Acta Obstetricia et Gynecologica.

2006; 85: 856 860

ORIGINAL ARTICLE

The role of mediolateral episiotomy during labour: Analysis of risk factors for obstetric anal sphincter tears

PAULIINA AUKEE1, HELENA SUNDSTROM1 & MATTI V. KAIRALUOMA2

Pelvic Floor Research & Therapy Unit, Department of Obstetrics and Gynaecology, 2Department of Gastroenterological Surgery, Jyvaskyla Central Hospital, Jyvaskyla, Finland
1

Abstract Background. To determine risk factors for third-degree and complete third- or fourth-degree anal sphincter tears in vaginal delivery. Methods. This is a retrospective comparative study. Fifty-three women who had sustained an anal sphincter tear were compared with 9,178 women without such a complication between August 1997 and October 2001. Obstetric data was collected from an electronic database. The main outcome measures were odds ratios. Results. In the whole study population, odds ratios (ORs) for third-degree tears were: primiparity, 8.34 (95% confidence interval [CI] 3.98 17.48); vacuum extraction, 5.22 (95% CI 2.69 10.13); parietal presentation, 3.97 (95% CI 1.16 13.64); and birth weight /4,000 g, 3.77 (95% CI 2.11 6.68); and for complete third- or fourth-degree tears odds ratios were 5.42, 2.98, 5.64, and 3.01, respectively. In multivariate analysis, mediolateral episiotomy appeared to be protective as regards third-degree tears (OR 0.37 [95% CI 0.2020 0.70]). Conclusions. Vacuum-assisted vaginal delivery bears an increased risk of third-degree anal sphincter tears in a maternity unit where forceps are not used. Restricted use of mediolateral episiotomy may have a protective effect on the perineum.

Key words: anal sphincter tear, vacuum extraction, risk factor

Introduction Obstetric trauma is one of the commonest causes of fecal incontinence (1,2). The incidence of anal incontinence following obstetric trauma is reported to range between 7 and 56% (3 6) and that of clinically evident anal sphincter rupture between 0.5 and 6% (3,7 10). Although obstetric lacerations involving the anal sphincter complex are uncommon, they should be considered as serious complications of vaginal delivery, as almost half of the affected women have persistent defecatory symptoms (7,10,11). Persistent defecatory symptoms may result from either direct perineal trauma or pudendal nerve damage during vaginal delivery (12 14). In previous reports, an increased risk of perineal tears has been associated with primiparity, birth weight over 4,000 g, episiotomy, large infant head diameter, delivery position, prolonged second stage of labor, use of oxytocin, epidural anesthesia, forceps

delivery, and vacuum extraction (7,9,15 24). The association between the use of episiotomy and perineal tears has been somewhat obscure and contradictory (9,16 18,24 27). The aim of the present study was to identify risk factors for third-degree and complete third- or fourth-degree anal sphincter tears in women undergoing vaginal delivery. Material and methods Data on all deliveries registered in the Jyvaskyla Central Hospital obstetric database (MAMA) between August 1997 and October 2001 was collected retrospectively and compared with data from the proctological database. During the study period there were a total of 11,255 deliveries beyond 22 weeks of gestation. Delivery was by cesarean section in 2,000 (18%) cases and these were excluded from

Correspondence: Pauliina Aukee, Pelvic Floor Research and Therapy Unit, Department of Obstetrics and Gynaecology, Jyvaskyla Central Hospital, Keskussairaalantie 19, FIN-40620 Jyvaskyla, Finland. E-mail: pauliina.aukee@ksshp.fi

(Received 18 January 2005; accepted 8 August 2005)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2006 Taylor & Francis DOI: 10.1080/00016340500408283

Risk factors for third-degree obstetric anal sphincter tears 857 the study. Only delivery data of fetus A were included in the study, and thus data on 9,178 deliveries (5,810 multipara and 3,368 primipara) remained for final analysis. Deliveries were performed according to Finnish routines in which the majority of uncomplicated deliveries are handled by midwives. Obstetricians or trainees were called upon when necessary to consult, to perform instrumental deliveries, or to inspect large tears and bleedings. Only mediolateral episiotomies were carried out. Vacuum cups used were either Bird or a soft cup, 50 60 mm in diameter. Forceps were not used in our hospital. Anal sphincter injury was classified as third degree when it involved the external anal sphincter with or without the internal sphincter, complete third degree when the whole thickness of the external sphincter was ruptured and fourth degree when it also involved the rectal mucosa. In data analysis, no difference was made between complete third-degree and fourthdegree lacerations. Partial external sphincter lesions were sutured end-to-end in the delivery room by obstetricians and complete third- and fourth-degree lesions were sutured in the operating theatre by the obstetrician on call, using the end-to-end technique, or by senior colorectal surgeons, using the overlap technique. The results of immediate repair using the overlap technique have been published previously (28). The data assessed included maternal age, parity, gestational age, induction of labour, duration of second stage, analgesia, induction of labour, augmentation of labour, use of mediolateral episiotomy, use of vacuum extraction, fetal presentation, fetal weight, fetal length, fetal head circumference, and the grade of perineal tear. The associations between the above factors and the occurrence and grade of perineal tear were calculated using univariate logistic regression, for the whole study group and for primiparas and multiparas separately. All factors with a p -value under 0.25 in univariate analysis were processed by forward stepwise multivariate logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. The chi-squared test and Fishers exact test were used for categorical data. The software used for statistical analysis was SPSS for Windows version 11.5.1 (SPSS Inc., Chicago, IL). A p -value less than 0.05 was considered as statistically significant. Results Obstetric and fetal characteristics are presented in Table I. During the study period there was a total of 53 (0.6%) third-degree anal sphincter tears of which 37 (0.4%) were classified as complete. In primiparas, the rates were 42 (1.2%) and 29 (0.9%), respectively. The rate of mediolateral episiotomy was 38% and that of vacuum extraction 6%. In women with vacuum-assisted delivery, third-degree sphincter ruptures occurred in 12 (3%) with mediolateral episiotomy and in 6 (8%) without mediolateral episiotomy (p 0/0.028) and complete third- or fourth-degree sphincter ruptures occurred in 6 (1%) versus 5 (7%) women (p 0/0.011), respectively. In univariate analysis third-degree anal sphincter tears were significantly associated with gestational age over 42 weeks, primiparity, prolonged duration of the second stage (over 2 hours), birth weight over 4,000 g, parietal presentation, and vacuum extraction. In primiparas, the respective factors were gestational age over 42 weeks, induction of labour, birth weight over 4,000 g, and vacuum extraction. In women with complete third- or fourth-degree anal sphincter tears, univariate analysis demonstrated association with primiparity, birth weight over 4,000 g, parietal presentation, and vacuum extraction. In primiparas with complete third- or fourthdegree anal sphincter tears, the associated factors were birth weight over 4,000 g, parietal presentation, and vacuum extraction. When analyzing the data in a multivariate model (Table II), taking into account all factors with a p-value under 0.25 in univariate analysis, primiparity, vacuum extraction, parietal presentation, and birth weight over 4,000 g were independently associated with third-degree tears and also with complete third- or fourth-degree perianal tears. In primiparas, independently associated factors were vacuum extraction and birth weight over 4,000 g. Multivariate logistic regression analysis demonstrated mediolateral episiotomy to have a protective role in relation to third-degree tears and in primiparas, also in relation to complete third- and fourth-degree tears. Discussion The incidence of third-degree perineal tears in our population was low (0.6%), and is in line with incidences reported in previous studies (3,7 10). In the present study the incidence of complete anal sphincter rupture was 0.4%, which is lower than that of 0.8% reported previously (21). From the beginning of the study period, special attention has been paid in our hospital to the diagnosis, classification, and treatment of sphincter tears. When comparing the data from the obstetric database with that from the proctologic database, no missed or falsely

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Table I. Obstetric characteristics of the study and the control group. Values are given as n (%). Sphincter tear No sphincter tear Total Primiparas Mean maternal age (years) Mean gestational age (days) (n0/9,144) Gestational age /42 weeks Induction of labor Augmentation of labor Epidural analgesia Mean duration of second stage (min) (n0/9,081) Second stage /2 h Mean birth weight (g) (n0/9132) Birth weight /4,000 g Episiotomy Vacuum extraction Presentation (n 0/9,074) Occipitoanterior presentation Occipitoposterior presentation Parietal presentation 9,125 3,368 29 279 258 1,219 5,077 2,132 29 142 3,577 1,710 3,418 511 (99) (37) (6) (12) (3) (13) (56) (23) (29) (2) (521) (19) (38) (6) 3rd degree 53 42 29 282 6 9 34 19 59 4 3,833 22 25 18 (0.6) (1.2) (5) (10) (11) (17) (64) (36) (40) (8) (490) (42) (48) (34) Complete 3rd/4th degree 37 29 30 282 2 4 24 13 61 2 3,828 14 16 11 (0.4) (0.9) (5) (9) (5) (11) (65) (35) (36) (6) (440) (38) (43) (30)

8,552 (95) 175 (2) 70 (0.8)

46 (87) 2 (4) 3 (6)

32 (87) 1 (3) 3 (8)

classified cases were found; thus the above-mentioned incidences can be considered to be accurate. Although the present data showed vacuum extraction to increase the risk of third-degree perineal tears, we are not against the use of vacuum extraction, as in the majority of cases (96%) it was advantageous for the delivery. In contrast to the high (20%) third-degree sphincter rupture rate in primiparas undergoing vacuum extraction reported by Parnell et al. (23), the rate was only 4% in the present study. Our results agree with those in prior reports suggesting an association between sphincter tears and primiparity (7,10,17,21). It has been supposed that the increased risk among nulliparas is related to relative inelasticity of the perineum. Special attention should be focused on those techniques that may

protect the perineum in the first vaginal delivery. According to the results of a meta-analysis by Eason et al. (29), perineal massage during pregnancy may help to prevent perineal trauma, especially in the first vaginal birth. Easing of the perineum was also related to a decrease in sphincter rupture risk in a study by Parnell et al. (23). Similarly, perineal support and close observation have been proven to reduce the risk (30,31). In this study, however, these techniques were not assessed. Macrosomia is a risk to both the fetus and the mother. Our results confirm those of previous studies, in which high birth weight has been shown to increase the risk of anal sphincter tears (8,12,18,21,31). At the moment there is not enough data to show that in nondiabetic women the induction of labour because of suspected fetal macrosomia

Table II. Outcome of stepwise multivariate logistic regression analysis of variables that potentially affect the incidence of sphincter tears. Sphincter tear 3rd degree p Primiparity Birth weight /4,000 g Episiotomy Parietal presentation Vacuum extraction Primiparas Birth weight /4,000 g Episiotomy Vacuum extraction B/0.001 B/0.001 0.002 0.028 B/0.001 0.008 0.004 B/0.001 OR 8.34 3.76 0.37 3.97 5.22 3.02 0.31 4.67 95% CI 3.98 17.48 2.11 6.68 0.20 0.70 1.16 13.64 2.69 10.13 1.33 6.85 0.14 0.70 2.01 10.86 p B/0.001 0.002 0.006 B/0.001 0.003 0.005 B/0.001 Complete 3rd/4th degree OR 5.42 3.01 5.64 2.98 3.33 0.327 5.00 95% CI 2.37 12.39 1.50 6.05 1.63 19.52 1.37 6.48 1.51 7.35 0.15 0.72 2.20 11.38

Risk factors for third-degree obstetric anal sphincter tears 859 would alter the risk of maternal or neonatal morbidity (32). In our western lifestyle weight control is a challenging problem among fertile aged women, as being overweight is related to gestational diabetes and macrosomia. An overweight condition has also been shown to be an independent risk factor for both urinary and anal incontinence (33). Our routine is to assess the need for mediolateral episiotomy on a case-by-case basis. In our study population the risk of sphincter tears was decreased when applying mediolateral episiotomy. This finding agrees with that reported by Poen et al. (18), but is in contrast to the findings of Williams (9). In three other studies median episiotomy has been clearly shown to increase the risk of tears (10,16,21). Eason and colleagues (29) proposed that mediolateral episiotomy does not protect the anal sphincter, but median episiotomy clearly puts it at greater risk. According to our results, mediolateral episiotomy in a vacuum-assisted delivery may protect the anal sphincter from tears. One possible bias in our study results from the fact that vacuum extractions were performed by doctors and not by midwives. According to Gupta and colleagues (8), doctor-conducted delivery is associated with an increased risk of perineal tears. On the other hand, in our hospital, doctors are called when the progress of delivery has altered or fetal distress is being treated. Over 90% of deliveries had occipital presentation. The number of cases of occipitoposterior presentation was low and that of parietal presentation was even lower, so no firm conclusions can be drawn as regards fetal presentation as a risk factor. Position and presentation should be clinically examined before vacuum extraction, but in the later stages of labour a large caput succedaneum may be present, making it difficult to define the position. This can be overcome by the use of ultrasonographic examination during labor; ultrasonography has been shown to determine the fetal occiput and spine positions accurately during labor in less than 2 min (34). In prevention of anal sphincter tears, the use of perineal massage prior to and during birth and manual perineal support should be further analyzed. In vacuum deliveries, perineal support and the timing of episiotomy may be difficult without good co-operation between the doctor and midwife. According to our experience in treating complete third- or fourth-degree tears, excellent results can be achieved by an experienced obstetrician or surgeon using meticulous techniques in an operating theatre setting with good lighting exposure and equipment (28). Women operated upon should have colorectal follow-up. After delivery it is natural for the mother to concentrate on the newborn infant and new family situation rather than on her own health. Therefore, it should be normal practice to check that the perineum and the pelvic floor are both anatomically and functionally in good condition after delivery. In Finland, all mothers undergo postpartum clinical examination 68 weeks after delivery. If signs of fecal incontinence exist at that time, the mother should be sent to a colorectal unit for further evaluation. Conclusions Primiparity and vacuum extraction are the main risk factors associated with third-degree sphincter tears in a maternity unit where forceps are not used. Restricted use of mediolateral episiotomy may have a protective effect on the perineum, especially in deliveries where vacuum extraction is used.

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