Geburtshilfe Frauenheilkd 2023; 83(02): 165-183
DOI: 10.1055/a-1933-2647
GebFra Science

Management of Third and Fourth-Degree Perineal Tears After Vaginal Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/079, December 2020)

Article in several languages: English | deutsch
Stephan Kropshofer
1   Frauenheilkunde und Geburtshilfe, Tirol Kliniken GmbH, Innsbruck, Austria
Thomas Aigmüller
2   Leoben Regional Hospital, Leoben, Austria
Kathrin Beilecke
3   Klinik für Urogynäkologie, Alexianer Sankt Hedwig Kliniken Berlin GmbH, Berlin, Germany
Andrea Frudinger
4   Department of Gynecology, Medical University of Graz, Graz, Austria
Ksenia Krögler-Halpern
5   Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
Engelbert Hanzal
5   Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
Hanns Helmer
6   Department of Obstetrics and Maternal-fetal Medicine, Medical University of Vienna, Vienna, Austria
Susanne Hölbfer
7   Wiener Gesundheitsverbund, Vienna, Austria
Hansjoerg Huemer
8   Frauenklinik, Bethesda Spital Basel, Basel, Switzerland
MoenieDer Kleyn Van
9   Midwivery, University of applied sciences, Graz, Austria
Irmgard Kronberger
10   Visceral- und Thoraxchirurgie, Tirol Kliniken GmbH, Innsbruck, Austria
Annette Kuhn
11   Urogynaecology, Inselspital Universitatsspital Bern, Bern, Switzerland
Johann Pfeifer
12   Department of Surgery, Medical University of Graz, Graz, Austria
Christl Reisenauer
13   Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
Karl Tamussino
4   Department of Gynecology, Medical University of Graz, Graz, Austria
Wolfgang Umek
5   Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
Dieter Kölle
14   Abteilung Gynäkologie, Sanatorium Hera, Vienna, Austria
Michael Abou-Dakn
15   Klinik für Gynäkologie, St Joseph Krankenhaus Berlin-Tempelhof, Berlin, Germany
Boris Gabriel
16   Klinik für Gynäkologie und Geburtshilfe, Josefs Hospital Wiesbaden, Wiesbaden, Germany
Oliver Schwandner
17   Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
Gunda Pristauz-Telsnigg
18   Abteilung Frauenheilkunde und Geburtshilfe, Landeskrankenhaus Feldbach Fürstenfeld, Feldbach, Austria
Petra Welskop
19   Österreichisches Hebammengremium, Innsbruck, Austria
Werner Bader
20   Gynäkologie und Geburtshilfe, Klinikum Bielefeld, Bielefeld, Germany
› Author Affiliations


Purpose This guideline provides recommendations for the diagnosis, treatment and follow-up care of 3rd and 4th degree perineal tears which occur during vaginal birth. The aim is to improve the management of 3rd and 4th degree perineal tears and reduce the immediate and long-term damage. The guideline is intended for midwives, obstetricians and physicians involved in caring for high-grade perineal tears.

Methods A selective search of the literature was carried out. Consensus about the recommendations and statements was achieved as part of a structured process during a consensus conference with neutral moderation.

Recommendations After every vaginal birth, a careful inspection and/or palpation by the obstetrician and/or the midwife must be carried out to exclude a 3rd or 4th degree perineal tear. Vaginal and anorectal palpation is essential to assess the extent of birth trauma. The surgical team must also include a specialist physician with the appropriate expertise (preferably an obstetrician or a gynecologist or a specialist for coloproctology) who must be on call. In exceptional cases, treatment may also be delayed for up to 12 hours postpartum to ensure that a specialist is available to treat the individual layers affected by trauma. As neither the end-to-end technique nor the overlapping technique have been found to offer better results for the management of tears of the external anal sphincter, the surgeon must use the method with which he/she is most familiar. Creation of a bowel stoma during primary management of a perineal tear is not indicated. Daily cleaning of the area under running water is recommended, particularly after bowel movements. Cleaning may be carried out either by rinsing or alternate cold and warm water douches. Therapy should also include the postoperative use of laxatives over a period of at least 2 weeks. The patient must be informed about the impact of the injury on subsequent births as well as the possibility of anal incontinence.

Publication History

Received: 17 August 2022

Accepted after revision: 23 August 2022

Article published online:
07 December 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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