Recurrent Risk of Anal Sphincter Laceration Among
Women With Vaginal Deliveries
Anny Spydslaug, MD, Lill I. S. Trogstad, MD, Anders Skrondal, PhD, and Anne Eskild, MD, PhD
OBJECTIVE: The first aim of this study was to estimate the
impact of anal sphincter laceration during the first delivery
on the risk of recurrence in the second delivery. The second
aim was to estimate the absolute risk of anal sphincter
laceration in the second delivery according to the history of
anal sphincter laceration and birth weight.
METHODS: In this population-based cohort study, the study
sample comprised all women included in the Norwegian
Medical Birth Registry with 2 consecutive singleton vaginal
deliveries during the period 1967–1998 (n ⴝ 486,463). The
impact of prior anal sphincter laceration on recurrent anal
sphincter laceration was estimated as crude and adjusted
odds ratios (ORs).
RESULTS: Anal sphincter laceration during first delivery
increased the risk for a sphincter laceration in the next
delivery, (adjusted OR 4.3, 95% confidence interval 关CI兴
3.8 – 4.8). Other risk factors were birth weight (adjusted
OR 23.6, 95% CI 16.5–33.6, birth weight > 5,000 g versus
birth weight < 3,000 grams), use of forceps (adjusted OR
5.1, 95% CI 4.3– 6.0), use of vacuum (adjusted OR 1.4, 95%
CI 1.1–1.7), and period of delivery (adjusted OR 4.3, 95%
CI 3.7–5.0 for 1995–1998 versus 1967–1975). The absolute
risks for anal sphincter laceration at second delivery for
women with prior laceration were 1.3% (95% CI 0.4 –3.2%)
for birth weight less than 3,000 g and 23.3% (95% CI
11.8 –38.6%) for birth weight more than 5,000 g.
CONCLUSION: Only 10% of women with anal sphincter
laceration at second delivery had a history of prior lacera-
tion. Prior anal sphincter laceration is associated with in-
creased risk of laceration in second delivery, in particular
in women who carry children with high birth weight.
(Obstet Gynecol 2005;105:307–13. © 2005 by The Amer-
ican College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-2
The prevalence of anal incontinence has been estimated
at 4 –17% among adults. The prevalence increases by
From the Department of Obstetrics and Gynaecology, Ullevaal University Hospital,
and Division of Epidemiology, Norwegian Institute of Public Health, Oslo,
Norway.
This study was funded by a grant from the Research Forum of Ullevaal University
Hospital.
VOL. 105, NO. 2, FEBRUARY 2005
© 2005 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
age. More women than men suffer from anal inconti-
nence.1–3 The principal cause of anal incontinence in
women is obstetric trauma. Such trauma may be caused
by mechanical damage, impairment of the innervations
of anal sphincter muscles, or both.4 –7 Mechanical dam-
age of the anal sphincter muscles is assumed to be the
most important risk factor for anal incontinence because
reinnervation of the pelvic floor has been shown to occur
in up to 80% of women with innervation impairment
after delivery.4,6,8 –10 There is also some evidence of
subtle nerve injury to the anal sphincter after vaginal
delivery. Such injury may accelerate the normal impact
of aging and may therefore explain the appearance of
anal incontinence many years after delivery.11
Studies have reported that 30 –50% of women with
third- or fourth-degree of perineal tears experience anal
incontinence.5,12–17 Most of the women who report
anal incontinence after severe perineal tears suffer from
gas incontinence. The symptoms seem to prevail for
years.17,18 Because symptoms of anal incontinence may
affect a women’s social, psychological, and sexual life,14 it is
important to prevent these tears. Severe perineal tears occur
in 0.5–3% of all women who deliver vaginally, and recent
studies have shown that the incidence may be increasing
(Bek KM. Obstetric anal sphincter rupture 关PhD thesis兴.
University of Aarhus, 1993:9-23).5,19
The risk factors for severe perineal tears include null
parity, median episiotomy, high birth weight, operative
vaginal delivery, prolonged labor, induced labor, epi-
dural anesthesia, and maternal age.4,5,12,20 –25 Three re-
cent studies have shown an increased risk of third- and
fourth-degree tears of the anal sphincter in women who
have a history of a severe laceration.26 –28 These studies
have not reported the absolute risk of anal sphincter
laceration in second delivery in women with a history of
such laceration. The prior studies also suffer from lim-
ited sample sizes. To gain a better understanding of the
recurrence risk of anal sphincter laceration, large popu-
lation-based studies are needed. A better understanding
of these risks is necessary in counseling women with
prior anal sphincter laceration.
0029-7844/05/$30.00 307
doi:10.1097/01.AOG.0000151114.35498.e9

In this study, which included all women in Norway
with first and second vaginal deliveries during the period
1967–1998, the first aim was to estimate the impact of
anal sphincter laceration during the first delivery on the
risk of recurrence in the second delivery. The second
aim was to calculate the absolute risk (during 1990 –
1998) of anal sphincter laceration as it relates to prior
anal sphincter laceration and birth weight of the off-
spring.
MATERIALS AND METHODS
The study was a population-based cohort study. The
data were extracted from the Medical Birth Registry of
Norway, 1967–1998. Since 1967, all deliveries in Nor-
way after 16 weeks of gestation, more than 1.8 million
births, have been recorded in the Medical Birth Regis-
try.29 The registration is based on standardized forms
completed by midwives in the delivery ward shortly
after delivery. The study population included all women
with 2 consecutive (first and second) singleton deliveries
(n ⫽ 547,405). The study sample was restricted to
308 Spydslaug et al Recurrent Risk of Anal Sphincter Laceration
Fig. 1. Number of women accord-
ing to mode of delivery in first and
second pregnancy in Norway dur-
ing 1967–1998 (n ⫽ 547,405).
* Women in our study sample, a
total of 486,463.
Spydslaug. Recurrent Risk of Anal Sphincter
Laceration. Obstet Gynecol 2005.
women who gave birth vaginally in both the first and
second deliveries (n ⫽ 486,463; Fig. 1). Women with
cesarean delivery at the first or the second delivery, and
thus not at risk of anal sphincter laceration, were ex-
cluded (n ⫽ 60,942, 11.1% of the study population).
Information on all variables was obtained from the
Medical Birth Registry of Norway. Anal sphincter lacer-
ation at the second delivery, coded “yes” or “no,” was
the outcome variable. In the Medical Birth Registry, anal
sphincter laceration is categorized as either “rupture of
the anal sphincter” or “total rupture of the anal sphinc-
ter.” These 2 categories were combined as our definition
of anal sphincter laceration.
The main explanatory variable was anal sphincter
laceration at the first delivery, coded “yes” or “no.”
Information on the other explanatory variables was ob-
tained for the second delivery as follows:
• Birth weight: categorized as less than 3,000, 3,000 –
3,499, 3,500 –3,999, 4,000 – 4,499, 4,500 – 4,999, or
more than 5,000 g.
• Use of forceps: coded “yes” or “no.”
OBSTETRICS & GYNECOLOGY
• Use of vacuum: coded “yes” or “no.”
• Maternal age: categorized as less than 25, 25–29, 30 –
34, 35–39, or 40 years of age or older.
• Period of delivery: categorized as 1967–1974, 1975–
1979, 1980 –1984, 1985–1989, 1990 –1994, or 1995–
1998.
• Use of epidural analgesia: coded “yes” or “no.”
• Prolonged labor: prolonged total duration of labor
(⬎ 24 hours) or prolonged second stage of labor (⬎ 60
minutes), coded “yes” or “no.”
Crude and adjusted odds ratios of anal sphincter
laceration at second delivery according to history of anal
sphincter laceration were estimated with 95% confidence
intervals in logistic regression models. Absolute risks of
anal sphincter laceration at second delivery according to
sphincter laceration at first delivery and birth weight
were estimated as prevalence with 95% confidence inter-
vals. All statistical analyses were performed using SPSS
10.0 (SPSS Inc, Chicago, IL).
RESULTS
At the second delivery, a total of 3,378 women (0.7%,
3,378/486,463) had an anal sphincter laceration. Of the
9,558 women with anal sphincter laceration at the first
delivery, 357 (3.7%) had recurrent anal sphincter lacer-
ation. Of the 495,903 women without anal sphincter
laceration at the first delivery 3,021 (0.6%) had a sphinc-
ter laceration at the second delivery. Hence 10.6% (357/
3,378) of all cases of anal sphincter laceration at the
second delivery were recurrent.
The crude odds ratio of anal sphincter laceration at the
second delivery was 6.5 (95% confidence interval 关CI兴
5.8 –7.3) when there was sphincter laceration at the first
delivery (Table 1). The crude odd ratios of the other risk
factors are also presented in Table 1.
The adjusted odds ratio (OR) of sphincter laceration
at the second delivery was 4.3 (95% CI 3.8 – 4.8) (Table
1). For women having a child with birth weight greater
than 5,000 g, the adjusted OR of anal sphincter lacera-
tion was 23.6 (95% CI 16.5–33.6) compared with having
a child with birth weight less than 3,000 g. Also, use of
forceps increased the risk of anal sphincter laceration at
the second delivery (adjusted OR 5.1, 95% CI 4.3– 6.0).
Use of epidural anesthesia seemed to be protective (ad-
justed OR 0.8, 95% CI 0.6 – 0.9). Giving birth during the
most recent years (1995–1998) gave an adjusted OR of
4.3 (95% CI 3.7–5.0) when compared with deliveries
during the beginning of the observation period (1967–
1975), which was the reference period.
The estimated impact of prior anal sphincter lacera-
tion was almost the same in each period (1967–1974:
VOL. 105, NO. 2, FEBRUARY 2005
adjusted OR 4.4, 95% CI 2.1–9.3; 1995–1998: adjusted
OR 3.7, 95% CI 3.0 – 4.5). Data from the other periods
are not shown.
In women with anal sphincter laceration during the
first delivery, the absolute risk of a recurrent laceration
increased from 1.3% (95% CI 0.4 –3.2%) (Table 2) for
birth weight less than 3,000 g to 23.3% (95% CI 11.8 –
38.6%) for birth weight more than 5,000 g. In women
without anal sphincter laceration during the first deliv-
ery, the risk for laceration at the next delivery increased
from 0.2% (95% CI 0.1– 0.3) to 3.7% (95% CI 2.5–5.4).
Hence, the increase in relative risk according to birth
weight of the offspring was 17.9 (23.3%/1.3%) for
women with sphincter laceration at the first delivery and
18.5 (3.7%/0.2%) for women without a laceration at the
first delivery. The increase in absolute risk according to
birth weight was 22% (23.3% –1.3%) for women with a
sphincter laceration at the first delivery and 3.5% (3.7%
– 0.2%) for those women without a laceration.
DISCUSSION
A history of anal sphincter laceration was associated with
a 4.3-fold increased risk of a severe obstetrical laceration
at second delivery compared with no history of sphincter
laceration. Only 10.6% (357/3,378) of all cases of anal
sphincter laceration at the second delivery were in
women with a history of laceration in the first pregnancy.
The absolute risk of anal sphincter laceration increased
according to the birth weight of the offspring, in partic-
ular in women with prior anal sphincter laceration. In
this group the risk was 1.3% (95% CI 0.4 –3.2%) for birth
weight less than 3,000 g and 23.3% (95% CI 11.8 –
38.6%) for birth weight greater than 5,000 g.
To our knowledge, the impact of an anal sphincter
laceration during the first delivery on the risk of a
sphincter laceration in the second delivery has been
reported in 3 studies only.26 –28 These studies have re-
ported an increased risk: Payne et al26 (crude OR 3.4,
95% CI 1.8 – 6.4), Peleg et al27 (adjusted OR 2.5, 95% CI
1.8 –3.4), and Martin et al28 (adjusted OR 5.3, 95%
3.9 –7.1). None of these studies have calculated the ab-
solute risk of anal sphincter lacerations at second deliv-
ery according to birth weight. In these studies women
who had their second delivery in a different hospital
were excluded, and the size of this proportion was not
given. Selection bias in follow-up may therefore have
caused biased risk estimates.
As in our study, prior studies have shown an impact of
high birth weight and use of forceps on the risk of
sphincter laceration.5,12,30 –32 The observed increased
risk of anal sphincter laceration during the study period,
even when controlling for these risk factors, could be
Spydslaug et al Recurrent Risk of Anal Sphincter Laceration 309
Table 1. Anal Sphincter Laceration at the Second Delivery According to Sphincter Laceration at the First Delivery, Birth
Weight, Forceps and Vacuum Use, Maternal Age, Use of Epidural, Prolonged Labor, and Period of Delivery*
Sphincter Laceration Second Delivery
Yes No
Total (n) % n % n cOR (95% CI) aOR (95% CI)
Sphincter laceration
first delivery
Yes 8,968 4.0 357 96.0 8,611 6.5 (5.8–7.3) 4.3 (3.8–4.8)
No 477,495 0.6 3,021 99.4 474,474 1.0 1.0
Birth weight (g)
⬍ 3,000 51,077 0.1 57 99.9 51,021 1.0 1.0
3,000–3,499 146,625 0.3 499 99.7 146,126 3.1 (2.3–4.0) 2.9 (2.2–3.8)
3,500–3,999 183,605 0.7 1,220 99.3 182,385 6.0 (4.6–7.8) 5.4 (4.1–7.0)
4,000–4,499 85,261 1.3 1,122 98.7 84,139 11.9 (9.1–15.6) 10.0 (7.6–13.0)
4,500–4,999 17,124 2.4 406 97.6 16,718 21.7 (16.5–28.7) 16.9 (12.8–22.4)
⬎ 5,000 2,118 3.4 72 96.6 2,046 31.5 (22.2–44.7) 23.6 (16.5–33.6)
Missing 653
Forceps
Yes 4,729 3.7 175 96.3 4,554 5.7 (4.9–6.7) 5.1 (4.3–6.0)
No 481,734 0.7 3,203 99.3 478,531 1.0 1.0
Vacuum
Yes 6,347 1.7 110 98.3 6,237 2.6 (2.1–3.1) 1.4 (1.1–1.7)
No 480,116 0.7 3,268 99.3 476,848 1.0 1.0
Maternal age (y)
⬍ 24 153,713 0.4 570 99.6 153,143 1.0 1.0
25–29 211,141 0.7 1,497 99.3 209,644 1.9 (1.7–2.1) 1.4 (1.2–1.5)
30–34 99,089 1.1 1,047 98.9 98,042 2.7 (2.6–3.2) 1.7 (1.5–1.9)
35–39 20,465 1.2 247 98.8 20,218 3.3 (2.8–3.8) 1.8 (1.5–2.1)
⬎ 40 2,055 0.8 17 99.2 2,038 2.2 (1.4–3.6) 1.1 (0.7–1.9)
Epidural
Yes 14,637 1.0 142 99.0 14,495 1.4 (1.2–1.7) 0.8 (0.6–0.9)
No 471,044 0.7 3,236 99.3 468,590 1.0 1.0
Prolonged labor
Yes 15,419 1.5 238 98.5 15,181 2.3 (2.0–2.7) 1.0 (0.8–1.2)
No 471,826 0.7 3,140 99.3 467,904 1.0 1.0
Period of delivery
1967–1974 98,372 0.2 217 99.8 98,155 1.0 1.0
1975–1979 85,451 0.3 266 99.7 85,185 1.4 (1.2–1.7) 1.3 (1.0–1.5)
1980–1984 77,348 0.5 412 99.5 76,936 2.4 (2.0–2.8) 2.0 (1.7–2.3)
1985–1989 76,454 0.8 577 99.2 75,877 3.4 (2.9–4.0) 2.6 (2.2–3.1)
1990–1994 82,619 1.2 990 98.8 81,629 5.4 (4.7–6.3) 4.0 (3.5–4.7)
1995–1998 66,219 1.4 916 98.6 65,303 6.3 (5.5–7.3) 4.3 (3.7–5.0)
cOR, crude odds ratio; aOR, adjusted odds ratio; CI, confidence interval.
* N ⫽ 486,463 women with a first and a second vaginal delivery in Norway, 1967–1998.

explained by differences in reporting over time. There
has, however, been little focus on sphincter laceration in
Norway. A true increase in the risk of sphincter lacera-
tion is therefore more likely. Also, other studies have
suggested that the risk of severe perineal tears may be
increasing (Bek KM. PhD thesis, 1993).5,19 It is difficult
to explain the increase over time in anal sphincter lacer-
ation, but we believe that changes in clinical practice
during the period may have occurred. A Swedish retro-
spective study has shown a difference in the incidence of
anal sphincter rupture between Sweden and Finland,
and this may be due to the difference in manual control
of the baby’s head when crowning.33 Changes in preg-
nant women over time, for example, changes in body
mass index, muscle strength in the pelvic floor, or mental
health, may be other possible explanations for the in-
creasing occurrence of anal sphincter laceration.
No validation of “rupture of the anal sphincter” or
“total rupture,” as categorized in the Norwegian Medical
Birth Registry, has been performed. In the Norwegian
clinical language used by doctors and midwives, these
categories include third and fourth degree of anal sphinc-
ter laceration. Less severe tears have other terms and are
not included in the above definition and therefore not
reported as such on the standardized forms. We are
therefore confident that when “rupture of the anal

310 Spydslaug et al Recurrent Risk of Anal Sphincter Laceration OBSTETRICS & GYNECOLOGY
Table 2. Absolute Risk (%) With Exact 95% Confidence Intervals for Anal Sphincter Laceration at Second Delivery
According to Sphincter Laceration at First Delivery and Birth Weight*
Sphincter Laceration at First Delivery
Yes
Birth Weight (g) % 95% CI
⬍ 3,000 1.3 0.4–3.2
3,000–3,499 3.0 2.1–4.2
3,500–3,999 4.1 3.2–5.1
4,000–4,499 8.0 6.5–9.7
4,500–4,999 10.1 6.9–14.0
⬎ 5,000 23.3 11.8–38.6
CI, confidence interval.
* N ⫽ 147,694 Norwegian women with a first and a second vaginal delivery in Norway, 1990 –1998.
sphincter” or “total rupture of the anal sphincter” is
reported, these represent severe tears of the anal sphinc-
ter. The prevalence of reported severe ruptures in our
study is also in agreement with other studies, which
support the validity of our classification. There has been
no change in categorization during the observation pe-
riod, and there has been very little focus on obstetric
trauma in vaginal deliveries among the public or the
professionals in Norway. An underreporting of severe
rupture during the observation period may have caused
an underestimate of the prevalence.
Anal sphincter laceration in women with a prior lac-
eration may be more likely to be reported to the Norwe-
gian Medical Birth Registry than anal sphincter lacera-
tion in women without such history. In such a case, the
impact of prior anal sphincter laceration may be overes-
timated.
All women in Norway with 2 consecutive vaginal
deliveries during 1967–1998 were included in our study.
Cesarean delivery at the second delivery was more
prevalent in women with prior anal sphincter laceration
than in women without such history (6.2% versus 3.7%).
Since women with a prior laceration have been more
likely to have a cesarean delivery than women without
laceration, the estimated impact of prior laceration may
have been underestimated.
Most of the known risk factors of sphincter laceration
are controlled for in our analyses. Episiotomy is a poten-
tial risk factor, but has not been reported to the Medical
Birth Registry. However, numerous studies have shown
that women with a midline episiotomy carry a higher
risk of sphincter laceration than women with a mediolat-
eral episiotomy or than those with no episiotomy.34 –37
In Norway, the mediolateral episiotomy has, during the
whole observation period, been the procedure of choice,
and since the middle of the 1980s, the use of episiotomy
has not been recommended as a routine procedure.
During the period 1980 –1998, the prevalence of sphinc-
ter laceration at second delivery has more than doubled.
VOL. 105, NO. 2, FEBRUARY 2005
No
n % 95% CI n
4/313 0.2 0.1–0.3 24/13,376
33/1,096 0.6 0.5–0.7 233/40,553
79/1,939 1.1 1.0–1.2 604/54,754
92/1,152 2.0 1.9–2.2 564/27,534
31/308 3.5 3.0–4.0 204/5,880
10/308 3.7 2.5–5.4 28/746
It is, however, not known whether this increase is asso-
ciated with decreased use of episiotomy.
Prior studies have shown epidural anesthesia to be a
risk factor of anal sphincter laceration.20,21 However,
other studies have not confirmed such finding.38,39 Epi-
dural anesthesia has been associated with instrumental
vaginal delivery and prolonged labor.38 – 40 In our study
epidural anesthesia seemed to protect against sphincter
laceration after control for known risk factors. This was
a surprising finding and has to our knowledge not been
shown in any other study. However, our finding may be
spurious, or the increased risk of anal sphincter lacera-
tion with epidural anesthesia in other studies could also
be explained by insufficient control for confounding
factors.
Other potential risk factors of anal sphincter laceration
include induction of labor, maternal body mass index,
and delivery position. In the initial data analyses, we
included both induction of labor and use of oxytocin but
did not find these variables to be significantly associated
with anal sphincter laceration. Information on maternal
body mass index and delivery position were not avail-
able in the Medical Birth Registry and could therefore
not be controlled for. There have been several random-
ized controlled trials of delivery position in the second
stage of labor, but no significant difference in the risk of
perineal trauma has been shown.41– 44 We have little
reason to believe that lack of control for the above factor
has caused biased estimates of the impact of prior sphinc-
ter laceration
Prior anal sphincter laceration increases the risk of
laceration at the next delivery. Few women with anal
sphincter laceration at the first delivery had recurrent
laceration (3.7%). This suggests that sphincter laceration
at the first delivery has little impact on future risk. Only
10% of anal sphincter laceration at second delivery was
in women with prior laceration. Eliminating this 10% of
the cases through cesarean delivery would have little
impact on the prevalence of sphincter laceration at the
Spydslaug et al Recurrent Risk of Anal Sphincter Laceration 311
second delivery. One would have to perform a total of 25
cesarean deliveries to prevent one case. Our absolute
risk estimates of repeated anal sphincter laceration ac-
cording to birth weight may be of help in counseling
women about mode of delivery. For birth weight less
than 4,000 g, the risk for a repeated sphincter laceration
was less than 4.1%. This risk is similar to risk at the first
delivery. Thus, for women with predelivery birth weight
estimated at less than 4,000 g, it may be reasonable to
recommend vaginal delivery. In delivery counseling,
presence of symptoms of anal dysfunction should also be
considered. Such symptoms may be aggravated by sub-
sequent vaginal delivery.45 For women delivering a child
with a birth weight of 4,000 –5,000 g, the risk of a new
sphincter laceration ranged from 8.0% to 23.3%. Hence,
in women with a history of sphincter laceration and with
estimated birth weight more than 4,000 g, cesarean
delivery may be an appropriate recommendation. It
must, however, be kept in mind that exact predelivery
birth weight estimates often are difficult to make. Only a
minor proportion in our study, less than 1% of the entire
cohort, had a child with a birth weight more than 4,000
g and a prior laceration. Intervention in this group will,
however, have very little impact on the prevention of
sphincter laceration in the second delivery in general.
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Address reprint requests to: Anny Spydslaug, Department of
Obstetrics and Gynecology, Ullevaal University Hospital,
0407 Oslo, Norway; e-mail: anny.spydslaug@ulleval.no.
Received July 22, 2004. Received in revised form September 23, 2004.
Accepted October 7, 2004.
Spydslaug et al Recurrent Risk of Anal Sphincter Laceration 313