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Prevention of 3rd and 4th Degree tears 2013

February 9, 2013

I attended a marvelous study yesterday in Plymouth(OASIS – Obstetric Anal Sphincter Injury)  and I feel inspired to share with the world about the evidence that was presented there on reducing the number of third and fourth degree tears at birth.

Suffering such a tear can lead to extraordinary long-term debilitating problems for women. Although many women have no long-term effects, some have issues with the  control of their bowels for the rest of their lives. It effects their home life, social life and careers. If we can prevent just one it would be worth it.

The evidence presented by Dr Katariina Laine ( Consultant Obstetrician Oslo)  showed a dramatic 50% reduction in the incidence of 3rd and 4th degree tears by the re-introduction of routine medio-lateral episiotomy for instrumental birth and a hands on technique for normal birth. Derriford Hospital in Plymouth had also shown a reduction in their rates following introduction of her methods. Results had been presented on the previous study day to midwives. I may revisit these in a future blog.

Since the HOOP(Hands on or poised) trial in 1998 we may have gone too far down the route of allowing uncontrolled births and subsequent third/fourth degree tears.   I think it is time to re-think and present this new evidence to women and give them an informed choice about a technique that may prevent distressing  long-term sequelae.  This conclusion was already presented by Jo Garcia (BMJ 1999) “In the light of the evidence from this study, a policy of hands poised care is not recommended”

The average incidence of third and fourth degree tears is 3-3.9 %.in the UK (RCOG 2007) For a unit with 7000 births per year – this is 273 women.

The women at risk are women with large babies, epidural, instrumental delivery, .  At the very least we should aim the new approach at these women at higher risk.

The other issue was the controversial topic of diagnosis. It was recommended that any women who had a vaginal delivery should be assessed to ensure the anal sphincter has suffered no damage during the delivery. Early and excellent repair has been shown to prevent many long-term issues.

To examine a woman with a working epidural would be easy and comfortable for the woman.  To ask another woman to get out the pool where she has just had a wonderful waterbirth with no analgesia may be more challenging.  I am sure however that she will thank you if you identify and ensure appropriate repair to  prevent potential  long-term uncontrolled diarrhoea.  Many women seen by colorectal surgeons are women whose severe tear was not recognised at birth.

It is time to step back in to the birth to use our midwifery skills to make it the best experience it can be whilst preventing a known risk.

The other practise that has been shown to help in the prevention of perineal tears in perineal massage “once or twice a week from 35wks  in the weeks prior to birth.  Beckman and Garret (2009)

Me,  I am hands-on and have been for 25 yrs. It was how I was trained and I am loathe to let go though can at waterbirths.

I am aware of two births in my practise that have resulted in severe tears. I can honestly say I probably did not examine all my ladies as well as I could so may have missed some. Guess what – I will in future with their informed consent.

The other thing I did yesterday was create a 4th degree in tear in a pigs bottom and then attempted with help to put it back together. My colleagues on the day were all medical staff.   It made me realise how much I did not want a woman to got through this.  Better to save from a severe tear than have to repair it.

Look for forward to any comments.

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3 Responses to “Prevention of 3rd and 4th Degree tears 2013”

  1. macaroonlady Says:

    Refreshing read. How widely known do you think the latest studies are? My greatest fear as a Mum deciding whether to choose a vaginal birth after a previous 3c tear, is that the staff in attendance aren’t up to date. Should I be worried?


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