remained fairly stable with 3.0% in 2013 and 2.7% in 2021.
Severe perineal trauma is defined as a third degree tear, which involves injury to the perineum which extends to the anal sphincter muscles; or a fourth degree tear, which involves injury to the perineum involving the external and internal sphincter and the anorectal epithelium (RCOG 2015). Severe trauma to the perineum can occur spontaneously or due to obstetric intervention during vaginal birth.
Severe perineal trauma is associated with maternal morbidity such as perineal pain, incontinence and subsequent difficult or painful sexual intercourse, and rarely, recto-vaginal fistula (RCOG 2015; ACSQHC 2021). The significant psychological effects of severe perineal trauma are under-researched but likely to be significant for many women in this situation (Priddis et al. 2013). While it may not always be possible to prevent these types of tears, the likelihood can be reduced through appropriate labour management and high-quality obstetric care (ACSQHC 2021, OECD 2021). Internationally, Australia's rate of third and fourth degree tears was higher than the average for OECD countries in 2019 or nearest year (OECD 2021). Variation between countries is likely to be affected by differences in clinical practice and reporting (ACSQHC 2018).
Risk factors during the antenatal period associated with an increased incidence of severe perineal trauma include nulliparity, young maternal age, ethnicity and poor nutritional status, high fetal weight, as well as previous experience of perineal tear (Dahlen et al. 2013). Intrapartum risk factors include fetal malpresentation (for example occipito-posterior position), episiotomy (especially midline), instrumental vaginal birth, prolonged second stage of labour, birth position and shoulder dystocia (Eskandar and Shet 2009; Hartman et al. 2005; Kudish et al. 2008; O'Mahony et al. 2010).
ACSQHC (Australian commission on Safety and Quality in Health Care) (2021) Third and fourth degree perineal tears clinical care standard, accessed 17 August 2022.
ACSQHC (Australian Commission on Safety and Quality in Health Care) (2018) The second Australian atlas of healthcare variation, accessed 2 March 2023.
Dahlen H, Proddis H, Schmied V, Sneddon A, Kettle C, Brown C and Thornton C (2013) ‘Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study’, British Medical Journal Open, 3(5): e002824, doi:10.1136/bmjopen-2013-002824
Eskandar O and Shet D (2009) ‘Risk factors for 3rd and 4th degree perineal tear’, Journal of Obstetrics and Gynaecology, 29:119–22, doi:10.1080/01443610802665090.
Hartman K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J and Lohr KN (2005) ‘Outcomes of routine episiotomy: a systematic review’, JAMA, 293:2141–8, doi:10.1001/jama.293.17.2141.
Kudish B, Sokol RJ and Kruger M (2008) ‘Trends in major modifiable risk factors for severe perineal trauma, 1996–2006’, International Journal of Gynaecology and Obstetrics, 102:165–70, doi:10.1016/j.ijgo.2008.02.017.
OECD (Organisation for Economic Co-operation and Development) (2019) Health at a glance 2021: OECD indicators, OECD Publishing, Paris.
O’Mahony F, Hofmeyr GJ and Menon V (2010) ‘Choice of instruments for assisted vaginal delivery’, Cochrane Database Systematic Review, 11:CD005455, doi:10.1002/14651858.CD005455.pub2.
Priddis H, Dahlen HG and Schmied V (2013) ‘Women’s experiences following severe perineal trauma: a meta-ethnographic synthesis’, Journal of Advanced Nursing, 64:748–59, doi:10.1111/jan.12005.
RCOG (The Royal College of Obstetricians and Gynaecologists) (2015) Green top guidelines: The management of Third- and Fourth-degree Perineal Tears: Green top guideline no. 29, accessed 6 October 2021.