• Australian Commission on Safety and Quality in Health Care, Standard 20/04/2021

The Australian Commission on Safety and Quality in Health Care has developed these indicators to support healthcare providers and local health services to monitor how well they implement the care described in the Third and Fourth Degree Perineal Tears Clinical Care Standard (ACSQHC 2021). The indicators included in this specification are a tool to support local clinical quality improvement and may be used to support other quality assurance and peer review activities. 

The indicators apply to all woman who have a vaginal birth.  Health services may choose to apply the indicators to a sub-set of the patient population based on the availability of hospital-level data and the focus of local clinical quality improvement activities.

The Third and Fourth Degree Perineal Tears clinical care standard applies to all pregnant women who are planning a vaginal birth, and to women who experience a third or fourth degree perineal tear. It applies to care provided during pregnancy, labour, birth and the postpartum period, as well as post-operative and longer-term follow-up care.

This standard applies to care provided in the following settings:

• Private obstetric (specialist) care
• Private midwifery care
• Care provided by general practitioners (GPs) and GP obstetricians
• Public hospital maternity and high-risk maternity care, including continuity of care models
• Remote area maternity care
• Community and home-based care
• Postnatal clinics specialising in the treatment of third and fourth degree perineal tears.

A clinical care standard is a small number of quality statements that describe the clinical care that a patient should be offered for a specific clinical condition.

This standard aims to reduce unwarranted clinical variation in rates of third or fourth degree perineal tears. It also aims to ensure that women who experience a third or fourth degree perineal tear receive appropriate care to optimise their physical and psychological recovery.

The term ‘clinician’ refers to all types of health professionals who provide direct clinical care to women before, during and after birth including:

• Aboriginal and Torres Strait Islander health workers
• Doctors (including obstetricians, gynaecologists, GPs and GP obstetricians, and colorectal surgeons)
• Midwives
• Nurses (including specialist continence nurses and women’s health nurses)
• Physiotherapists
• Psychologists.

The quality statements that are included in the Third and Fourth Degree Perineal Tears clinical care standard are as follows:

1. Information, shared decision making and informed consent. During the antenatal period, a woman is informed about the risk for a third or fourth degree perineal tear. Throughout pregnancy, labour and birth she is supported to make decisions and provide informed consent for the care she receives.
2. Reducing risk during pregnancy, labour and birth. A woman choosing a vaginal birth is offered evidence-based care to reduce her risk of a third or fourth degree perineal tear.
3.  Instrumental vaginal birth-When intervention is indicated in a vaginal birth, the choice of intervention is based on the clinical situation, the benefits and risks of each option and discussion with the woman.
4. Identifying third and fourth degree perineal tears. After a vaginal birth, a woman is offered examination by an appropriately trained clinician to exclude the possibility of a third or fourth degree perineal tear. A tear is classified using the Royal College of Obstetricians and Gynaecologists classification and is documented in the woman’s healthcare record.
5. Repairing third and fourth degree perineal tears. When a woman has a third or fourth degree perineal tear, it is promptly repaired by an appropriately trained and experienced clinician, in a suitable environment.
6. Postoperative care. After repair of a third or fourth degree perineal tear, a woman receives postoperative care that includes the opportunity for debriefing, physiotherapy and psychosocial support.
7. Follow-up care post-discharge. A woman with a third or fourth degree perineal tear receives individualised continuity of care and appropriate follow-up and referral to optimise her ongoing physical, emotional, psychological and sexual health.