DOI: 10.1111/1471-0528.

12886 General obstetrics

www.bjog.org

Impact of third- and fourth-degree perineal tears

at first birth on subsequent pregnancy
outcomes: a cohort study
LC Edozien,a,* I Gurol-Urganci,b,c,* DA Cromwell,b EJ Adams,d DH Richmond,c,d TA Mahmood,c
JH van der Meulenb
a
Maternal and Fetal Health Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK b Department
of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK c Office for Research and Clinical
Audit, Lindsay Stewart R&D Centre, Royal College of Obstetricians and Gynaecologists (RCOG), London, UK d Department of
Urogynaecology, Liverpool Women’s NHS Foundation Trust, Liverpool, UK
Correspondence: Dr I Gurol-Urganci, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine,
15–17 Tavistock Place, London, WC1H 9SH, UK. Email ipek.gurol@lshtm.ac.uk

Accepted 16 April 2014. Published Online 9 July 2014.

Objective To investigate, among women who have had a third- or
fourth-degree perineal tear, the mode of delivery in subsequent
pregnancies as well as the recurrence rate of third- or
fourth-degree tears.
Design A retrospective cohort study of deliveries using a national
administrative database.
Setting The English National Health Service between 1 April 2004
and 31 March 2012.
Population A total of 639 402 primiparous women who had a
singleton, term, vaginal live birth between April 2004 and March
2011, and a second birth before April 2012.
Methods Multivariable logistic regression models were used to
estimate odds ratios, adjusted for other risk factors.
Main outcome measures Mode of delivery and recurrence of tears
at second birth.
Results The rate of elective caesarean at second birth was 24.2% for
women with a third- or fourth-degree tear at first birth, and 1.5%
for women without (adjusted odds ratio, aOR 18.3, 95% confidence
interval, 95% CI 16.4–20.4). Among women who had a vaginal
delivery at second birth, the rate of third- or fourth-degree tears was
7.2% for women with a third- or fourth-degree tear at first birth,
compared with 1.3% for women without (aOR 5.5, 95% CI 5.2–5.9).
Conclusions The risk of a severe perineal tear is increased five-fold
in women who had a third- or fourth-degree tear in their first
delivery. This increased risk should be taken into account when
decisions about mode of delivery are made.
Keywords Administrative data, caesarean section, severe perineal
trauma.
Linked article This article is commented on by Barber MD. p.
1704 in this issue. To view this mini commentary visit http://
dx.doi.org/10.1111/1471-0528.12887.

Please cite this paper as: Edozien LC, Gurol-Urganci I, Cromwell DA, Adams EJ, Richmond DH, Mahmood TA, van der Meulen JH. Impact of third- and
fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study. BJOG 2014;121:1695–1704.

having another perineal tear. The rate of reported severe

Introduction
Pregnant women and their obstetricians face a challenge
when deciding on mode of delivery after a severe perineal
tear damaging the anal sphincter (third degree) and the
rectal mucosa (fourth degree). A choice has to be made
between a planned caesarean section, which avoids the risk
of another anal sphincter rupture, but carries its own mor-
bidity, and a vaginal birth with the prospect of the woman
*LCE and IG–U share joint first authorship of this paper.
perineal tears has been increasing1,2: in England, it tripled
from 1.8 to 5.9% between 2000 and 2012.3
To counsel women appropriately, local and national
information should be available on the recurrence rate
after anal sphincter rupture, and on the impact of the
woman’s age and whether or not she has had an episiot-
omy or instrumental delivery for previous pregnancies.
Large, population-based studies based in Norway,4,5 Swe-
den,6 and Denmark7 reported that, compared with women
who do not have rupture of the anal sphincter, women

ª 2014 Royal College of Obstetricians and Gynaecologists 1695

 Edozien et al.
with a rupture have an up to five-fold increased risk of a
third- or fourth-degree tear at vaginal delivery in the
next pregnancy. A recent population-based study in
Australia found no such increase, however.8 Results from
hospital-based studies range from no increase to up to
eight-fold higher risks.9–16 Apart from the size and setting
of the studies, there are other factors that make compari-
sons between studies and applicability to maternity care
in England difficult. For example, in some settings episiot-
omies are commonly or exclusively made in the midline
(unlike the UK practice of mediolateral episiotomy).
Compared with mediolateral episiotomies, midline episiot-
omies carry a higher risk of third- or fourth-degree peri-
neal tear.2,17,18
Among women who have had a third- or fourth-degree
perineal tear in England, this study investigates the mode
of delivery in the subsequent pregnancy and the
recurrence rate of third- or fourth-degree tears. The study
used a large population-based database that includes all
maternity admissions in National Health Service (NHS)
hospitals.
Methods
We used the Hospital Episode Statistics (HES) database
to identify births that have taken place in English NHS
trusts (acute hospital organisations). The HES database
contains patient demographics, clinical information, and
administrative data for each inpatient episode of care
since 1997. The records are extracted from local patient
administration systems, and undergo a series of validation
and cleaning processes before being made available for
analysis.19 A unique identifier links episodes of care
related to the same patient, which enables studies to
examine events before or after an index episode. Diagnos-
tic information is coded using the tenth revision of the
International Classification of Diseases (ICD10),20 and
operative procedures are coded using the fourth revision
of the UK Office for Population Censuses and Surveys
classification (OPCS4)21. For maternity episodes, supple-
mentary fields known as the ‘maternity tail’ capture par-
ity, birthweight, gestational age, method of delivery, and
pregnancy outcome; however, the completeness of data in
the maternity tail varies across NHS trusts in England.
For example, birthweight and parity are available in 79
and 65% of the delivery episodes, respectively.
This study included primiparous women aged 16–
45 years, who had a live, singleton, vaginal birth between 1
April 2004 and 31 March 2011, and who also had a second
birth by 31 March 2012. For the analysis of mode of deliv-
ery at second birth, we excluded women who had a multi-
ple pregnancy, non-cephalic presentation, or placenta
praevia or abruption, as these are indications for elective
1696
caesarean section. We also excluded women who went into
preterm labour because they do not have a choice about
mode of delivery. Preterm labour was identified by ICD10
code ‘O60’. For the analysis of recurrence of obstetric tears,
we further restricted the cohort to women who had a vagi-
nal (including instrumental) birth.
For both the first and second birth, third- or fourth-de-
gree perineal tears were identified by ICD10 codes ‘O70.2’
and ‘O70.3’, respectively. Mode of delivery was defined
using information in the OPCS4 procedure codes, and we
distinguished between non-instrumental vaginal (OPCS4
codes ‘R23’ and ‘R24’), forceps (‘R21’), and ventouse
(‘R22’), or if not defined using OPCS4 codes, by the deliv-
ery method specified in the maternity tail. OPCS4 code
‘R27.1’ identified whether or not an episiotomy had been
performed.
Parity was defined using historical data from the HES
database because the maternity tail is incomplete. A woman
was defined as primiparous if there was no evidence of a
birth prior to the index delivery, using minimum 7 years
of obstetric history. Recent research suggests that over 90%
of women in this population have their second child within
7 years of the first delivery.22
We identified the following potential confounding risk
factors. Maternal demographic factors were age at second
birth (<20, 20–24, 25–29, 30–34, ≥35 years), ethnicity
(white, Asian, Afro-Caribbean, other, unknown), and
socio-economic deprivation of the mother’s area of resi-
dence using the index of multiple deprivation (IMD)
(quintiles of 32 480 areas in England ranked according to a
measure of deprivation that combines a range of economic,
social, and housing indicators).23 Obstetric risk factors for
the analysis of mode of delivery at second birth included
mode of delivery, episiotomy, and birthweight at first birth,
and pre-existing conditions (hypertension, diabetes) and
gestational diabetes at second birth. Obstetric risk factors
for the analysis of recurrence of tears at second birth
included mode of delivery, episiotomy, birthweight,
prolonged labour, and shoulder dystocia at second birth.
The duration of labour was marked as prolonged if the
delivery record included an ICD10 diagnosis code ‘O63’
(long labour), whereas shoulder dystocia was identified by
ICD10 code ‘O66.0’ (obstructed labour caused by shoulder
dystocia). The year of the second birth was included as a
linear variable in the logistic regression model to take
into account changes in clinical practice over time. The
interval between the first and second birth was calculated
from the date of the first birth to the date of the second
birth.
We used logistic regression models to estimate odds
ratios adjusted for confounding risk factors reflecting the
relative risks associated with third- or fourth-degree tears
at first birth, and having an elective caesarean section at
ª 2014 Royal College of Obstetricians and Gynaecologists
 Outcomes after severe perineal tears

the second birth. We also used logistic regression models
to estimate the relative risks associated with third- or
fourth-degree tears at first birth and the occurrence of
third- or fourth-degree tears at second birth. To account
for a lack of independence in the data of women treated in
the same trust, we used the Huber sandwich estimator to
calculate robust standard errors. All analyses were per-
formed in STATA/SE 12.
Results
There were 1 719 539 singleton, vaginal, live births to pri-
miparous women aged 16–45 years between April 2004 and
March 2011. Of these, 707 184 (41.1%) women went on to
have a second delivery within the study time frame. Using
information from the second delivery record, we excluded
women who had a preterm delivery (4.0%) or an indica-
tion for elective caesarean section (4.5%) (Figure 1).
This left 639 402 women in the cohort. The prevalence
of third- or fourth-degree tears at first birth for the
cohort was 3.8%. At second birth, 15 190 (2.3%) women
had an elective caesarean section. Table 1 describes the
rates of elective caesarean section according to maternal
and obstetric risk factors. For most factors, the rate of
elective caesarean was typically between 1 and 4%. In
comparison, among women who had a third- or fourth--
degree tear at first birth, 24.2% were delivered by elective
caesarean section (adjusted odds ratio, aOR 18.3, 95%
confidence interval, 95% CI 16.4–20.4). Women who had
an instrumental delivery or an episiotomy were also
more likely to have an elective caesarean section. Other
factors that were associated with higher elective caesarean
section rates were older age, white ethnicity, living in a
less-deprived area, pre-existing or gestational diabetes,
higher birthweights, and longer birth intervals. The rate
of elective caesarean section increased during the study
period.
Of the women included in the cohort, 619 717 (96.9%)
had a vaginal delivery. The rate of third- or fourth-degree
tears at second birth was 1.5% (Table 2), less than half of
the rate among primiparous women. Among women with
a third- or fourth-degree tear at first birth, the unadjusted
rate of recurrence was 7.2%, compared with 1.3% among
women without a tear, and this increased risk remained
five times higher after adjustment for potential confound-
ing factors (aOR 5.5, 95% CI 5.2–5.9). Among the other

1 719 539 women who had live,

singleton, vaginal first births

1 012 355 (58.9%) women 707 184 (41.1%) women with

with no further births in the second births in the study
study period period
Exclude women with:
- Preterm birth
QUESTION 1: Impact on mode of delivery - Multiple birth
[Table 1] - Breech delivery
- Placenta praevia/abruptio
at second birth. (n = 52 592)

15 190 (2.3%) women have 639 402 (97.7%) women

an elective caesarean have a trial of labour at
section at second birth second birth.

Exclude women with:

QUESTION 2: Recurrence of tears - Emergency caesarean section
[Table 2] at second birth. (n = 19 685)

619 717 have a vaginal

delivery at second birth

610 614 (98.5%) women do 9103 (1.5%) women have a

not have a third/fourth third/fourth degree tear at
degree tear at second birth second birth

Figure 1. Flowchart.

ª 2014 Royal College of Obstetricians and Gynaecologists 1697

 Edozien et al.

Table 1. Impact of third- or fourth-degree perineal tears at first birth on elective caesarean section as mode of delivery at second birth
(n = 654 592)

Distribution of Elective caesarean Crude OR Adjusted OR P

factor (%) section rate (%) (95% CI) (95% CI)

Maternal age
<20 years 3.2 0.8 0.42 (0.36–0.48) 0.57 (0.49–0.67) <0.001
20–24 years 22.2 1.2 0.58 (0.55–0.62) 0.71 (0.67–0.76)
25–29 years 26.5 2.0 1 1
30–34 years 29.3 2.9 1.46 (1.39–1.54) 1.23 (1.16–1.30)
>35 years 18.8 3.6 1.86 (1.74–1.98) 1.58 (1.48–1.68)
Ethnicity
White 75.2 2.6 1 1 <0.001
Asian 10.6 1.5 0.59 (0.52–0.67) 0.57 (0.51–0.63)
Afro-Caribbean 5.1 1.3 0.49 (0.42–0.57) 0.62 (0.53–0.73)
Other 3.9 1.7 0.67 (0.60–0.75) 0.71 (0.63–0.80)
Unknown 5.2 1.7 0.64 (0.56–0.73) 0.70 (0.61–0.80)
Deprivation (quintile)
Least deprived 17.9 3.2 1 1 0.007
2 17.0 2.9 0.90 (0.84–0.96) 1.00 (0.93–1.07)
3 18.2 2.5 0.76 (0.71–0.81) 0.95 (0.89–1.03)
4 20.8 2.0 0.62 (0.57–0.67) 0.09 (0.83–0.98)
Most deprived 26.1 1.5 0.46 (0.41–0.51) 0.86 (0.78–0.96)
Characteristics of first birth
Third- or fourth-degree tear 3.8 24.2 21.5 (19.4–23.8) 18.3 (16.4–20.4) <0.001
No third- or fourth-degree tear 96.2 1.5 1 1
Mode of delivery
Non-instrumental 74.5 1.5 1 1 <0.001
Forceps 10.4 6.9 4.82 (4.57–5.09) 2.84 (2.65–3.03)
Vacuum 15.0 3.1 2.11 (2.01–2.22) 1.72 (1.62–1.82)
Episiotomy 30.0 3.3 1.78 (1.69–1.87) 1.18 (1.11–1.25) <0.001
Birthweight
<2500 grams 3.5 0.9 0.44 (0.39–0.50) 0.70 (0.60–0.80) <0.001
2500–4000 grams 67.8 2.0 1 1
>4000 grams 5.8 6.6 3.46 (3.28–3.66) 2.40 (2.26–2.55)
Unknown 22.8 2.4 1.20 (1.11–1.31) 1.18 (1.09–1.29)
Preterm birth 3.5 1.4 0.58 (0.51–0.65) 0.95 (0.83–1.10) 0.512
Risk factors at second birth
Diabetes 0.2 7.1 3.24 (2.60–4.05) 3.17 (2.41–4.17) <0.001
Hypertension 0.3 2.2 0.95 (0.69–1.32) 0.78 (0.55–1.12) 0.175
Gestational diabetes 1.9 4.7 2.10 (1.86–2.37) 1.94 (1.69–2.22) <0.001
Interbirth interval
Less than 2 years 34.2 2.0 0.82 (0.78–0.86) 0.97 (0.92–1.02) <0.001
2–3 years 33.9 2.4 1 1
3–4 years 17.8 2.6 1.06 (1.01–1.11) 1.13 (1.07–1.18)
More than 4 years 14.1 2.6 1.07 (1.02–1.13) 1.31 (1.23–1.38)
Year of subsequent birth
2005 1.3 1.6 1 1
Change per year 1.05 (1.04–1.06) 0.98 (0.96–1.00) 0.010

risk factors, the factors with the highest increase in the risk
of third- or fourth-degree tears at second birth were high
birthweight, forceps delivery, and the presence of shoulder
dystocia. The risk of a third- or fourth-degree tear was also
higher in older women, in women living in the least
deprived communities, and in Asian women. Women who
had an episiotomy were less likely to experience a severe
perineal tear. The adjusted risk of third- or fourth-degree
tears increased with birthweight and shoulder dystocia, but
was not associated with the duration of labour. To test the
robustness of our results, we re-ran the analyses using
multilevel logistic regression in which the effect of patient

1698 ª 2014 Royal College of Obstetricians and Gynaecologists

 Outcomes after severe perineal tears

Table 2. Impact of third- or fourth-degree perineal tears at first birth on recurrence of tears at second birth (n = 619 717)

Distribution of Third- or fourth-degree Crude OR Adjusted OR P

factor (%) tear rate (%) (95% CI) (95% CI)

Maternal age
<20 years 3.3 0.3 0.23 (0.18–0.30) 0.33 (0.25–0.42) <0.001
20–24 years 22.6 0.7 0.50 (0.46–0.54) 0.58 (0.53–0.62)
25–29 years 26.6 1.4 1 1
30–34 years 29.1 2.0 1.43 (1.35–1.52) 1.35 (1.28–1.42)
>35 years 18.3 2.0 1.42 (1.34–1.51) 1.36 (1.28–1.44)
Ethnicity
White 75.1 1.4 1 1 <0.001
Asian 10.6 1.9 1.33 (1.23–1.44) 1.59 (1.48–1.71)
Afro-Caribbean 5.1 1.3 0.87 (0.77–0.98) 1.01 (0.90–1.13)
Other 3.9 1.3 0.89 (0.78–1.02) 0.96 (0.85–1.09)
Unknown 5.3 1.2 0.85 (0.75–0.97) 0.92 (0.81–1.04)
Deprivation (quintile)
Least deprived 17.7 2.0 1 1 <0.001
2 16.9 1.7 0.83 (0.78–0.89) 0.87 (0.82–0.94)
3 18.2 1.5 0.75 (0.69–0.81) 0.84 (0.77–0.91)
4 20.9 1.3 0.67 (0.61–0.73) 0.81 (0.74–0.88)
Most deprived 26.3 1.1 0.53 (0.49–0.58) 0.74 (0.68–0.80)
Characteristics of first birth
Third- or fourth-degree tear 2.8 7.2 5.92 (5.56–6.31) 5.51 (5.18–5.86) <0.001
No third- or fourth-degree tear 97.2 1.3 1 1
Risk factors at second birth
Mode of delivery
Non-instrumental 96.1 1.4 1 1 <0.001
Forceps 1.4 5.0 3.73 (3.32–4.19) 4.02 (3.51–4.60)
Vacuum 2.5 1.9 1.39 (1.21–1.59) 1.34 (1.16–1.55)
Episiotomy 5.5 2.3 1.63 (1.47–1.81) 0.66 (0.58–0.75) <0.001
Birthweight
<2500 grams 1.6 0.2 0.15 (0.09–0.23) 0.16 (0.1–0.25) <0.001
2500–4000 grams 70.4 1.2 1
>4000 grams 11.8 3.1 2.58 (2.44–2.73) 2.29 (2.16–2.43)
Unknown 16.2 1.3 1.09 (0.99–1.19) 1.14 (1.04–1.26)
Long labour 2.4 2.3 1.61 (1.43–1.82) 0.89 (0.78–1.01) 0.068
Shoulder dystocia 1.1 5.8 4.27 (3.83–4.76) 2.92 (2.59–3.28) <0.001
Interbirth interval
Less than 2 years 34.4 1.2 0.77 (0.73–0.82) 0.91 (0.86–0.96) <0.001
2–3 years 33.9 1.5 1 1
3–4 years 17.7 1.7 1.13 (1.07–1.20) 1.11 (1.04–1.17)
More than 4 years 13.9 1.7 1.08 (1.01–1.15) 1.04 (0.97–1.11)
Year of subsequent birth
2005 1.3 0.6 1 1 <0.001
Change per year 1.10 (1.08–1.12) 1.06 (1.04–1.08)

clustering within NHS trusts was modelled as a random
coefficient. These analyses produced comparable results to
those presented here (Table S1).
Discussion
Main findings
The rate of elective caesarean section in the subsequent
pregnancy for women with a severe perineal tear in their
first delivery was 24.2%. For women who had a vaginal
delivery in the second pregnancy, a third- or fourth-degree
tear at first birth increased the risk of recurrence of a tear
by five-fold.
Strengths and limitations
This study included over 600 000 first and second births in
women who delivered in an NHS hospital over a 7–year
period. HES captures over 96% of all deliveries in

ª 2014 Royal College of Obstetricians and Gynaecologists 1699

 Edozien et al.
England,24 and provides a large sample size required for
the analysis of rare outcomes.
This study represents practice in England. Recent popu-
lation-based studies demonstrated an increase in the rate of
reported obstetric tears in the last decade.3 Since then,
there have also been significant changes in the management
of second-stage labour,25 and a lower threshold for per-
forming an elective caesarean section.26,27
A limitation of this study is that our adjusted results
may contain residual confounding because we were not
able to control for some risk factors, such as intrapartum
anaesthesia,28,29 experience of the birth attendant,30,31 the
angle and size of an episiotomy,32–34 or fetal head circum-
ference,7 which may affect the risk of third- or fourth-de-
gree tears at second birth. It is unlikely, however, that any
residual confounding caused by the absence of these risk
factors could account for the observed large differences in
the risk of recurrence.
Although it has been suggested that the diagnostic cod-
ing in the administrative data sets is potentially inaccurate,
the majority of NHS trusts submit good-quality data to
HES that conforms to national recommendations,35–37 and
the data are sufficiently robust for research and deci-
sion-making.38 Recent publications have demonstrated that,
when data completeness, consistency, and accuracy are
analysed carefully,39,40 HES is a valuable source of data for
studies exploring patterns of care and reproductive
epidemiology.3,41–43
Finally, we focused on primiparous women, as birth
order is a risk factor for perineal tears,4,6,12,15,44–46 but our
‘lookback’ approach to define parity may have resulted in
some multiparous women whose first birth was not
recorded in HES, for example because they delivered in
another country, being incorrectly labelled as primipa-
rous.39 Sensitivity analyses using 10 years of patient history
to identify primiparous status or the information in the
maternity tail, instead of the current approach, yielded
comparable results (Table S2).
Interpretation (findings in light of other evidence)
This is the first study of mode of delivery and recurrence
rate in a pregnancy subsequent to a third- or fourth-degree
perineal tear in England. The prevalence of a third- or
fourth-degree perineal tear at first birth (in this population
of women who had a second birth during the study period)
was 3.8%. Women who have had a third- or fourth-degree
perineal tear in their first birth can be advised that the
chance of having a similar tear in the next birth is approxi-
mately 7 in 100. This study confirms the finding of previ-
ous studies elsewhere that there is a manifold increase in
the risk of an anal sphincter rupture at delivery in women
who had a third- or fourth-degree tear at the previous
delivery (Norwegian 1967–1998 cohort, aOR 4.3, 95% CI
1700
3.8–4.8;4 Norwegian 1967–2004 cohort, aOR 4.2, 95%
CI 3.9–4.5;5 and Swedish 1973–1997 cohort, aOR 4.7, 95%
CI 4.3–5.2;6 Danish 1997–2010 cohort, aOR 5.9, 95% CI
5.4–6.5).7 Two population-based studies, from Australia
and the USA,8,47 did not find an increased risk of recur-
rence; however, the Australian study did not adjust for case
mix,8 and the US study reported on practice from more
than 20 years ago.47 Hospital-based cohort studies with
comparable control groups also showed a two- to five-fold
increase in the risk of recurrence.13,14,16
Mode of delivery after a third- or fourth-degree tear has
been reported in few studies. In population-based studies,
the rate of elective caesarean section after an anal sphincter
rupture was 6.0% (Sweden),5 6.2% (Norway),4 6.2% (Aus-
tralia),8 7.2% (USA),47 17.4% (Australia),48 and 29.9%
(Denmark).7 In hospital-based studies, the rates of elective
caesarean section after a prior third- or fourth-degree tear
was 19.6% (Ireland),10 18.6% (Israel),16 and 8.1% (USA).8
These differences in elective caesarean section rates may
reflect the time periods studied or variations in the man-
agement of pregnancies after third- or fourth-degree tears
across countries. The most comparable cohorts in terms of
time period and design with ours are the studies from Aus-
tralia (2000–2009) and Denmark (1997–2010).7,48 These
relatively high rates of elective caesarean section may be the
result from the perceived high risk of recurrence of tear
associated with vaginal birth and the lack of evidence or
professional guidance on how to identify women who are
at high risk of functional impairment following vaginal
delivery, for whom the balance of risks and benefits favours
an elective caesarean section. A survey of clinicians based
in the UK found that 70% of coloproctologists and 22% of
obstetricians would recommend an elective caesarean sec-
tion to prevent anal incontinence following prior anal
sphincter injury.31
Our study reports on the recurrence of tears and mode
of delivery, but in the absence of large, population-based
studies on functional outcomes or quality of life after a
severe tear, we are unable to comment categorically on
whether the relatively high caesarean section rates are jus-
tified. Although a caesarean section will prevent a recur-
rence of a repeat perineal tear, it is also associated with
risks to the mother and the baby.49 A study that com-
pared outcomes after elective caesarean section versus vag-
inal delivery, specifically for women with a previous anal
sphincter rupture, found that the prevalence of any mor-
bid event was 11.3% in the caesarean section group versus
4.2% for vaginal deliveries (relative risk, RR 2.7, 95% CI
2.6–2.8).50 These risks of an elective caesarean section have
to be weighed against the clinical, psychological, and social
burden of anal incontinence.51 One could argue that the
best approach for women with a previous tear is not to
offer them an elective caesarean section but to improve
ª 2014 Royal College of Obstetricians and Gynaecologists

delivery suite practice, for example by providing manual
support of the perineum in the second stage of labour,
which significantly reduces the rate of anal sphincter
rupture.52–54
For clinicians advising pregnant women with a previous
anal sphincter rupture, robust evidence on whether and
under what conditions to recommend an elective caesarean
section is lacking. One could consider using additional cri-
teria to guide decision-making. For example, an elective
caesarean section could be considered if there is evidence
of a persisting defect after repair or if anal manometry
shows reduced squeeze pressures. Unfortunately, many
units do not have a dedicated perineal post-trauma clinic
with endoanal ultrasound scan and anal manometry facili-
ties, and in those units decisions on mode of delivery
may have to be made solely on the basis of history and
maternal preference. It should be noted, however, that a
persisting defect after a repair and reduced squeeze pressure
should not be considered in isolation, as they do not on
their own give information about functional or long-term
outcome.
Our study showed that the risk factors (other than prior
severe tear) for a third- or fourth-degree perineal tear at
second birth are similar to risk factors at first pregnancy,3
such as birthweight and instrumental deliveries (in
particular use of forceps), but the effects were generally
lower. This is consistent with the findings of previous
studies.4,5,7,12 The most likely clinical explanation is that
the lower risk of recurrence at second births reflects the
stretching of the perineum at the prior delivery. At first
births, the effects of birthweight and instrumental
delivery are complemented by relatively rigid perineal
tissues.
In addition to known risk factors at second pregnancy,
women who had an instrumental delivery, episiotomy, and
a higher birthweight baby at first birth, and longer birth
intervals, had higher rates of elective caesarean section at
second birth. Similar associations were found in a popula-
tion-based study in Australia.48 It is likely that elective
caesarean section is offered by clinicians or preferred by
women after obstetric interventions or adverse pregnancy
outcomes, because of the possibility of recurrence of risk
factors (such as macrosomia) or childbirth-related dis-
tress.55–57 Women who lived in less deprived areas were
more likely to have an elective caesarean section. This
result is in agreement with previous studies from England
and Scotland.58,59
Conclusion
A national guideline on the optimal mode of delivery for
women with a prior anal sphincter rupture is needed, and
the results of this study along with those of other studies
ª 2014 Royal College of Obstetricians and Gynaecologists
Outcomes after severe perineal tears
can inform the development of such a guideline. The find-
ings could also be helpful as a starting point to women and
their obstetricians in discussing mode of delivery in their
next pregnancy.
Disclosure of interests
None.
Contribution to authorship
IGU, LCE, TAM, LA, and JHvdM conceived the study.
IGU and DAC contributed to its design and conducted the
analyses. IGU and LCE wrote the article, and DAC, TAM,
LA, DR, and JHvdM commented on drafts. All authors
approved the final version for publication.
Details of ethics approval
The 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.
Funding
IGU is supported by the Royal College of Obstetricians and
Gynaecologists.
Acknowledgements
We thank the Department of Health for providing the
Hospital Episode Statistics data used in this study.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Results with multilevel regression models, as
compared with Huber sandwich estimators.
Table S2. Sensitivity analyses with alternative derivations
of primiparous status, and using complete birthweight
data. &
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