Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: Time trends and risk factors

I. Gurol-Urganci, D. A. Cromwell, L. C. Edozien, T. A. Mahmood, E. J. Adams, D. H. Richmond, A. Templeton, J. H. Van Der Meulen

    Research output: Contribution to journalArticlepeer-review


    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. © 2013 RCOG.
    Original languageEnglish
    Pages (from-to)1516-1525
    Number of pages9
    JournalBJOG: An International Journal of Obstetrics and Gynaecology
    Issue number12
    Publication statusPublished - Nov 2013


    • Episiotomy
    • instrumental delivery
    • severe perineal trauma
    • trends
    • vaginal delivery


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