Risk factors for third degree perineal ruptures during delivery

OBJECTIVE: To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery. DESIGN: A population-based observational study. POPULATION: All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study. METHODS: Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors. MAIN OUTCOME MEASURES: An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20-0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97-3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further. CONCLUSIONS: Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.