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 examines the proportion of third and fourth degree tears among all women who gave birth vaginally, and among all vaginal first births.
Key findings
In 2023, 4.6% of women giving birth for the first time and giving birth vaginally, and 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 over time for vaginal first births while decreasing slightly from 5.2% in 2013 to 4.6% in 2023
- has fluctuated around 3% for all vaginal births over time (3.0% in 2013 and 2.7% in 2023)
- was highest in women born in Southern and Central Asia (5.7% in 2023) and South-East Asia (4.1% in 2023) for all vaginal births
- was higher for instrumental vaginal births (5.3% in 2023) compared with non-instrumental vaginal births (2.2% in 2023) for all vaginal births
- was highest in women aged 25–29 (3.2% in 2023) and lowest in women aged 40 and over (1.4% in 2023) 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. Use the drop-down menus to view data by selected characteristics and the latest year button to explore data for 2023.
Figure 15: Third and fourth degree tears
This data visualisation presents data on third and fourth degree tears. Interactive charts show proportions for the most recent data and over time, for selected demographic and birth characteristics.
Clinical commentary
Severe perineal trauma is defined as a third degree tear, which involves injury to the perineum that extends to the anal sphincter muscles; or a fourth degree tear that 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 (ACSQHC 2021b; RCOG 2015). 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 2021b; OECD 2021). Internationally, Australia’s rates of third and fourth degree tears were higher than the OECD averages of 1.4 per 100 non-instrumental vaginal deliveries, and 5.3 per 100 instrumental vaginal deliveries, for 2019 or the nearest year (OECD 2021). Variation between countries is likely to be affected by differences in clinical practice and reporting (ACSQHC 2017).
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).
Indicator specifications and data
Excel source data tables are available from Data.
For more information, refer to Data specifications and Methods.
ACSQHC (2017) The second Australian atlas of healthcare variation, ACSQHC, Australian Government, accessed 2 March 2023.
ACSQHC (2021b) Third and fourth degree perineal tears clinical care standard, ACSQHC, Australian Government, accessed 17 August 2022.
Dahlen H, Priddis 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 (2021) Health at a glance 2021: OECD indicators, OECD Publishing, Paris, accessed 6 June 2023.
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 (2015) The Management of Third- and Fourth-degree Perineal Tears: Green-top Guideline no. 29, RCOG, accessed 6 October 2021.