Severe tears & pelvic floor injury
Was My Tear Missed? Signs a Third or Fourth Degree Tear Was Misdiagnosed
The short answer
If you were told you had a "small" or "second degree" tear, but you now have leaking wind, bowel urgency, soiling, or accidents, your tear may have involved the anal sphincter and been missed. After every vaginal birth, you should be offered a careful examination, including a rectal examination, specifically to look for this. A missed sphincter tear is one of the most common causes of lasting bowel problems after birth. It's also one of the clearer situations where a medical negligence claim may be possible. Below are the signs, what should have happened, and what to do next.
"They said it was just a small tear."
Someone stitched you up in the birth suite, maybe while you were holding your baby for the first time. You were told it was a second degree tear, or a graze, or "just a few stitches".
Then, weeks later, things weren't right. You couldn't hold in wind. You had to run to the toilet. There were marks in your underwear you couldn't explain. Maybe you had an accident, and sat on the bathroom floor feeling humiliated and frightened.
You might have mentioned it at your six-week check and been told it would settle. You might not have mentioned it at all, because who talks about this?
If your symptoms don't match what you were told about your tear, that mismatch matters.
Signs your tear may have been worse than you were told
None of these prove a tear was missed. But each is a reason to ask for a proper assessment.
- You can't control wind, or it escapes without warning
- Bowel urgency: when you need to go, you need to go now
- Soiling or staining in your underwear
- Accidents, with liquid or solid stool
- Wind or faeces passing from the vagina, which can be a sign of a fistula
- Pain or a gap near the back passage that doesn't heal as expected
- A feeling that the area is "different": thinner, misshapen, or not closing properly
I've written separately about one of the most common of these symptoms in "I can't control wind after birth".
The four degrees of tear, explained
| Degree | What's injured | In plain terms |
|---|---|---|
| First | Skin only | A graze or small skin tear |
| Second | Skin and perineal muscle | The most common tear needing stitches |
| Third (3a, 3b, 3c) | Extends into the anal sphincter, the muscle that controls your back passage | A serious injury that needs specialist repair |
| Fourth | Through the sphincter and into the lining of the bowel | The most severe tear |
Third and fourth degree tears are often called OASIS (obstetric anal sphincter injuries). The Royal Hospital for Women's perineal trauma guideline notes that more than 85% of women who give birth vaginally have some tearing. Most tears are first or second degree. But a third degree tear can look like a second degree tear on the surface, which is exactly why a careful check matters. NSW Health explains the degrees on its HealthStats perineal tears page.
What should have happened after the birth
This is where a missed tear becomes a question about care.
A careful examination, including a rectal exam.
Australia's national clinical care standard on identifying severe tears says that after a vaginal birth you should be offered an examination to check for these tears, including a rectal examination, with your consent. The Royal Hospital for Women's guideline describes a systematic examination in good light, with a rectal exam to exclude sphincter injury, and another after the repair.
Extra care when your risk was higher.
Some births carry a higher risk of severe tears: a first vaginal birth, a large baby, a long pushing stage, or an instrument birth. The college that sets standards for obstetricians, RANZCOG, notes in its instrumental birth statement that forceps carry a higher risk of severe tearing than vacuum. If you had forceps, a missed sphincter tear should have been actively looked for.
Repair by the right person, in the right place.
Severe tears should be repaired by an experienced doctor, usually in an operating theatre. The Royal Hospital for Women's third and fourth degree tear procedure requires theatre transfer for most severe tears. It sets out antibiotics, laxatives, physiotherapy referral, and follow-up at a specialist clinic at 4 weeks and 4 months.
If none of that happened, because your tear was never identified, you also missed the care that's designed to give a severe tear the best chance of healing well.
Why tears get missed
- No rectal examination was done, or it wasn't done properly
- Poor lighting, poor pain relief, or a rushed check after a difficult birth
- Swelling or bleeding made the injury hard to see
- The person examining didn't have enough experience with severe tears
- Symptoms afterwards were put down to "normal recovery"
That last point matters too. Being told repeatedly that your symptoms are normal, when they aren't, is something I've written about in "It's normal after a baby" and in when being dismissed by a doctor becomes a legal issue.
If this is landing for you, and you're realising your symptoms don't fit the tear you were told you had, I'd be glad to listen. No pressure, and no need to have it all worked out.
What to do now
1. Ask for a proper assessment.
Ask your GP for a referral to a urogynaecologist, colorectal surgeon, or hospital perineal clinic. An endoanal ultrasound can show whether the sphincter muscle has been torn, even years later. A pelvic health physiotherapist can also assess you. The Australian Physiotherapy Association's position statement on physical birth trauma describes the imaging used to detect these injuries.
2. Get support with symptoms now.
The free National Continence Helpline, through Pelvic Floor First, is on 1800 33 00 66, staffed by continence nurses. Healthdirect has a plain-English overview of faecal incontinence, which lists complications of vaginal birth among the causes.
3. Write down your story.
Note what you were told about your tear, who stitched it and where, when your symptoms started, and every time you raised them. Ask for a copy of your birth records, especially the notes about the repair.
4. Ask the hospital what happened.
NSW public hospitals are expected to have honest conversations when care falls short. This is called open disclosure.
When a missed tear may be negligence
A tear can't always be prevented. But identifying it is a basic, expected part of care after birth. If a severe tear was there and wasn't found, and that caused you lasting harm, a claim may be possible. That includes tears that were stitched as minor ones when they needed specialist repair.
The two questions in a claim
Breach: did the examination and repair fall below what a competent clinician should have done? Causation: if the tear had been found and properly repaired, would your symptoms be better now?
In plain terms: was it missed, and did missing it make a difference? Independent experts review your records to answer both.
Compensation can cover future surgery, physiotherapy, continence aids, lost income and the impact on your life. My article on what a pelvic floor injury claim can cover explains more. For the wider picture of severe tears, see "It's just part of having a baby" and maternal birth injuries: what we must talk about.
Frequently asked questions
Can a third degree tear be diagnosed years later?
Yes. An endoanal ultrasound can show damage to the anal sphincter long after the birth. Many women are only diagnosed when they're finally referred to the right specialist.
I didn't have a rectal exam after the birth. Is that wrong?
National guidance says you should be offered one, with your consent, to check for sphincter injury. If it wasn't offered, that's worth noting. Whether it amounts to negligence depends on the whole picture.
Is it too late to do anything?
Often not. Treatment can still help years later. Legal time limits often run from when you knew, or ought to have known, about the injury and its cause, rather than from the birth itself. But the rules are strict, so please get advice soon. You can read more about time limits under the Limitation Act 1969 (NSW).
I'm too embarrassed to talk about this.
That's so understandable, and so common. Please know these conversations are routine for continence nurses, pelvic floor physios, and me. You can share as much or as little as you're comfortable with.
A closing thought
You've probably been quietly managing this: the pads, the planning, the fear of being caught out. You've done that on your own, often for a long time.
So here's a question to sit with: if you knew for certain that this wasn't something you just had to live with, what would you want to do next?
Keep reading: Birth trauma and obstetric negligence · Delayed and missed diagnosis claims
This article is general information only. It is not medical or legal advice, and it doesn't replace advice from your own doctor, midwife or physiotherapist. Reading it does not create a lawyer–client relationship. If you are in crisis, please call Lifeline on 13 11 14 or 000 in an emergency.
