Birth trauma · 16 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

Should I Have a Caesarean Next Time? Birth After a Third or Fourth Degree Tear

She was fourteen weeks pregnant when her obstetrician asked, almost in passing, whether she wanted to book a caesarean “because of how badly you tore last time”. She hadn’t known it was that bad. She went home and spent the evening reading comment threads, half of them saying a caesarean was the best decision they ever made, half saying their second vaginal birth was healing. She ended the night more frightened and more confused than when she started.

If you are trying to decide how to have your next baby after a third or fourth degree tear, this guide is for you. It is one of the biggest decisions women face after a severe tear, and too often it is made with too little information, too late, or with someone else’s preferences doing the talking. I’m a lawyer, not a doctor, so I can’t tell you which option is right for you. What I can do is set out what the guidelines say, what you are entitled to know, the tests that can help, and your rights if you feel you are not being listened to.

What the guidelines say

There is no single Australian rule, but the guidance points the same way:

• The Royal College of Obstetricians and Gynaecologists’ Green-top Guideline No. 29, published on RANZCOG’s website, says women who had a third or fourth degree tear should be counselled about the risks of a future vaginal birth, and that women who still have symptoms, or abnormal endoanal ultrasound or manometry results, should have the option of a planned caesarean.
• The Royal Hospital for Women in Sydney’s procedure asks clinicians to discuss mode of birth early in pregnancy, revisit it as needed and again around 36 weeks, and to recommend or consider a caesarean where a woman has current incontinence symptoms, has had a previous fourth degree tear, or requests one.
• The Queensland Clinical Guideline on perineal care notes that endoanal ultrasound and anorectal manometry may help guide decisions about mode of birth in women with anal sphincter symptoms.
• Mater Mothers’ Hospital tells women that if they have fully recovered, there is little evidence to favour one mode of birth over the other, but that if they have ongoing incontinence, especially of the bowel, a vaginal birth may make it worse.
• RANZCOG’s Caesarean Birth on Maternal Request statement (C-Obs 39) says all women making decisions about mode of birth have a right to make an informed choice about their care, after a full discussion over time of the benefits and harms.

What it can mean for you

Where you sit depends mostly on how you have healed. These are the questions your obstetrician should be working through with you.

Situation 1You have fully recovered and your tests are normal

Situation 2You still have symptoms

Situation 3You had a fourth degree tear, or a defect on ultrasound

Before you decideThe tests that help

• A symptom review: an honest conversation about bowel, wind, bladder, pain and sex, ideally using a questionnaire.
• Endoanal ultrasound: shows whether the sphincter healed fully, or whether there is a gap.
• Anorectal manometry: measures how well the sphincter squeezes at rest and on effort.
• A pelvic health physiotherapy assessment: of the pelvic floor and scar tissue.

Ideally these happen before or early in your next pregnancy, so you are not making the decision in a rush at 36 weeks.

If you plan a vaginal birthReducing the risk of tearing again

Things that are commonly discussed include:

• a warm compress on the perineum and hands-on support as the baby’s head is born, with slow, guided pushing
• an experienced clinician present for the birth, and a plan for who will repair any tear and where
• a clear plan about assisted birth: RANZCOG’s Instrumental Vaginal Birth statement notes that forceps carry a higher risk of sphincter injury than vacuum, and that an episiotomy at the right angle reduces sphincter injury in first-time assisted births
• birth positions and pushing that suit you, discussed in advance

Victoria’s Better Births for Women collaborative, which introduced a bundle of these practices, reported a 45% reduction in severe tears across participating services.

What a planned caesarean involves

A planned caesarean removes the risk of another tear during the birth itself, and RANZCOG’s C-Obs 39 notes that it is associated with lower rates of anal sphincter injury and of later surgery for prolapse and stress incontinence. It is also major abdominal surgery, with its own risks, including infection, blood loss, and risks in future pregnancies such as placental problems and uterine rupture. Planned caesareans are usually not done before 39 weeks unless there is another reason.

Women who have had both describe very different experiences: some found a planned caesarean far easier than their tear recovery, others found it harder than expected. That is exactly why the decision should be yours, made with good information.

Questions to ask

1. What grade was my previous tear, and how well has it healed?
2. Can I have an endoanal ultrasound and manometry before I decide?
3. Given my symptoms and results, what are my chances of another severe tear, and of worse bowel control, with a vaginal birth?
4. What are the risks of a planned caesarean for me and my baby, now and for future pregnancies?
5. If I plan a vaginal birth, what will be done to reduce the risk of tearing again?
6. If I need an assisted birth, would you use vacuum or forceps, and would you do an episiotomy?
7. Who would repair any tear, and where?
8. If you don't support my preference, can you refer me for a second opinion?

Your rights

The decision about how you give birth is yours to make with your care team, and it should be a genuine, informed decision. In Rogers v Whitaker (1992) 175 CLR 479, the High Court held that doctors must warn patients of material risks, meaning risks that a reasonable person in the patient’s position would be likely to attach significance to, or that the doctor knows, or should know, this particular patient would. For a woman who has already had a sphincter injury, the risk of further damage to her bowel control is plainly material.

Birth plans matter too. In Gawthrop v Bendigo Health [2026] VSC 157, the Supreme Court of Victoria found a hospital negligent where a woman had been reassured that her birth plan could be followed, without being warned of the practical limits on that. The case was about a different part of maternity care, but the message is the same: what you are told during pregnancy about your options needs to be accurate and complete.

RANZCOG’s C-Obs 39 also recognises that if an obstetrician declines a request for a caesarean, both the clinician and the woman have a right to seek a second opinion. You don’t have to accept a refusal without explanation.

When it can point to something going wrong

• no one discussed your options, or the discussion only happened late in pregnancy or in labour
• you weren’t told about the risk to your bowel control, or your ongoing symptoms weren’t considered
• you asked for tests, such as an endoanal ultrasound, and were refused without good reason
• you were told a caesarean wasn’t available, without a proper discussion or an offer of a second opinion
• you tore severely again in circumstances where the agreed plan to reduce that risk was not followed

How the law looks at it

Care 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 that was widely accepted by peer professional opinion as competent practice, unless that opinion is irrational. Other states have similar rules. Where the complaint is about not being warned, the question is also whether, properly informed, you would have chosen differently, and whether that would probably have avoided the harm. The High Court considered how causation works in failure-to-warn cases in Wallace v Kam (2013) 250 CLR 375.

Time limits apply. In New South Wales, a claim generally has to be started within three years of 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, with an outer limit of 12 years (Limitation Act 1969 (NSW) s 50C). Other states and territories have their own rules, so it is better to ask early than to wait.

In my practice

Many of the women I work with after a second severe tear say the same thing: “No one ever asked me how my bowels were.” The decision about the next birth was made by default, because no one raised it, or raised it at 38 weeks when it felt too late to change course.

In my doctoral research on patterns of failure in medical negligence, consent that is really just information delivered too late is a recurring theme. A conversation at 36 weeks, with a baby on the way and no time for tests, is not the same as a decision made with you early in pregnancy. If you are planning another baby, you can start that conversation now, before you are even pregnant.

Both/and: a vaginal birth may go beautifully, and you still deserve the full picture

Both things are true. Many women who choose a vaginal birth after a severe tear have a far easier birth and recovery the second time. And every woman deserves to make that choice knowing the real risks for her, based on her own symptoms and tests. Encouragement and honest information are not opposites. You should have both.

The bigger picture

The NSW Legislative Council’s Birth Trauma inquiry, which received more than 4,000 submissions and made 43 recommendations, found that much birth trauma stems from avoidable and preventable factors. RANZCOG’s Birth Trauma Roundtable Final Report (July 2026) described consent as an ongoing process needing clear explanation of options and real opportunities for women to take part in decisions. Planning your next birth after a severe tear is exactly where that matters most.

Support

• National Continence Helpline: 1800 33 00 66, free advice from nurse continence specialists, run by the Continence Foundation of Australia.
• PANDA (Perinatal Anxiety & Depression Australia): 1300 726 306, or panda.org.au.
• Birth Trauma Australia: birthtrauma.org.au, information and peer support for physical and emotional birth trauma.
• Our guide to finding support after birth trauma.

Whatever you decide, you are allowed to want a different experience this time, to ask hard questions, and to change your mind. The right choice is the one you make with clear information and real support.

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
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Caesarean Birth on Maternal Request (CBMR). C-Obs 39, 2023. ranzcog.edu.au
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Instrumental Vaginal Birth. C-Obs 16, 2020. 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
• Mater Mothers’ Hospital. Recovering from third and fourth degree perineal tears (patient information). mater.org.au
• Gloucestershire Hospitals NHS Foundation Trust. Third and fourth degree tears following childbirth (patient information). gloshospitals.nhs.uk
• Safer Care Victoria. Better Births for Women improvement collaborative. safercare.vic.gov.au
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Birth Trauma Roundtable Final Report. July 2026. ranzcog.edu.au
• Legislative Council Select Committee on Birth Trauma (NSW). Birth trauma. Report, tabled 29 May 2024. parliament.nsw.gov.au
• Rogers v Whitaker (1992) 175 CLR 479; [1992] HCA 58.
• Gawthrop v Bendigo Health [2026] VSC 157.
• Wallace v Kam (2013) 250 CLR 375; [2013] HCA 19.
• Civil Liability Act 2002 (NSW), including ss 5D, 5O, 12, 15, 16 and 33.
• Limitation Act 1969 (NSW) s 50C.

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.