bjo12363

Third- and fourth-degree perineal tears amongprimiparous women in England between 2000and 2012: time trends and risk factorsI Gurol-Urganci,a,b DA Cromwell,a LC Edozien,c TA Mahmood,b EJ Adams,d DH Richmond,b,d

A Templeton,b JH van der Meulena

a Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, b Office for Research and

Clinical Audit, Lindsay Stewart R&D Centre, Royal College of Obstetricians and Gynaecologists (RCOG), London, c Maternal and Fetal Health

Research, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, d Department of Urogynaecology, Liverpool

Womens NHS Foundation Trust, Liverpool, UK

Correspondence: Dr Ipek Gurol-Urganci, Department of Health Services Research and Policy, London School of Hygiene and Tropical

Medicine, 1517 Tavistock Place, London, WC1H 9SH, UK. Email [email protected]

Accepted 17 May 2013. Published Online 3 July 2013.

Objective To describe the trends of severe perineal tears in

England and to investigate to what extent the changes in related

risk factors could explain the observed trends.

Design A retrospective cohort study of singleton deliveries from a

national administrative database.

Setting The English National Health Service between 1 April 2000

and 31 March 2012.

Population A cohort of 1 035 253 primiparous women who had a

singleton, term, cephalic, vaginal birth.

Methods Multivariable logistic regression was used to estimate

the impact of financial year of birth (labelled by starting year),

adjusting for major risk factors.

Main outcome measure The rate of third-degree (anal sphincter

is torn) or fourth-degree (anal sphincter as well as rectal mucosa

are torn) perineal tears.

Results The rate of reported third- or fourth-degree perineal tears

tripled from 1.8 to 5.9% during the study period. The rate of

episiotomy varied between 30 and 36%. An increasing proportion

of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental

deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A

higher risk of third- or fourth-degree perineal tears was associated

with a maternal age above 25 years, instrumental delivery (forceps

and ventouse), especially without episiotomy, Asian ethnicity, a

more affluent socio-economic status, higher birthweight, and

shoulder dystocia.

Conclusions Changes in major risk factors are unlikely

explanations for the observed increase in the rate of third- or

fourth-degree tears. The improved recognition of tears following

the implementation of a standardised classification of perineal

tears is the most likely explanation.

Keywords Episiotomy, instrumental delivery, severe perineal

trauma, trends, vaginal delivery.

Please cite this paper as: Gurol-Urganci I, Cromwell D, Edozien L, Mahmood T, Adams E, Richmond D, Templeton A, van der Meulen J. Third- and

fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120:15161525.

Introduction

Recent population-based studies from Scandinavian coun-

tries and Canada have identified an increase in the occur-

rence of severe obstetric anal sphincter injuries.15 In the

UK, a study from a single unit reported that the combined

rate of third-degree (anal sphincter is torn) and fourth-

degree perineal tears (anal sphincter as well as rectal

mucosa are torn) increased from 1.3% in 2001 to 4.6% in

2010.6 One possible reason for this trend is the rise in

maternal age at first birth and maternal weight, which are

linked to a higher birthweight and risk of perineal tears.

Other reasons include increased awareness and training,

which is likely to result in a better case detection and

recording of obstetric injuries, and changes in the manage-

ment of the second stage of labour.1,5

The aim of this study was to describe the time trends in

obstetric anal sphincter injuries in England, recorded in a

large population-based database that includes all maternity

admissions in the English National Health Service (NHS).

We also investigated risk factors for these injuries

and explored to what extent changes in these relevant risk

1516 2013 RCOG

DOI: 10.1111/1471-0528.12363

www.bjog.orgGeneral obstetrics

factors and in obstetric practice were linked to the observed

trends.

Methods

We used the Hospital Episode Statistics (HES) database to

identify all deliveries that took place in English NHS Trusts

(acute hospital organizations) from April 2000 to March

2012. HES is a data warehouse that includes records of all

inpatient admissions and day cases in English NHS Trusts.

The data are extracted from local patient administration

systems, and undergo a series of validation and cleaning

processes before being made available for analysis.7

The HES database contains patient demographics, clini-

cal information, and administrative data for each inpatient

episode of care. Diagnostic information is coded using the

International Classification of Diseases 10th revision

(ICD10),8 and operative procedures are coded using the

UK Office for Population Censuses and Surveys classifica-

tion, fourth revision (OPCS4).9 For maternity episodes, the

HES database has supplementary fields known as the

maternity tail, which captures parity, birthweight, gesta-

tional age, method of delivery, and pregnancy outcome.

The accuracy and completeness of diagnostic and proce-

dures data are high.10 The maternity tail is not compulsory,

and the level of data completeness varies across Trusts. For

example, birthweight and parity are available in 79 and

65% of the delivery episodes, respectively.

The study included only primiparous women aged 1545 years, who had a singleton, term, cephalic, vaginal birth.

We confined the analysis to NHS Trusts that had parity

information recorded in at least half of the deliveries, and

that had a proportion of primiparous women between 25

and 55% (overall about 40% of women giving birth are

primiparous in England and Wales). The quality of parity

data was evaluated for each year of the study.

Cases of perineal tears were identified by ICD10 codes

O70.0 (first-degree perineal laceration), O70.1 (second

degree), O70.2 (third degree), and O70.3 (fourth degree).

Mode of delivery was defined using information in the

OPCS4 procedure codes, and we distinguished between

vaginal (OPCS4 codes R23 and R24), forceps (R21), and

ventouse (R22), or if not defined using OPCS4 codes, by

the delivery method specified in the maternity tail. These

three modes were further stratified by whether or not an

episiotomy had been performed (OPCS4 code R27.1).

We identified the following potential risk factors. Mater-

nal demographic factors were age (

Women older than 25 years were reported to have a third-

or fourth-degree tear at least twice as often as teenage

mothers. Women living in the least deprived communities,

and those with non-white ethnicities were also more likely

to have a severe obstetric tear. Asian women had a risk of

a third- or fourth-degree tear that was more than twice as

high as women from a white ethnic background (adjusted

OR 2.27, 95% CI 2.142.41).Women who had an episiotomy were less likely to expe-

rience a severe perineal tear, regardless of the mode of

delivery. Across the different modes of delivery, women

who had a non-instrumental or a ventouse delivery with an

episiotomy had the lowest rates of third- or fourth-degree

tears. Use of forceps increased the risk of a tear, with a for-

ceps delivery without an episiotomy increasing the odds of

a tear six-fold compared with a vaginal delivery without an

episiotomy. The adjusted risk of third- or fourth-degree

tears increased with birthweight and shoulder dystocia, but

was not associated with the duration of labour.

Figure 3 shows the time trends within risk groups

according to maternal age, ethnicity, mode of delivery, and

shoulder dystocia. The rate of obstetric tears increased in

17.0 16.6

35.2

15

20

25

30

35

40

1.8

5.9

0

5

10

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Case

s of

tear

s, p

er 1

00 b

irth

s

First degree Second degree Third/Fourth degree

28.6

Figure 1. Trends in the rate of obstetric tears. Rates are expressed per 100 singleton, term, cephalic, vaginal first births.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2009 2010

Normal Ventouse Forceps

Normal % with episiotomy Ventouse % with episiotomy Forceps % with episiotomy

Figure 2. Trends in the rates of forceps, ventouse, and non-instrumental deliveries. Rates are expressed per 100 singleton, term, cephalic, vaginal

first births.

1518 2013 RCOG

Gurol-Urganci et al.

Table 1. Rate of third- or fourth-degree perineal tears in 1 035 253 singleton, term, cephalic, vaginal first births according to maternal and

obstetric risk factors

Prevalence of risk factor (%) Rate of tear per 100 births (%) Crude OR (95% CI) Adjusted OR (95% CI)

Year of delivery (Financial years)

2000 1.8

2001 2.0 1.16 (1.021.31) 1.13 (0.991.29)

2002 2.4 1.35 (1.191.52) 1.32 (1.171.49)

2003 2.8 1.63 (1.431.85) 1.57 (1.371.80)

2004 3.0 1.75 (1.561.98) 1.68 (1.481.90)

2005 3.7 2.14 (1.912.39) 2.02 (1.792.26)

2006 4.2 2.48 (2.192.81) 2.29 (2.012.62)

2007 4.7 2.74 (2.413.12) 2.48 (2.142.87)

2008 4.9 2.85 (2.523.23) 2.56 (2.212.96)

2009 5.1 2.98 (2.613.41) 2.70 (2.333.13)

2010 5.6 3.31 (2.903.77) 3.02 (2.633.45)

2011 5.9 3.48 (3.033.99) 3.15 (2.743.62)

Maternal age (years)

all groups, with the largest absolute increase in women

undergoing a forceps delivery without an episiotomy (Fig-

ure 3c) and in women with an Asian ethnic background

(Figure 3b).

Discussion

We found a three-fold increase in the rate of reported

third- or fourth-degree perineal tears in England, with the

rate rising from 1.8% in 2000 to 5.9% in 2011. An

increased risk of a severe tear was associated with a mater-

nal age above 25 years, forceps and ventouse delivery, espe-

cially without episiotomy, Asian ethnicity, a more affluent

socio-economic status, higher birthweight, and shoulder

dystocia. The use of an episiotomy was protective; however,

the increase in the rate of severe perineal injury over the

study period could not be explained by temporal changes

in the major risk factors.

Using HES data has several advantages for trying to

describe patterns of maternity care. First, over 96% of all

deliveries in England occur in NHS Trusts, and are there-

fore captured by HES,12 which gives large sample sizes for

outcomes that are relatively rare, such as third- or fourth-

degree perineal tears. Second, the availability of data since

1997 allows for the analysis of patterns of care over time.

Finally, the data are able to capture multiple procedures

and diagnoses at an individual level, and so provide a rich

description of the patient case mix.

A weakness of administrative data sets is that the coding

of the diagnoses and procedures is potentially inaccurate;

however, studies have demonstrated that the majority of

NHS Trusts submit good-quality data to HES that con-

forms with national recommendations.1315 A recent sys-

tematic review of discharge coding accuracy in the UK

concluded that routinely collected data are sufficiently

robust to support their use for research and managerial

decision-making.10 The richness of the data also makes it

possible to develop coding frameworks and data quality

criteria to identify hospitals with divergent coding practices

by combining diagnosis, procedure, and administrative

codes.16 A number of recent publications have demon-

strated that when analysed carefully, HES is a valuable

source of data to explore patterns of care as well as sup-

porting epidemiological studies related to childbirth.1719

This study included half of all vaginal singleton term

births in primiparous women who delivered in an NHS

0

2

4

6

8

10

12

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Case

s of

tear

s, p

er 1

00 b

irth

sCa

ses

of te

ars,

per

100

bir

ths

0

2

4

6

8

10

12

Case

s of

tear

s, p

er 1

00 b

irth

s

0

2

4

6

8

10

12

Case

s of

tear

s, p

er 1

00 b

irth

s

hospital over a 12year period. We focused on primiparouswomen, as earlier studies had concluded that birth order

and a perineal tear in an earlier birth are important risk

factors.2026 Excluding NHS Trusts with poor data quality

may have introduced bias, as the risk-adjusted tear rates at

these hospitals may be different from the rates observed in

hospitals with better data quality. However, the effect size

of selection bias is likely to be small because the distribu-

tions of outcome and risk factors in both groups were sim-

ilar (Table S1). This finding is in agreement with a recent

study that concluded that using birth cohorts from hospi-

tals with high completeness of recording is likely to be

valid and nationally representative.27 A second method to

identify parity is to examine the womens obstetric history.

In a sensitivity analysis, we constructed a data set of pri-

miparous women, using 10 years of obstetric history, cov-

ering a study period from April 2007 to March 2012. The

adjusted estimates of risk of obstetric tears from this data

set were compared with the results from the data set gener-

ated using high-quality parity information for the same

period. Both methods yielded comparable results (data not

shown).

We were unable to control for a number of risk factors,

such as the type of anaesthetic used, that might have influ-

enced our results. Data on intrapartum anaesthetic use is

available in HES, but this information is contained in the

maternity tail, and was missing in about one-third of all

patient records. Therefore, we omitted this variable from

the analysis. In the subsample of records for whom this

information was available, the adjusted effect of epidural

analgesia was OR 1.10 (95% CI 0.941.29), and the inclu-sion of epidural in the logistic regression model did not

significantly modify the effect size of other risk factors. This

result is consistent with other studies on the impact of an

epidural anaesthetic on third- or fourth-degree tears.28,29

We were also unable to control for perineal protection

techniques applied during the second stage of labour, or

the experience or preferences of the birth attendant.30,31

Similarly, the angle and size of an episiotomy is likely to

influence the risk of tears,3234 but this information was

not available in our data set.

Comparison with previous literatureThe rate of reported third- or fourth-degree tears in single-

ton, term, cephalic, vaginal first births in England was

5.9% in 2011. This rate of clinically recognised anal sphinc-

ter injuries falls within the wide range of figures reported

elsewhere. In large population-based studies using birth

registry or administrative hospital data, the incidence was

1.8% in Finland,5 3.64.2% in Norway, Denmark, and Swe-den,1,2 and 4.55.4% in the USA.20,35 It is known that theactual rate of anal sphincter lacerations is significantly

higher than the reported rates. Studies using endoanal

ultrasonography have found clinically occult anal sphincter

defects in up to one-third of vaginal deliveries.36

We found that the risk of perineal tears was lower in

younger women. The risk of a severe perineal injury in

teenage primiparous women was less than half the risk in

women older than 25 years, which corresponds to the rates

in Norway.1 However, maternal age was not always identi-

fied as a risk factor for severe tears.28,37,38

Differences in risk for ethnicity have been demonstrated in

studies from Norway, Sweden, UK, and the USA.1,2,20,3840 It

has been suggested that differences in the anatomy of the

perineum, such as perineal body length and thickness among

different ethnic groups, may be contributing factors.39

Mode of delivery is a key determinant of the risk of peri-

neal tears, with studies consistently demonstrating that

women with instrumental deliveries have higher rates of

anal sphincter tears,2,23,28,37 and that forceps deliveries carry

the highest risk of third- or fourth-degree perineal tears.

The risk of having a severe perineal injury has been

reported to be 1.514.0 times higher with forceps, and upto four times higher with ventouse, than with spontaneous

vaginal delivery.2123,38,41,42

We considered it more informative to analyse combina-

tions of mode of delivery and use of episiotomy in contrast

to analysing both as separate risk factors, which has been

the case in most studies. This allows for the effect of episi-

otomy to vary by delivery mode. Midline episiotomies are

known to increase the risk of third- or fourth-degree peri-

neal tears.21,22,41,42 For mediolateral episiotomies, although

the evidence is not conclusive,43,44 most studies suggest that

this technique protects against severe tears.20,23,28,29,32,37,41,4547

The results of studies that analysed specific combinations

of mode of delivery and episiotomy use were consistent

with ours. These studies found that mediolateral episiot-

omy reduced the risk of tears in instrumental vaginal deliv-

eries.1,46,47

Our findings on shoulder dystocia and birthweight con-

firms the results of previous studies, which found that

shoulder dystocia and birthweights higher than 4000 g dou-

ble the risk of perineal tears.2023,45,48 An increase in the

incidence of these risk factors could contribute to a higher

rate of tears. However, the distribution of birthweights in

our population did not change over the study period. In

fact, the use of episiotomy in instrumental deliveries for

babies with birthweights over 4000 g increased from 77.5%

in 2000 to 85.6% in 2011, which is likely to reduce the risk

of severe tears for this group. We did not find evidence that

a longer duration of labour increases the risk of severe tears,

which is in contrast to a number of other studies.23,37,45,48

Possible explanations for the observed trendsIt is important to monitor trends in the incidence of third-

or fourth-degree perineal tears, and the underlying explana-

2013 RCOG 1521

Third- and fourth-degree perineal tears in England

tions, because severe perineal trauma is listed as an index

of quality of care in the RCOG Maternity Dashboard,49

and by Australian,50 European,51 and US national quality

accreditation systems.52 These nationally reported trends

can be used for benchmarking. A trend towards an increas-

ing incidence of third- or fourth-degree perineal tears, as

found in this study, does not necessarily indicate poor-

quality care. It may indicate, at least in the short term, an

improved quality of care through better detection and

reporting.53

The most likely explanation for the rising rate of

reported severe perineal injury is improved recognition.

This would be a result of two recent developments: the

introduction of a standardised classification of perineal

tears, and better training of staff in recognising and repair-

ing perineal tears.54 The Royal College of Obstetricians and

Gynaecologists published evidence-based guidelines for the

management of third- or fourth-degree perineal tears in

2001 (second edition in 2007).55 All maternity units in

England should now have written policies on the diagnosis

and management of tears.56 Prior to the introduction of

the standardised classification, some clinicians will have

classified injuries to the anal sphincter as second-degree

tears.31,55,57 In the last decade, specific training in the iden-

tification and repair of perineal tears has become estab-

lished as an essential component of postgraduate training

and continuing professional development for doctors and

midwives. Studies in the UK that have evaluated the imple-

mentation of the documentation proforma and auditable

standards recommended in the new guideline,58,59 and in

training interventions,60 confirm that the increased aware-

ness and appropriate examination have increased the likeli-

hood of perineal tears being detected.61

Another possible explanation is a gradual improvement

in the coding of tears in the English HES database. How-

ever, better coding is unlikely to have had a major impact

as the completeness and accuracy of data coding of third-

or fourth-degree perineal tears were found to be high in

databases in the USA, Norway, and Australia.6264 In all

these countries the sensitivity of coding of third- or fourth-

degree tears was higher than 90%, and the majority of dis-

crepancies occurred in the coding of first- and second-

degree tears.62

Our results and those of other studies demonstratethat changes in the main risk factors do not explain the

observed increase in the rates of severe perineal tears.13,5,35

However, there have been significant changes in the man-

agement of the second stage of labour in the last decade. In

the 1990s, ventouse was advocated as the instrument of

first choice for instrumental vaginal delivery.65,66 As the

rate of failed instrumental delivery increased, clinical guide-

lines moved to recommending the use of the instrument

best suited to the individual circumstances.67 The National

Institute for Clinical Excellence (NICE) Guidelines for in-

trapartum care also recommended that routine episiotomy

should not be performed during spontaneous vaginal birth,

but that it should be used with any forceps delivery.67

These changes, as well as the fact that an episiotomy was

not performed in one or two of every ten forceps deliveries

in our study population, may have contributed to the

increase in the rates of third- or fourth-degree tears in Eng-

land.

Changes in the application of perineal protection tech-

niques may also have played a role.6871 The implemen-

tation of manual assistance and perineal protection

techniques during the second stage of labour have signif-

icantly reduced the incidence of perineal tears in Nor-

way.72,73 Antenatal perineal massage reduces the

likelihood of perineal trauma (mainly episiotomies), but

is not routinely practiced in the UK.74 Wider application

of the hands-poised approach, combined with the reluc-

tance to use episiotomies, could have resulted in a

higher risk of a third- or fourth-degree tears.3,75,76 Also,

women are increasingly encouraged to use their preferred

birth positions, which may have reduced perineal protec-

tion.5,48

Conclusion

This study found that, between April 2000 and March

2012, the rate of reported third- or fourth-degree perineal

tears for first births tripled in England. This trend mirrors

those reported from other developed countries such as Fin-

land, Norway, and Canada. The most likely explanation for

the increasing rate is improved diagnosis through the intro-

duction of a standardised classification of perineal tears

and the better training of staff. Changes in the patterns of

maternal risk factors and modes of delivery are unlikely

explanations.

Disclosure of interestsNone.

Contribution to authorshipIGU, LCE, TAM, LA, and JHvdM conceived the study.

IGU and DAC contributed to its design and conducted the

analyses. IGU wrote the article, and DAC, LCE, TAM, LA,

DR, AT, and JHvdM commented on drafts. All authors

approved the final version for publication.

Details of ethics approvalThe study is exempt from UK National Research Ethics

Service approval because it involved the analysis of an

existing data set of anonymised data for service evaluation.

Approvals for the use of HES data were obtained as part of

the standard Hospitals Episode Statistics approval process.

1522 2013 RCOG


FundingIG-U is supported by the Royal College of Obstetricians

and Gynaecologists.

AcknowledgementWe thank the Department of Health for providing the HES

data used in this study.

Supporting Information

Additional Supporting Information may be found in the

online version of this article:

Table S1. Maternal and obstetric risk factors in single-

ton, term vaginal births: comparison of included and

excluded episodes.&

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