Birth trauma · 18 min read · Published 27 October 2026 · Reviewed 27 October 2026 · Next review April 2027

By Dr Rosemary Listing, PhD (Law) · Medical negligence lawyer since 2013 · Of Counsel, Peter Evans & Associates

“Nobody Told Me How Bad My Tear Was”: Missed, Misgraded and Unexplained Tears

She found out by accident. Fourteen months after the birth, a pelvic health physio read the referral letter out loud and said, gently, “so, with a 3b tear…” She stopped her. No one had ever said those words to her. She had been told she “tore a bit” and had “a few stitches”. She had spent fourteen months thinking she was healing badly from something small.

If you have that same sinking feeling, that what you have been living with doesn’t match what you were told, this guide is for you. I’m a lawyer, not a doctor. But a large part of my work is reading birth records alongside women and helping them understand, often for the first time, what actually happened. So let me explain how tears are graded, why they get missed or not mentioned, and what you are entitled to know.

How tears are graded

Perineal tears are graded from first to fourth degree. The grading most Australian hospitals use comes from the Royal College of Obstetricians and Gynaecologists’ Green-top Guideline No. 29, which RANZCOG publishes on its website.

How often tears are missed

More often than most women are told. In a well-known study by Andrews and colleagues, published in 2006, an experienced researcher re-examined women after their first vaginal birth. The rate of sphincter injury rose from 11% to 25% once the women were examined again, and every injury the researcher found was confirmed on ultrasound. Midwives had not identified 87% of the injuries, and doctors had not identified 27%.

That research is now twenty years old, and training has improved. But it is one of the reasons the national Third and Fourth Degree Perineal Tears Clinical Care Standard exists. Its fourth quality statement expects that, after a vaginal birth, a woman is examined by a suitably trained clinician, including a genito-anal (rectal) examination, so that any tear is identified, graded and documented.

What should have happened, step by step

Step 1A careful examination straight after birth

After a vaginal birth with any tear, the standard expects a systematic examination by someone trained to recognise sphincter injury. That usually includes a rectal examination, with your consent, because it is often the only way to feel whether the sphincter is intact. The Royal Hospital for Women’s procedure in Sydney recommends a rectal examination before the repair, explained to the woman and documented, including if she declines.

Step 2The grade, recorded at the repair

The repair note should record the grade (for example “3b”), who repaired it, where it was repaired, the type of anaesthetic, and the technique. In that Sydney procedure, 3b, 3c and fourth degree tears go to an operating theatre, and a rectal examination is done again at the end of the repair to check that no stitches have been placed incorrectly.

Step 3Being told before you go home

The Queensland Clinical Guideline on perineal care tells staff to inform women about the extent and nature of their injury, its possible short and long term effects, and the importance of follow-up. The Sydney procedure asks for a review by a registrar or consultant before discharge, ideally on day one, covering the diagnosis and what it means. Hearing “you tore a bit” while you are holding a newborn, or being told in hushed tones during the repair, is not the same thing.

Step 4Follow-up that looks for what was missed

If you have symptoms after any tear, such as trouble holding wind, urgency, leaking, ongoing pain, or a feeling that something isn’t right, those symptoms deserve to be investigated, whatever grade is written in your notes. An endoanal ultrasound can show whether the sphincter is intact. The Queensland guideline lists endoanal ultrasound and anorectal manometry as options where incontinence or pain persists.

Step 5Open disclosure, if something went wrong

The Australian Open Disclosure Framework (updated in June 2026) says that conversation should happen as soon as possible after harm is recognised, and that patients must have the opportunity to describe what happened from their perspective. In New South Wales, the Health policy directive PD2023_034 Open Disclosure says open disclosure must occur whenever a patient has been harmed, with the first conversation by the treating team within 24 hours of the incident being identified.

A missed sphincter injury discovered later, a repair that failed, or a tear that was graded wrongly can all be the kind of event that should lead to open disclosure. You can ask for it.

Signs your tear may have been worse than you were told

Only an examination and, often, an ultrasound can answer this. But these are the kinds of symptoms that make it worth asking the question, especially if you were told you had a first or second degree tear:

• you can’t hold in wind, or it escapes without warning
• you get sudden urgency to open your bowels, or can’t always make it to the toilet
• you have soiling or skid marks you can’t explain
• wind or poo comes from your vagina
• the perineum feels like it has a dip, gap or “nothing there”
• you have pain, pressure or heaviness that hasn’t settled months later
• someone examining you later says something like “that was more than a second degree tear”

If any of these apply, our articles on not being able to control wind after birth and pelvic floor damage and incontinence after childbirth go into more detail.

How to find out your real grade

1. Ask for your records

   Ask the hospital for a copy of your full maternity records, including the birth summary, the perineal repair note, any operating theatre record, the postnatal ward notes and the discharge summary. In Australia there is no general common law right to your medical records (the High Court said so in Breen v Williams (1996) 186 CLR 71), but you can request them under privacy and health records laws, such as the Health Records and Information Privacy Act 2002 (NSW) for public and private health services in NSW, or the Privacy Act 1988 (Cth) for private providers. Our guide to getting and reading your birth records walks you through it.

2. Look for the words that matter

   In the repair note, look for “3a”, “3b”, “3c”, “4th degree”, “OASI” or “OASIS”, “EAS” (external anal sphincter), “IAS” (internal anal sphincter), “PR” (rectal examination) and “theatre”. Notes saying “2nd degree” alongside “PR not performed”, or no mention of a rectal examination at all, are worth asking about.

3. Ask for an explanation

   You can ask the hospital to explain what was recorded, ideally in a meeting or a birth debrief with a senior obstetrician. You can bring someone with you, and ask for the answers in writing.

4. Ask for testing if you have symptoms

   If your symptoms don’t match what is written, ask your GP to refer you to a perineal clinic, urogynaecologist or colorectal surgeon, and ask whether an endoanal ultrasound is appropriate.

To the Patient Liaison Officer / Director of Maternity Services
[Hospital name]

Re: [Your full name], date of birth [DOB], MRN [if known]
Birth of my baby on [date]

I gave birth at your hospital on [date] and had a perineal tear that was repaired. I was not given a clear explanation of my injury, and I have had ongoing symptoms since, including [briefly list, e.g. difficulty controlling wind, urgency, pain].

Please:
1. Provide a copy of my complete maternity records, including the perineal repair note, any operating theatre record, postnatal notes and discharge summary.
2. Confirm in writing the grade of my tear as recorded, who examined and repaired it, where it was repaired, and whether a rectal examination was performed before and after the repair.
3. Arrange a meeting with a senior obstetrician to explain my injury and my records.
4. Advise whether any review or open disclosure process has occurred or will occur in relation to my care.

I would prefer to be contacted by [email / phone]. I would appreciate an acknowledgement within 7 days.

Yours sincerely,
[Name]
[Contact details]

If you are unhappy with the response, our guide to making a complaint after a traumatic birth explains the next steps, including your state’s independent health complaints body.

What doctors usually check when a missed tear is suspected

• Your history: the birth, the repair, and your bowel, bladder and pain symptoms since
• An examination of the perineum and the sphincter, including a gentle rectal examination to feel muscle tone and squeeze
• An endoanal ultrasound, which shows whether there is a gap in the external or internal sphincter
• Anorectal manometry, which measures how well the sphincter squeezes
• A plan, which may include pelvic health physiotherapy, biofeedback, bowel management, or a surgical repair of the sphincter by a colorectal surgeon

Questions to ask

1. What grade of tear is recorded in my notes?
2. Who examined me after the birth, and were they trained to identify sphincter injuries?
3. Was a rectal examination done before the repair? After the repair?
4. Who repaired my tear, and where (birth suite or theatre)?
5. Given my symptoms, could my tear have involved the sphincter?
6. Can I have an endoanal ultrasound?
7. If the sphincter was injured and not repaired, what are my options now?
8. Has this been reviewed by the hospital, and has there been open disclosure?

When it can point to something going wrong

Not every tear that turns out to be worse than first thought means someone was negligent. Some injuries are genuinely hard to detect. But it can point to a problem with care if, for example:

• no rectal examination was offered or done, and the sphincter injury was missed
• the person who examined and graded the tear wasn’t trained to recognise sphincter injury, and no one more senior checked
• a third or fourth degree tear was repaired in the birth room as a second degree tear, so the sphincter was never repaired
• you were never told your grade, or what it meant, so you didn’t know to seek help
• you reported bowel or wind symptoms and weren’t investigated, because your notes said “second degree”
• the hospital later realised the injury was missed but did not tell you

How the law looks at it

Whether care was negligent is judged against what was widely accepted as competent professional practice at the time. In New South Wales, section 5O of the Civil Liability Act 2002 (NSW) provides that a professional is not negligent if they acted in a way widely accepted by peer professional opinion as competent practice, unless that opinion is irrational. Other states have similar rules. The national standard and the state guidelines above are strong evidence of what competent practice looked like.

Information matters in law, too. In Rogers v Whitaker (1992) 175 CLR 479, the High Court made clear that patients are entitled to the information a reasonable person in their position would want in order to make decisions about their care. A woman who isn’t told she has a sphincter injury can’t make informed decisions about follow-up, physiotherapy, or how she gives birth next time.

Time limits, and why not being told matters. In New South Wales, a claim generally has to be started within three years of the date the claim is “discoverable”: when you knew, or ought to have known, that you had been injured, that the injury was caused by someone’s fault, and that it was serious enough to justify a claim. There is an outer limit of 12 years (Limitation Act 1969 (NSW) s 50C). If you weren’t told what happened, that may affect when time started to run, but these rules are complicated and differ between states, so please get advice early rather than assume you are within time.

Our article “It’s just part of having a baby”: when a severe perineal tear wasn’t your fault explains the legal side in more detail, and our birth injury map shows how these injuries connect to others.

In my practice

Reading birth records with women is some of the most important work I do, and some of the hardest. Very often the grade is right there on the page, written by the person who repaired the tear, and the woman is seeing it for the first time. Sometimes the opposite is true: the notes say “second degree, PR not done”, and a later ultrasound tells a different story.

In my doctoral research on patterns of failure in medical negligence, poor communication comes up again and again, not as a side issue but as part of the harm itself. A woman who isn’t told what happened can’t ask for the right care, can’t make informed choices about her next birth, and is left to wonder whether the problem is her. Being told the truth, even years later, is often the first thing that helps.

Both/and: it can be hard to spot, and you still deserved to be told

Both things can be true. Sphincter injuries can be genuinely difficult to identify, even for experienced clinicians. And you still had the right to a proper examination, an honest explanation, and follow-up that took your symptoms seriously. Acknowledging that something was difficult doesn’t mean accepting that it was handled well.

You also don’t need to know whether anyone was at fault before you ask what grade you had. That is your information. It is about your body. You are entitled to it.

The bigger picture

RANZCOG’s Birth Trauma Roundtable Final Report (July 2026) heard from women about delayed diagnosis, inconsistent advice and consent processes that felt rushed or unclear, and noted that consumers were often unsure where to seek help after birth. When the grade of a tear isn’t explained, women don’t know what to ask for. That is a system gap as much as an individual one, and it is part of why it matters so much to ask, in writing, for your records and an explanation.

Support

• National Continence Helpline: 1800 33 00 66, run by the Continence Foundation of Australia.
• PANDA: 1300 726 306, or panda.org.au.
• Birth Trauma Australia: birthtrauma.org.au.
• Our guide to finding support after birth trauma.

If you have just discovered that your injury was worse than you were told, give yourself a moment. Whatever you are feeling, relief, anger, grief or all of it at once, makes sense. You haven’t been imagining it. And now that you know, you can ask for the care you should have had from the start.

With care,
Rosemary

Frequently asked questions

References

• Australian Commission on Safety and Quality in Health Care. Third and Fourth Degree Perineal Tears Clinical Care Standard. Sydney: ACSQHC, 2021. safetyandquality.gov.au
• Australian Commission on Safety and Quality in Health Care. Australian Open Disclosure Framework. June 2026. safetyandquality.gov.au
• NSW Health. Open Disclosure. Policy Directive PD2023_034. health.nsw.gov.au
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Birth Trauma Roundtable Final Report. July 2026. ranzcog.edu.au
• Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears. Green-top Guideline No. 29, 2015 (published on the RANZCOG website). ranzcog.edu.au
• Queensland Clinical Guidelines. Perineal care. Guideline MN18.30. Queensland Health. health.qld.gov.au
• Royal Hospital for Women, South Eastern Sydney Local Health District. Third and fourth degree tears: repair and management. Clinical Business Rule, 2023. seslhd.health.nsw.gov.au
• Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries: myth or reality? BJOG 2006;113(2):195–200.
• Rogers v Whitaker (1992) 175 CLR 479; [1992] HCA 58.
• Breen v Williams (1996) 186 CLR 71; [1996] HCA 57.
• Civil Liability Act 2002 (NSW) s 5O.
• Limitation Act 1969 (NSW) s 50C.
• Health Records and Information Privacy Act 2002 (NSW); Privacy Act 1988 (Cth), Australian Privacy Principle 12.

Client stories in this article are composites drawn from many women’s experiences and have been changed so that no one can be identified. They do not describe any individual client.

This article is general information only. It isn’t medical or legal advice about your situation, and reading it doesn’t create a lawyer and client relationship. If you are worried about your health, please see your doctor, midwife or hospital. If you are in crisis, call 000 or Lifeline on 13 11 14. Legal services are provided by Peter Evans & Associates.