IJG-07841; No of Pages 9

International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

REVIEW ARTICLE

Risk factors for severe perineal lacerations during childbirth

Vasileios Pergialiotis ⁎, Dimitrios Vlachos, Athanasios Protopapas, Kaliopi Pappa, Georgios Vlachos
First Department of Obstetrics and Gynecology, Athens University Medical School, Alexandra Hospital, Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Background: Severe perineal lacerations represent a significant complication of normal labor with a strong impact
Received 4 June 2013 on quality of life. Objectives: To identify factors that lead to the occurrence of severe perineal lacerations. Search
Received in revised form 19 September 2013 strategy: We searched MEDLINE, Scopus, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials,
Accepted 30 December 2013 Google Scholar and reference lists from all included studies. Selection criteria: We included prospective and
retrospective observational studies. Data collection and analysis: Predetermined data were collected and analyzed
Keywords:
with the Mantel–Haenszel fixed-effects model or the DerSimonian–Laird random-effects model. Main results:
Episiotomy
Forceps
The meta-analysis included 22 studies (n = 651 934). Women with severe perineal tears were more likely to
Perineal lacerations have had heavier infants (mean difference 192.88 g [95% CI, 139.80–245.96 g]), an episiotomy (OR 3.82 [95%
Perineal tears CI, 1.96–7.42]), or an operative vaginal delivery (OR 5.10 [95% CI, 3.33–7.83]). Epidural anesthesia (OR 1.95
[95% CI, 1.63–2.32]), labor induction (OR 1.08 [95% CI, 1.02–1.14]), and labor augmentation (OR 1.95 [95% CI,
1.56–2.44]) were also more common among women with perineal lacerations. Conclusions: Various factors
contribute to the occurrence of perineal lacerations. Future studies should consistently evaluate all examined
parameters to determine their possible interrelation.
© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction 2. Materials and methods

Vaginal birth is occasionally accompanied by complications such as
severe perineal lacerations, cervical lacerations, and vaginal tears. Peri-
neal injuries are divided into 4 categories according to the anatomic
structures involved. As proposed by the National Institute for Health
and Care Excellence, third-degree lacerations involve the anal sphincter
complex (including its external and internal components), whereas
fourth-degree lacerations extend to the rectal mucosa, exposing the in-
testinal lumen [1]. The incidence of third- and fourth-degree tears in the
USA is 6.4% [2]. The impact of severe perineal tearing on the postopera-
tive quality of life varies. Fitzpatrick et al. [3] reported in a review that up
to 25% of women with severe perineal tearing experience transient al-
terations in fecal continence, and 4% have persistent problems. Careful
primary repair is important for the postpartum course, but there is no
current evidence to support the superiority of a particular repair
technique (overlapping repair versus simple approximation of the
anal sphincter) [4].
Since the mid-1990s, numerous studies have examined the effects of
fetal and maternal factors and iatrogenic manipulations on the occur-
rence of perineal tearing. However, the reported results are not always
in agreement.
The present meta-analysis assessed a variety of prognostic factors
that might lead to the occurrence of severe perineal lacerations.
⁎ Corresponding author at: 6, Danaidon Street, Halandri 15 232, Greece. Tel.: +30 69
47326 459.
E-mail address: pergialiotis@hotmail.com (V. Pergialiotis).
2.1. Literature search and data collection
MEDLINE (1966–2013), Scopus (2004–2013), ClinicalTrials.gov
(1997–2013), the Cochrane Central Register of Controlled Trials
(1999–2013), and Google Scholar (2004–2013) were used for the pri-
mary search. We aimed to use the lowest number of keywords that en-
abled us to retrieve eligible studies for hand-searching without having
significant article losses. Only human studies were considered.
For MEDLINE, the following search string was used: (“perineum”
[MeSH Terms] OR “perineum”[All Fields] OR “perineal”[All Fields])
AND (“lacerations”[MeSH Terms] OR “lacerations”[All Fields]). Scopus
was searched using the terms perineum AND perineal AND laceration*.
The Cochrane Central Register of Controlled Trials was searched
using the terms perineal AND/OR perineum AND laceration*.
ClinicalTrials.gov was searched for perineal laceration*. Finally, an ex-
tended search string—(perineum AND perineal AND laceration* AND
labor AND episiotomy AND operative AND vacuum AND forceps)—
was used for Google Scholar.
The reference lists of electronically retrieved articles that were se-
lected for inclusion in the present review were also searched manually
to identify articles that might have been missed in the electronic search.
All articles that met or were presumed to meet the inclusion criteria
were retrieved in full, with 1 exception [5].
Overall, 454 articles were found in MEDLINE and 462 in Scopus. Of
these, 36 articles were presumed to be relevant to the topic and were re-
trieved in full. In addition, 3 articles were retrieved after reviewing the

0020-7292/$ – see front matter © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijgo.2013.09.034

Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
 2
dx.doi.org/10.1016/j.ijgo.2013.09.034
Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://

Table 1
Maternal and neonatal characteristics.

Date; first author Total Severe Controlsa Age, yb BMI BMI at Asian Previous Primiparitya Pregnancy Birth
number tearsa before deliveryc ethnicitya cesarean duration, wk weight, g
pregnancyc deliverya

1994; Anthony [11] 43 309 599 (1.4) 42 710 (98.6) N/A N/A N/A 15/599 (2.5) vs N/A 316/599 (52.8) vs N/A N/A
796/42 710 (1.9) 17 295/42 710 (40.5)
1997; Labrecque [25] 6522 1002 (15.4) 5520 (84.6) N/A N/A N/A N/A N/A N/A N/A N/A
1997; Klein [23] 459 75 (16.3) 384 (83.7) 28.8 ± 3.7 vs N/A N/A N/A N/A N/A N/A 3552 ± 429 vs
27.9 ± 4.1 3282 ± 442
1999; Robinson [29] 1942 276 (14.2) 1666 (85.8) N/A N/A N/A N/A N/A N/A N/A N/A

V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
2000; Jones [22] 15 204 131 (0.9) 15 073 (99.1) N/A N/A N/A N/A N/A 109/131 (83.2) vs N/A N/A
7032/15 073 (46.7)
2000; Samuelsson [30] 2883 95 (3.3) 2788 (96.7) N/A N/A N/A N/A N/A 66/95 (69.5) vs N/A N/A
1230/2788 (44.1)
2000; Angioli [10] 50 210 1124 (2.2) 49 086 (97.8) 24.3 ± 6.10 vs N/A N/A N/A N/A 892/1460 (61.1) vs N/A 3439 ± 476 vs
25.5 ± 6.36 18 468/49 086 (37.6) 3205 ± 600
2001; de Leeuw [15] 28 4783 5528 (1.9) 27 9255 (98.1) N/A N/A N/A N/A N/A 3355/5528 (60.7) vs N/A N/A
12 1525/27 9255 (43.5)
2001; Jandér [21] 428 214 (50.0) 214 (50.0) N/A N/A N/A N/A N/A 177/214 (92.7) vs N/A N/A
104/214 (48.6)
2001; Bodner-Adler [13] 1118 37 (3.3) 1081 (96.7) N/A N/A N/A N/A N/A 20/37 (54.1) vs N/A N/A
551/1081 (51)
2002; Riskin-Mashiah [28] 23 244 1905 (8.2) 21 339 (91.8) 23.5 ± 5.2 vs N/A N/A 65/1905 (3.4) vs N/A 1426/1905 (74.9) vs N/A 3425 ± 477 vs
24.8 ± 5.8 361/21 339 (1.7) 6948/21 339 (32.6) 3270 ± 560
2004; Macarthur [27] 350 46 (13.1) 304 (86.9) N/A N/A N/A N/A N/A 41/46 (89.1) vs N/A N/A
150/304 (49.3)
2006; Eogan [16] 100 54 (54) 46 (46.0) 30 vs N/A N/A N/A N/A N/A N/A 3755 vs
31 3504
2005; Hudelist [20] 201 46 (22.9) 155 (77.1) 29 vs N/A 26.2 vs N/A N/A 32/46 (69.6) vs 40 + 3 vs 3570 vs
29 26.3 71/155 (45.8) 40 + 0 3336
2005; Sheiner [31] 98 524 79 (0.1) 98 445 (99.9) 27.0 ± 4.8 vs N/A N/A N/A N/A 36/79 (45.6) vs 279.3 ± 8.3 vs 3483 ± 483 vs
27.9 ± 5.8 22 204/98 445 (22.6) 277.8 ± 8.7 d 3258 ± 430
2006; Aukee [12] 9178 53 (0.6) 9125 (99.4) 29 vs N/A N/A N/A N/A N/A 279 vs 3577 vs
29 282 d 3833
2007; Dahlen [14] 6595 134 (2) 6461 (98.0) 30.3 vs N/A N/A 35/134 (26.1) vs N/A 108/134 (80.6) vs N/A N/A
30.9 1021/6461 (15.8) 3064/6461 (47.4)
2007; Lowder [26] 20 674 2533 (12.3) 18 150 (87.7) N/A N/A N/A N/A 260/2533 (10.2) vs N/A N/A N/A
1172/18 150 (6.4)
2006; Kudish [24] 33 842 1229 (3.6) 32 613 (96.4) N/A N/A N/A N/A N/A N/A N/A N/A
2010; Hornemann [19] 2967 50 (1.7) 2917 (98.3) N/A N/A N/A N/A N/A N/A N/A N/A
2011; Groutz (a) [17] 300 60 (20) 240 (80) 31.2 ± 4.7 vs 21.7 ± 2.9 vs 27.2 ± 4.1 vs 6/60 (10.0) vs 3/60 (5.0) vs N/A 39.5 ± 1.5 vs 3372 ± 463 vs
33.5 ± 4.7 21.9 ± 3.8 27.2 ± 4.1 4/240 (1.7) 18/240 (7.5) 39.4 ± 1.3 3229 ± 428
2011; Groutz (b) [18] 38 522 96 (0.3) 38 426 (99.8) 30.5 ± 4.8 vs 21.9 ± 3.4 vs 27.1 ± 3.5 vs 14/96 (14.6) vs N/A 65/96 (67.7) vs 39.6 ± 1.4 vs 3369 ± 469 vs
31.1 ± 4.7 22.1 ± 3.7 27.3 ± 3.9 552/38 426 (1.4) 16 480/38 426 (42.9) 39.2 ± 1.5 3252 ± 445

Abbreviation: BMI, body mass index.

a
Values are given as number (percentage).
b
Values are given as mean ± SD.
c
Calculated as weight in kilograms divided by the square of height in meters.
d
Pregnancy duration reported in days.
dx.doi.org/10.1016/j.ijgo.2013.09.034
Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://

Table 2
Labor characteristics 1.a

Date; first author Labor induction Labor augmentation Epidural analgesia Duration of second Persistent occiput Breech Mediolateral Median
stage, min posterior presentation episiotomy episiotomy

1994; Anthony [11] 169/599 (28.2) vs N/A N/A N/A N/A N/A 68/599 (11.4) vs 13/599 (2.2) vs
12 409/42 710 (29.1) 12 736/42 710 (29.8) 556/42 710 (1.3)
1997; Labrecque [25] N/A N/A 810/1002 (80.8) vs N/A N/A N/A N/A 906/1002 (90.4) vs
N/A N/A
1997; Klein [23] N/A N/A 55/75 (73.3) vs 100.6 ± 68.1 vs N/A N/A N/A N/A
221/384 (57.5) 78.7 ± 58.9

V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
1999; Robinson [29] 67/276 (24.3) vs 134/276 (48.6) vs N/A N/A N/A N/A N/A N/A
405/1666 (24.3) 644/1666 (38.7)
2000; Jones [22] N/A N/A N/A N/A 17/131 (13.0) vs 3/131 (2.3) vs N/A N/A
332/15 073 (2.2) 346/15 073 (2.3)
2000; Samuelsson [30] N/A N/A 42/95 (44.2) vs N/A 6/95 (6.3) vs 0/95 (0.0) vs 21/95 (22.1) vs N/A
730/2788 (26.2) 96/2788 (3.4) 46/2788 (1.6) 302/2788 (10.8)
2000; Angioli [10] N/A N/A N/A N/A N/A N/A 614/1124 (54.6) vs 294/1124 (26.2) vs
12 747/49 086 (26.0) 4136/49 086 (8.4)
2001; de Leeuw [15] 972/5528 (17.6) vs N/A N/A N/A 250/5528 (4.5) vs 103/5528 (0.2) vs 1234/5528 (22.3) vs 109/5528 (2.0) vs
45 428/27 9255 (16.3) 7014/27 9255 (2.5) 9739/27 9255 (3.5) 96 016/27 9255 (34.4) 3505/27 9255 (1.3)
2001; Jandér [21] 23/214 (10.7) vs 158/214 (73.8) vs 73/214 (33.2) vs N/A 13/214 (6.1) vs 4/214 (1.9) vs 32/214(15.0) vs 25/214 (11.7) vs
18/214 (8.4) 96/214 (44.9) 55/214 (25.7) 3/214 (1.4) 4/214 (1.9) 17/214 (7.9) 7/214 (3.3)
2001; Bodner-Adler [13] N/A 19/37 (51.4) vs 14/37 (37.8) vs N/A N/A N/A 3/37 (8.1) vs 19/37 (51.4) vs
318/1081 (29.4) 263/1081 (24.3) 112/1081 (10.4) 108/1081 (9.9)
2002; Riskin-Mashiah [28] 181/1905 (9.5) vs 861/1905 (45.2) vs 767/1905 (40.3) vs N/A N/A N/A 67/1905 (3.5) vs 1466/1905 (77.0) vs
1899/21 339 (6.6) 6181/21 339 (29.0) 4529/21 339 (21.2) 255/21 339 (1.2) 3983/21 339 (18.7)
2004; Macarthur [27] N/A N/A 42/46 (91.3) vs N/A N/A N/A N/A N/A
200/304 (65.8)
2006; Eogan [16] N/A N/A N/A N/A N/A N/A N/A N/A
2005; Hudelist [20] 2/46 (4.3) vs 11/46 (23.9) vs 2/46 (4.4) vs 40 vs N/A N/A N/A N/A
12/155 (7.7) 43/155 (27.7) 11/155 (7.1) 21
2005; Sheiner [31] 13/79 (16.5) vs N/A 10/79 (12.7) vs N/A N/A N/A 43/79 (54.4) vs N/A
9478/98 445 (9.6) 7644/98 445 (7.8) 29 266/98 445 (29.7)
2006; Aukee [12] 9/53 (17.0) vs 34/53 (64.2) vs 19/53 (35.8) vs N/A 2/53 (3.8) vs N/A N/A N/A
1219/9125 (13.4) 5077/9125 (55.6) 2132/9125 (23.4) 175/9125 (1.9)
2007; Dahlen [14] 27/134 (20.1) vs 43/134 (32.0) vs 54/134 (40.3) vs N/A N/A N/A N/A N/A
1295/6461 (20.0) 1004/6461 (15.5) 1813/6461 (28.1)
2007; Lowder [26] N/A N/A N/A N/A N/A N/A N/A 1855/2533 (73.2) vs
9705/18 150 (53.5)
2006; Kudish [24] N/A N/A 852/1229 (69.3) vs N/A N/A N/A 3/1229 (0.2) vs 717/1229 (58.3) vs
15 952/32 613 (48.9) 30/32 613 (0.1) 3277/32 613 (10.0)
2010; Hornemann [19] N/A N/A N/A N/A 4/50 (8.0) vs N/A 43/50 (86.0) vs 2/50 (4) vs
46/2917 (1.6) 1580/2917 (54.2) 210/2917 (7.2)
2011; Groutz (a) [17] N/A 29/60 (48.3) vs 49/60 (81.7) vs 91 ± 75 vs 6/60 (10.0) vs N/A N/A N/A
84/240 (35.0) 174/240 (72.5) 58 ± 51 9/240 (3.8)
2011; Groutz (b) [18] N/A N/A 74/96 (77.1) vs 83 ± 68 vs 8/96 (8.3) vs N/A N/A N/A
29 310/38 426 (76.3) 62 ± 61 1268/38 426 (3.3)
a
Values are given as number (percentage) or mean ± SD.

3
4 V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

reference lists. After reviewing the articles in full, we excluded 17
papers because they did not investigate the outcomes included in the
present review. The final meta-analysis included 22 articles.
All investigators were in agreement with regard to the eligibility
criteria and the definitions of primary and secondary outcomes. Two
authors (P.V. and V.G.) abstracted and tabulated predetermined data—
including maternal and neonatal somatometric indices and labor
characteristics—from each selected article. The other authors reviewed
the data independently to increase the reliability of the findings.
The authors consulted the Meta-analysis Of Observational Studies in
Epidemiology statement [6].
2.2. Definitions
Women with third- or fourth-degree perineal laceration (severe
injury) comprised the study group, whereas women with no laceration
or with first- or second-degree tears comprised the control group. The pri-
mary outcomes were neonatal birth weight, episiotomy, and instrumen-
tal delivery. Episiotomy was subdivided into mediolateral and median
episiotomy where these data were available, and instrumental delivery
was subdivided into vacuum and metallic forceps delivery. The remaining
tabulated indices, including maternal age, Asian ethnicity, primiparity,
pregnancy duration, labor induction and labor augmentation, epidural an-
algesia, duration of the second stage of labor, breech presentation, and
persistent occiput posterior, served as secondary outcomes. Asian ethnic-
ity has been implicated as a possible risk factor by several studies and was,
therefore, included in the present evaluation—even though a systematic
review [7] contains conflicting evidence regarding the relative risk of
perineal tears among Asian women.
2.3. Statistical analysis
A minimum of 4 studies was required to perform a statistical analy-
sis of selected indices. The meta-analysis was performed using RevMan
5.1 (Cochrane Collaboration, Oxford, UK). The heterogeneity between
randomized controlled trials was assessed using the χ2 and I2 tests,
with P b 0.05 being considered statistically significant. Odds ratios
(OR) and 95% confidence intervals (CI) were calculated for all primary
and secondary outcomes, using either the Mantel–Haenszel fixed-
effects model (FEM) or the DerSimonian–Laird random-effects model
(REM). The FEM was used if neither the χ2 test nor the I2 test indicated
heterogeneity between the studies. If there was statistically significant
heterogeneity, the results were interpreted using the REM.
For indices that were evaluated in more than 10 studies, publication
bias was assessed with the Egger test [8], using Comprehensive Meta-
Analysis version 2 (Biostat, Englewood, NJ, USA). The significance level
in the analysis of publication bias was set at P b 0.05. Adjustments for

Table 3
Labor characteristics 2.a

Date; first author Episiotomy Spontaneous delivery Instrumental delivery Vacuum delivery Forceps delivery

1994; Anthony [11] 81/599 (13.6) vs N/A N/A N/A N/A

13 292/42 710 (31.1)
1997; Labrecque [25] 906/1002 (90.4) vs N/A N/A N/A N/A
N/A
1997; Klein [23] 74/75 (98.6) vs 40/75 (53.3) vs 35/75 (46.7) vs N/A 35/75 (46.7) vs
260/384 (67.7) 336/384 (87.5) 48/384 (12.5) 48/384 (12.5)
1999; Robinson [29] 220/276 (79.7) vs 141/276 (51.1) vs 135/276 (48.9) vs 48/276 (17.4) vs 87/276 (31.5) vs
704/1666 (42.3) 1478/1666 (88.7) 188/1666 (11.3) 113/1666 (6.8) 75/1666 (45)
2000; Jones [22] N/A N/A 52/131 (39.7) vs N/A 52/131 (39.7) vs
2031/15 073 (13.5) 2031/15 073 (13.5)
2000; Samuelsson [30] N/A N/A 17/95 (17.9) vs 17/95 (17.9) vs N/A
142/2788 (5.1) 142/2788 (5.1)
2000; Angioli [10] 908/1124 (80.8) vs 805/1124 (71.6) vs 319/1124 (28.4) vs 136/1124 (12.1) vs 183/1124 (16.3) vs
16 883/49 086 (34.4) 46 990/49 086 (95.7) 2096/49 086 (4.3) 1326/49 086 (2.7) 770/49 086 (1.6)
2001; de Leeuw [15] 1343/5528 (23.6) vs 4052/5528 (73.3) vs 1146/5528 (20.7) vs 720/5528 (13.0) vs 375/5528 (6.8) vs
99 521/27 9255 (35.7) 23 3947/27 9255 (83.8) 31 425/27 9255 (11.3) 23 195/27 9255 (83.0) 7625/27 9255 (2.7)
2001; Jandér [21] 57/214 (26.7) vs 135/214 (63.1) vs 79/214 (36.9) vs 78/214 (36.4) vs 1/214 (0.5) vs
24/214 (11.2) 193/214 (90.2) 21/214 (9.8) 21/214 (9.8) 0/214 (0.0)
2001; Bodner-Adler [13] 22/37 (59.5) vs 29/37 (78.3) vs 8/37 (21.7) vs N/A 8/37 (21.7) vs
220/1081 (20.4) 983/1081 (90.9) 78/1081 (7.2) 78/1081 (7.2)
2002; Riskin-Mashiah [28] 1533/1905 (80.5) vs 1086/1905 (57.0) vs 819/1905 (43) vs 118/1905 (6.2) vs 701/1905 (36.8) vs
4238/21 339 (19.9) 20 139/21 339 (94.4) 1200/21 339 (5.6) 404/21 339 (1.9) 796/21 339 (3.7)
2004; Macarthur [27] N/A N/A N/A N/A N/A
2006; Eogan [16] N/A 19/54 (35.4) vs 23/54 (48.1) vs 15/54 (27.8) vs 8/54 (14.8) vs
27/46 (58.4) 14/46 (30.4) 10/46 (21.7) 4/46 (8.7)
2005; Hudelist [20] 29/46 (63.0) vs N/A 13/46 (28.3) vs N/A 13/46 (28.3) vs
59/155 (38.1) 14/155 (9.0) 14/155 (9.0)
2005; Sheiner [31] 43/79 (54.4) vs 57/79 (72.1) vs 22/79 (27.9) vs 19/79 (24.1) vs 3/79 (3.8) vs
29 266/98 445 (29.7) 95 464/98 445 (97.0) 2981/98 445 (3.0) 2848/98 445 (2.9) 133/98 445 (0.1)
2006; Aukee [12] 25/53 (47.2) vs N/A 18/53 (34.0) vs 18/53 (34.0) vs N/A
3418/9125 (37.5) 511/9125 (5.6) 511/9125 (5.6)
2007; Dahlen [14] 38/134 (28.4) vs 84/134 (62.7) vs 50/134 (37.3) vs N/A N/A
795/6461 (12.3) 5467/6461 (84.6) 994/6461 (15.4)
2007; Lowder [26] 3/2533 (0.1) vs N/A 593/2533 (23.4) vs N/A 593/2533 (23.4) vs
30/18 150 (0.1) 1910/18 150 (10.5) 1910/18 150 (10.5)
2006; Kudish [24] 720/1229 (58.6) vs 693/1229 (56.4) vs 536/1229 (43.6) vs N/A N/A
3317/32 613 (10.2) 30 645/32 613 (94.0) 1968/32 613 (6.0)
2010; Hornemann [19] 45/50 (90.0) vs 37/50 (74.0) vs 12/50 (24.0) vs 7/50 (14) vs 5/50 (10) vs
1790/2917 (61.3) 2689/2917 (92.2) 228/2917 (7.8) 121/2917 (4.1) 107/2917 (3.7)
2011; Groutz (a) [17] N/A N/A 16/60 (26.7) vs 16/60 (26.7) vs N/A
9/240 (3.8) 9/240 (3.8)
2011; Groutz (b) [18] N/A N/A 20/96 (20.8) vs 20/96 (20.8) vs N/A
2166/38 426 (5.7) 2166/38 426 (5.7)
a
Values are given as number (percentage).

Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
 V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx 5

Fig. 1. Neonatal birth weight and incidence of severe perineal lacerations.

publication bias were made using the trim and fill method proposed by
Duval and Tweedie [9].
3. Results
The present review included 22 articles [10–31]. The studies includ-
ed 651 934 women, 15 366 (2.4%) of whom developed third- or fourth-
degree perineal lacerations (severe perineal lacerations group); the re-
maining 625 998 (96.0%) had minor or no severe perineal lacerations.
The present meta-analysis included 2 studies by Groutz et al. [17,18];
the first study [17] was included because labor augmentation was not
analyzed in the larger second study [18]. Maternal and neonatal charac-
teristics and labor characteristics from the included studies are provided
in Tables 1–3.
3.1. Primary outcomes
The neonatal birth weight in the group with severe perineal tears
was significantly higher than that in the control group, the mean
difference being 192.88 g (95% CI, 139.80–245.96 g; P b 0.001)
(Fig. 1). The analysis (REM) included 210 959 women from 5 studies
[10,18,23,28,31]. No publication bias was noted for the included
studies (P = 0.69).
Episiotomy was performed significantly more often among women
with severe perineal tears (OR 3.69 [95% CI, 1.45–9.38; P b 0.001])
(Fig. 2). The analysis (REM) included 590 642 women from 15 studies
[10–15,19–22,24,26,28,29,31]. The same was observed for median epi-
siotomy (OR 3.82 [95% CI, 1.96–7.42]; P b 0.001) (the analysis [REM] in-
cluded 460 584 women from 9 studies [10,11,13,15,19,21,24,26,28])
(Fig. 3), but not for mediolateral episiotomy (OR 1.72 [95% CI,
0.81–3.65]; P = 0.16) (the analysis [REM] included 541 368 women
from 10 studies [10,11,13,15,19,21,24,28,30,31]) (Fig. 4). No publication
bias was noted for the studies included in the episiotomy analysis
(P = 0.35), the mediolateral episiotomy analysis (P = 0.28), or the
median episiotomy analysis (P = 0.76).
Instrumental delivery was also significantly more prevalent among
women with severe perineal lacerations (OR 5.10 [95% CI, 3.33–7.83];
P b 0.001) (the analysis [REM] included 590 883 women from 18 stud-
ies [10,12–16,18–24,26,28–31]) (Fig. 5), regardless of whether women
had a vacuum delivery (OR 3.98 [95% CI, 2.60–6.09]; P b 0.001)
(the analysis [REM] included 512 781 women from 11 studies
[10,12,15,16,18,19,21,28–31]) (Fig. 6) or a metallic forceps delivery
(OR 5.50 [95% CI, 3.17–9.55]; P b 0.001) (the analysis [REM] included
499 435 women from 12 studies [10,13,15,16,19,20,22,23,26,28,
29,31]) (Fig. 7). No publication bias was noted for the studies included
in the instrumental delivery analysis (P = 0.38) or in the metallic for-
ceps analysis (P = 0.70). However, there was publication bias among
the studies included in the vacuum extraction analysis (P = 0.02).
The adjusted OR after application of the trim and fill method was 2.01
(95% CI, 1.35–2.99; P = 0.012).
3.2. Secondary outcomes
3.2.1. Primiparity
Primiparity was significantly more prevalent among women with
severe perineal lacerations (OR 3.24 [95% CI, 2.20–4.76]; P b 0.001).
The analysis (REM) included 515 161 women from 12 studies
[11,13–15,18,20–22,27,28,30,31]. There was heterogeneity between
the studies (I2 = 97%), but no publication bias (P = 0.37).

Fig. 2. Episiotomy (all types) and incidence of severe perineal lacerations.

Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
6 V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

Fig. 3. Median episiotomy and incidence of severe perineal lacerations.

3.2.2. Asian ethnicity 3.2.3. Labor induction

Asian ethnicity was associated with an increased risk of severe per-
ineal lacerations (OR 2.74 [95% CI, 1.31–5.72]; P b 0.01). This analysis
(REM) included 111 697 women from 4 studies [11,14,18,28]. There
was significant heterogeneity between the studies (I2 = 92%), but no
publication bias (P = 0.54).
Women in the severe lacerations group had significantly higher
rates of labor induction than controls (OR 1.08 [95% CI, 1.02–1.14];
P = 0.01). The analysis (FEM) included 468 204 women from 9 studies
[11,12,14,15,20,21,28,29,31]. No heterogeneity between the studies was
identified (I2 = 0%), and there was no publication bias (P = 0.92).

Fig. 4. Mediolateral episiotomy and incidence of severe perineal lacerations.

Fig. 5. Instrumental delivery (all types) and incidence of severe perineal lacerations.

Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
 V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx 7

Fig. 6. Vacuum extraction and incidence of severe perineal lacerations.

3.2.4. Labor augmentation 3.3. Outcomes not included in meta-analysis

Similarly to labor induction, women in the severe lacerations group
had significantly higher rates of labor augmentation (OR 1.95 [95% CI,
1.56–2.44]; P b 0.001). The analysis (REM) included 43 006 women
from 8 studies [12–14,17,20,21,28,29]. There was heterogeneity
between the studies (I2 = 67%), but no publication bias (P = 0.77).
3.2.5. Epidural anesthesia
Women with severe perineal tears were offered epidural anesthesia
significantly more often than the control group (OR 1.95 [95% CI,
1.63–2.32]; P b 0.001). The analysis (REM) included 66 044 women
from 11 studies [12–14,18,20,21,23,24,27,28,31]. There was het-
erogeneity between the studies (I2 = 64%) and publication bias
(P = 0.037). The OR adjusted by the trim and fill method was 2.29
(95% CI, 1.89–2.71; P b 0.001).
Neither maternal age nor pregnancy duration indices were signifi-
cantly different between the 2 groups [10,12,14,16–18,20,23,28,31].
Maternal body mass index values before pregnancy and at delivery
were also comparable between the 2 groups [18,20]. Lowder et al. [26]
reported a significantly higher rate of severe perineal lacerations
among women with a vaginal birth after cesarean delivery (VBAC)
compared with multiparous women (260/1423 versus 193/6068;
P b 0.001). However, the results for women in the VBAC arm were sim-
ilar to those of primiparous women (2080/13 183). Groutz et al. [18]
also reported a higher rate of lacerations among women in the VBAC
group than among those in the non-VBAC group (3/60 versus 18/240),
but this finding did not reach statistical significance (P = 0.777) [18].
The second stage of labor was also prolonged among women with
third- or fourth-degree tears, but this result was not statistically signif-
icant (P = 0.195) [18].

3.2.6. Persistent occiput posterior presentation 4. Discussion

Women with severe perineal lacerations had significantly higher
rates of persistent occiput posterior presentation (OR 3.09 [95% CI,
1.81–5.29]; P b 0.001). The analysis (REM) included 353 965 patients
from 7 studies [12,15,18,19,21,22,30]. There was heterogeneity
between the studies (I2 = 78%), but no publication bias (P = 0.13).
Severe perineal laceration represents a major complication of nor-
mal labor that requires advanced surgical skills during reconstruction
to avoid postoperative bowel incontinence. Persistent fecal incon-
tinence rates are fairly low (4%) among women experiencing anal

Fig. 7. Metallic forceps delivery and incidence of severe perineal lacerations.

Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
8 V. Pergialiotis et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
sphincter tears [3]. Persistent flatus incontinence, however, is signifi-
cantly more frequent, reaching rates as high as 35% [32]. Identifying in-
dividual factors that may lead to third- or fourth-degree perineal
lacerations is difficult because in most women several risk factors
seem to interact.
In the present review, we identified significantly higher rates of
routine episiotomy and operative vaginal delivery (metallic forceps or
vacuum delivery) among women with third- or fourth-degree perineal
tearing. In particular, median episiotomy was significantly more preva-
lent among patients in the study group, but this was not the case with
mediolateral episiotomy. This finding is in accordance with a previous
report [16] that larger angles of episiotomy from the perineal midline
lead to reduced rates of sphincter disruption.
The neonatal birth weight was significantly higher in the group with
severe tearing of the perineum. Labor induction, labor augmentation,
and epidural anesthesia were also more prevalent among these
women, and abnormal cephalic presentation, especially persistent
occiput posterior, seems to be a causative factor, too.
Some of the factors that predispose to severe perineal lacerations are
modifiable. The authors of 2 studies conducted in the Nordic countries
[33,34] proposed the use of an intervention program that involves im-
proved communication with the parturient and delivery of the infant
under proper visualization of the perineum. This ensures the provision
of adequate perineal support, leading to reduced rates of third- and
fourth-degree perineal tearing. Similar results have been obtained by
supporting the fetal head during crowning with one hand, and
instructing the mother not to push after delivery of the head in order
to slow down the process of birth [35].
Factors that ultimately lead to the occurrence of severe perineal tear-
ing are interrelated. Although episiotomy was more prevalent among
women with this complication in the present study, its strict avoidance
cannot be seen as the ultimate preventive measure. Of particular inter-
est is a recent randomized controlled trial [36] that found no difference
in the frequency of severe perineal lacerations between women offered
routine episiotomy and those receiving restrictive episiotomy. Howev-
er, a quasi-randomized controlled trial [37] revealed a higher incidence
of anal incontinence among women who were offered routine episioto-
my. Alperin et al. [38] also observed a significantly increased occurrence
of severe perineal lacerations in subsequent vaginal deliveries after rou-
tine episiotomy [38], although the results of a recent study are conflict-
ing [39]. The discrepancies in the incidence of mediolateral episiotomy
among women with severe perineal lacerations could be explained by
technical differences. Eogan et al. [16] have evaluated the angle of
mediolateral episiotomy as a factor that may influence the incidence
of perineal tears. The effect of lateral episiotomy has also been investi-
gated [40]. Karbanova et al. [41] proposed the ischial tuberosity as a ref-
erence point to define the type of episiotomy in future trials in the field.
The authors of a review published in 1999 [42] discussed the possi-
bility that labor might be prolonged when epidural anesthesia is used.
The results of more recent randomized controlled trials [43,44] are con-
flicting. In the present systematic review, women with third- or fourth-
degree lacerations had a significantly longer second stage of labor
[18,20,23]. However, prolongation of the second stage was not investi-
gated in comparison with the administration of epidural anesthesia,
and it is therefore difficult to hypothesize their interplay in the patho-
genesis of severe tears. There is also evidence that the performance of
epidural anesthesia among parturients increases the rates of forceps
and vacuum-assisted deliveries [45,46]. In the present review, we
could not extract information from the included studies regarding
operative vaginal delivery rates among women with epidural block.
4.1. Study limitations
Some of the factors investigated in the present review were not
consistently available from the included studies. A meta-analysis to as-
sess the influence of the body mass index on the occurrence of perineal
Please cite this article as: Pergialiotis V, et al, Risk factors for severe perineal lacerations during childbirth, Int J Gynecol Obstet (2014), http://
dx.doi.org/10.1016/j.ijgo.2013.09.034
lacerations was not possible because of insufficient data. Meta-
regression analyses to investigate interrelations such as the effect of
the body mass index on the birth weight, or the effect of epidural anal-
gesia on the duration of the second stage and on instrumental delivery,
were also precluded for the same reason. The angle of mediolateral epi-
siotomies might vary between studies, which could explain conflicting
results. Shoulder dystocia—a factor that, in our experience, predisposes
to the occurrence of perineal lacerations—was also not recorded.
5. Conclusion
The present review identified significantly higher rates of severe
perineal tearing among primiparous women and among women who
were offered labor induction, augmentation of labor, epidural anesthe-
sia, an operative vaginal technique for the delivery of the neonate, or
an episiotomy procedure (especially median episiotomy).
Several factors that contribute to the occurrence of perineal lacera-
tions are modifiable. Among them, the parameters that are easiest to
address include proper visualization of the perineum and adequate
support of the fetal head. Instructing the parturient not to push could
also prove adequate in reducing the incidence of this significant compli-
cation. We would also like to emphasize that whenever an episiotomy
procedure is performed, the mediolateral approach, with an angle of
more than 45 degrees from the perineal midline, is to be preferred to
minimize the risk of potential third- or fourth-degree lacerations.
Future studies should consistently examine all factors that potential-
ly influence the occurrence of perineal tears and evaluate their interre-
lation to enable a high-quality analysis and appropriate interpretation
of the results. In particular, the indices investigated in the present
study should be reported, episiotomy angles should be recorded, and
the perineum should be inspected during crowning.
Conflict of interest
The authors have no conflicts of interest.
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