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Written on 10th January 2020 by Tara Pileggi-Byrne

According to The Royal College of Obstetricians and Gynaecologists (RCOG), up to 90% of women will suffer a vaginal or perineal tear/graze during childbirth. For most women, although painful at the time, the wounds heal without any long-term problems, however, for those who suffer more severe and extensive perineal tears, the consequences can be life-changing, including permanent bowel incontinence and perineal pain. 

Perineal tears can be classified depending on their severity. The most severe tears are third and fourth degree tears. According to the RCOG, third or fourth degree tears occur in 3% of women having a vaginal birth.

The symptoms associated with perineal tears are not openly discussed, as symptoms of bowel incontinence and flatulence can be embarrassing for women to talk about. Many women suffer without any support or remain unaware that their symptoms are not a common part of childbirth. A woman may be entitled to claim compensation where she is suffering from ongoing consequences of a third/fourth degree tear which was undiagnosed or incorrectly treated as a result of maternity or obstetric mistakes.

What is a perineal tear?

The area between the vagina and the anus is the perineum. During labour and childbirth there is a lot of pressure on the perineum and this sometimes results in tearing to the perineum as the baby is delivered.

Sometimes it is necessary for a doctor or midwife to make a cut in the perineum to allow the baby to be delivered and minimise the risk of an uncontrolled and severe tear. This is known as an episiotomy. Episiotomies are not routinely carried out and are not required in every birth.

How are different tears classified?

The RCOG’s Green Top guideline on the management of third and fourth degree tears classifies perineal tears according to their severity as follows:

  • First degree tear – injury to the perineal skin and/or vaginal mucosa;
  • Second degree tear – injury to perineum involving perineal muscles but not involving the anal sphincter;
  • Third degree tear – injury to the perineum involving the external and/or internal anal sphincters.
  • Fourth degree tear – injury to the perineum involving the external and/or internal anal sphincters and anorectal mucosa.

Third and fourth degree tears are the most severe as they involve the internal and external anal sphincters, causing impaired bowel function.

What are the symptoms of a third or fourth degree tear?

 From a physical perspective, third and fourth degree tears are painful. They require suturing (stitching) and take time to heal. Sitting and passing urine become painful. Third and fourth degree tears can lead to bladder but more often, bowel problems including incontinence, urgency and flatulence. These bowel problems often resolve but can be permanent. There is also a risk of infection to the wound.

Sometimes a fistula (hole) can develop between the anus and the vagina after the tear has healed and this may require surgery. Scar tissue can develop once the tear has healed. The scar tissue can be itchy and raised and this can be uncomfortable.

In very severe cases, a woman may need multiple procedures to suture the area and may even need a colostomy which diverts part of the bowel through an opening in the abdomen.

It is possible to have a further vaginal birth after suffering a third or fourth degree tear, although in circumstances where a woman is suffering with ongoing symptoms, she may choose to give birth by caesarean section.

It is important to recognise that severe life-changing and very personal physical injury also has a psychological impact on the sufferer. Pain and/or incontinence, can affect social, sexual and intimate relationships. They may find it difficult to talk about the symptoms with a partner. Women may become isolated from friends, co-workers and family as they feel unable to leave the home.

Do I have a case?

It is not always possible to avoid these severe tears as they happen spontaneously during the birth and cannot be predicted. There are certain factors which may make a woman more prone to suffering a tear and these include:

  • first time pregnancies;
  • women of South Asian origin;
  • multiple births;
  • a birth weight greater than 4kg;
  • a prolonged second stage of labour;
  • instrumental delivery (involving forceps or Ventouse.)

Boyes Turner’s obstetric negligence specialists have secured compensation for clients in cases where severe tears should have been avoided, such as negligent performance of an episiotomy, or where a severe tear is misdiagnosed, incorrectly sutured or surgical treatment takes place too late to avoid permanent injury. A third or fourth degree tear requires timely suturing in theatre. In cases of delay, a woman may need more than one repair surgery and may require further treatment such as biofeedback treatment and/or sacral nerve stimulation.

How much compensation will I receive?

If we are able to establish that a client has received negligent treatment resulting in a third or fourth degree tear or in providing treatment for a third or fourth degree tear which has caused serious injury, our client will be entitled to claim compensation for her injuries and consequential financial losses.

The amount of compensation that can be claimed will depend on the circumstances of each individual case and the effect of the injuries on our client.

In cases involving obstetric injury, we have helped clients recover compensation for:

  • pain, suffering and loss of amenity suffered as a result of the injury;
  • the costs of therapies, such as counselling and specialist physiotherapy;
  • the costs of medication or private health care, including further surgery or treatment;
  • the costs of travel expenses to and from GP or hospital appointments;
  • loss of earnings;
  • miscellaneous expenses such as replacement clothing, bedding, incontinence pads and laundry;
  • the costs of adaptations to the home, for example, the creation of an en-suite/additional bathroom;
  • the costs of domestic assistance/help with childcare.

Nursing and Midwifery Council’s – Future Midwifery Standards

On 3 October 2019, the Nursing and Midwifery Council approved the ‘Future Midwifery Standards’ which are due to take effect from 31 January 2020. The Standards will replace the current standards which have been in place since 2009.

The new standard will include guidance on perianal tears, which is not included in the current standard, and guidance on midwife’s role in suturing of episiotomy, repairs of 1st and 2nd degree perianal tears and referring a woman on for further treatment if there has been additional trauma.

Boyes Turner welcome the new standards in the hope that this will lead to an increased awareness and recognition of the importance of correct classification and treatment of perineal birth injuries and reduce the numbers of women who suffer avoidable but permanent harm.

If you have suffered severe injury from medical negligence and would like to find out more about making a claim, contact by email at