Ivana Alexander was anxious about having her first baby.
The 30-year-old had gestational diabetes and knew her baby was big, so she says she asked staff at Angliss hospital if she could have a caesarean.
She remembers being told that a doctor would only do one in some circumstances, and that she should have a vaginal birth instead. It was a sliding door moment that would change her life forever.
As a doctor pulled out her 4 kilogram son with a vacuum, Ms Alexander says she felt him rip through her perineum (the skin between her vagina and anus).
"I felt like I was dying," she says of the birth which has put her off having another child.
Ms Alexander, now 33, says a midwife at the public hospital in Ferntree Gully stitched her up after the delivery while repeatedly asking a doctor if she was doing it correctly. The pain remained intolerable over the next 24 hours.
"It was excruciating," she says. "The stitches came out the next day and they discharged me home the following day with antibiotics and panadeine forte which causes constipation."
Two and half years later, Ms Alexander says she is doubly incontinent, has difficulties with sex, and is still seeking help to repair the tender skin that was torn apart. She has spent thousands of dollars on private reconstructive surgery and fears she will have to wear a pad for the rest of her life.
"I repeatedly asked for a doctor to see me during my labour because I feared what was happening. The midwife ignored those requests for hours," she says. "If I was given a caesarean, none of this would have happened".
A spokesman for the hospital would not comment on Ms Alexander's case but said staff acknowledged they could improve their rate and management of perineal tears.
"We are working with our clinicians to increase awareness, clinical review and education to ensure that severe perineal trauma is diagnosed, managed and reported appropriately, and will continue to do so," he said.
Obstetricians say Ms Alexander's experience of a fourth-degree perineal tear is rare, with less than 1 per cent of all mothers experiencing such trauma. This equates to up to 3000 of the 300,000 births that occurred in Australia in 2014.
But a Victorian Government report has revealed hospitals are being urged to check their clinicians' competence in preventing and diagnosing the injury.
The report also shows that some hospitals have 13 times the rate of 3rd and 4th degree tears than other hospitals, and that statewide, public hospitals have double the tearing rate of private ones. The data only includes healthy women giving birth, not those with complications such as obesity and diabetes which tends to lead to bigger babies, so it's likely to be an under-estimate of the overall problem.
Professor Euan Wallace, an obstetrician and one of the authors of the report, said while hospitals could use the data to discuss improvements, women should be careful about interpreting it because some may be better at diagnosing the problem and reporting data compared to others.
Nonetheless, he said there were a range of things hospitals could be doing to prevent tears. For example, he said, Asian women, who have higher rates of tearing should be managed by more experienced staff.
Bernadette White, an obstetrician and spokeswoman for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said women most at risk include first time mothers, women whose babies are in the posterior position (facing upwards) and those who need forceps or a vacuum to assist the delivery.
Dr White said although it could be difficult to predict the size of a woman's baby and the likelihood of a tear, more experienced doctors probably had lower rates of perineal tears compared to junior doctors who are still learning.
This might explain some of the difference between private hospital rates where women have experienced doctors and midwives delivering their babies, compared to public hospitals where junior doctors work. Private hospitals also have higher rates of caesareans, which would lower the rate, Dr White said.
"Good techniques for how you assist a woman with the birth probably can have some influence on reducing the risk, but it won't get rid of it. Sometimes even the most skilled doctor doing the most careful birth can have a patient with a third or fourth degree tear," she said.
"Probably what's more important is diagnosing it when it occurs and making sure it is repaired by someone with the skills and technique to do it properly because the reason these things can be bad news is because if they don't get repaired and heal well, there can be long term consequences."
Anne Shortall, a lawyer with Slater and Gordon who is exploring compensation for Ms Alexander, said women giving birth should be clearly informed about the risks of both vaginal and caesarean delivery so that they can make an informed choice about their birth options.
"The fact that some hospitals appear to have significantly higher rates of severe perineal injuries is of serious concern and should be investigated," she said.
Spokespeople for the seven hospitals with the worst rates said they were all working to reduce the problem, with some adding that low numbers of births potentially made their data look worse.
For example, the CEO of Mansfield District Hospital, Cameron Butler, said one woman out of 10 in his hospital's data had experienced a reportable tear, giving the hospital a rate of 10 per cent.