Perineal Tears
RCOG Green-top Guideline No.29 The Management of Third- and Fourth-Degree Perineal Tears. Jun 2015.
NICE guideline [NG235] Intrapartum care. Last updated: Nov 2025.
More specific management of 1st/2nd degree perineal tears added (18/11/2025).
Background Information
Classification
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
|
| 4th | Anal sphincter complex (EAS + IAS) PLUS anorectal mucosa |
Obstetric anal sphincter injuries (OASIS): encompass both 3rd and 4th degree perineal tears
Risk Factors
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
Prevention
RCOG recommends the following points to prevent OASIS:
- 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
Detection and Diagnosis
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 button hole tears.
Management
1st and 2nd Degree Tears
1st and 2nd degree tears can be managed in the labour/delivery suite (operating theatre not routinely required)
- Ensure adequate analgesia
- Suturing (under LA)
- 1st degree → skin suturing is typically indicated to improve healing, unless the skin edges are well opposed
- 2nd degree → perineal muscle suturing is indicated
3rd and 4th degree tears
3rd and 4th degree tears (OASIS) should be repaired in the operating theatre (under GA / LA) by a trained clinician
- If there is excessive bleeding → vaginal packing and take to theatre ASAP
Post-repair management (only applies ot 3rd and 4th degree tears):
- Perform a 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