International Urogynecology Journal

, Volume 28, Issue 3, pp 381–389 | Cite as

Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience

  • Madhu Naidu
  • Abdul H. Sultan
  • Ranee ThakarEmail author
Original Article


Introduction and hypothesis

Obstetric anal sphincter injuries (OASIs) are associated with significant short-term and long-term morbidity. Over the past decade, there has been a steady rise in the rate of OASIs. There is therefore a compelling need to identify strategies to minimize OASIs. The objective of this study was to determine if perineal support at the time of vaginal delivery can reduce the incidence and severity of OASIs.


All labour ward staff including midwives and doctors were invited to train in the technique of perineal support during vaginal delivery. Two experts from Norway conducted workshops with practical hands-on training on pelvic models. The midwives and doctors underwent further training with women in labour, and mandatory training was continued within the department. All midwives and doctors were instructed to support the perineum during both spontaneous and assisted vaginal delivery.


From April 2011 to November 2014, 11,135 women underwent vaginal delivery. The OASI rate decreased from 4.7 % to 4.1 % (p = 0.11). There was a significant reduction (0.9 % to 0.3 %, p < 0.001) in 3c third-degree and fourth-degree tears (major OASIs). In a multivariate analysis, perineal support was associated with a significant reduction in the rates of OASIs (23 %; OR 0.77, 95 % CI 0.63 – 0.95, p = 0.01]) and major OASIs (71 %; OR 0.34, 95 % CI 0.17 – 0.69, p = 0.03).


This interventional study showed that perineal support during vaginal delivery can reduce the risk of major OASIs. With sustained reinforcement of this intervention programme, we anticipate a further reduction in OASI rates.


OASIs Perineal support Prevention of OASI Manual perineal protection 



We thank Katriina Laine and Wenche Rotvold for providing hands-on training on manual perineal protection.

Compliance with ethical standards

Conflicts of interest



We thank the Research and Development Committee of Croydon (previously Mayday) Health Services for providing a grant to fund the training intervention programme.


  1. 1.
    Gurol-Urganci I, Cromwell D, Edozien L, Mahmood T, Adams E, Richmond D, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG. 2013;120(12):1516–1525. doi: 10.1111/1471-0528.12363.CrossRefPubMedGoogle Scholar
  2. 2.
    Tyagi V, Perera M, Guerrero K. Trends in obstetric anal sphincter injuries over 10 years. J Obstet Gynaecol. 2013;33(8):844–849. doi: 10.3109/01443615.2013.831045.CrossRefPubMedGoogle Scholar
  3. 3.
    Ampt A, Ford J, Roberts C, Morris J. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001–2009. Aust N Z J Obstet Gynaecol. 2013;53(1):9–16. doi: 10.1111/ajo.12038.CrossRefPubMedGoogle Scholar
  4. 4.
    Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S. The increased incidence of obstetric anal sphincter rupture – an emerging trend in Finland. Prev Med. 2009;49(6):535–540. doi: 10.1016/j.ypmed.2009.10.005.CrossRefPubMedGoogle Scholar
  5. 5.
    LaCross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health. 2015;60(1):37–47. doi: 10.1111/jmwh.12283.CrossRefPubMedGoogle Scholar
  6. 6.
    Radestad I, Olsson A, Nissen E, Rubertsson C. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth. 2008;35(2):98–106. doi: 10.1111/j.1523-536X.2008.00222.x.CrossRefPubMedGoogle Scholar
  7. 7.
    Roos AM, Thakar R, Sultan AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter? Ultrasound Obstet Gynecol. 2010;36(3):368–374. doi: 10.1002/uog.7512.CrossRefPubMedGoogle Scholar
  8. 8.
    Edozien LC, Gurol-Urganci I, Cromwell DA, Adams EJ, Richmond DH, Mahmood TA, et al. Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study. BJOG. 2014;121(13):1695–1703. doi: 10.1111/1471-0528.12886.CrossRefPubMedGoogle Scholar
  9. 9.
    Pirhonen J, Grenman S, Haadem K, Gudmundsson S, Lindqvist P, Siihola S, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland – result of difference in manual help to the baby’s head. Acta Obstet Gynecol Scand. 1998;77(10):974–977.CrossRefPubMedGoogle Scholar
  10. 10.
    Laine K, Pirhonen T, Rolland R, Pirhonen J. Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol. 2008;111(5):1053–7. doi: 10.1097/AOG.0b013e31816c4402.CrossRefPubMedGoogle Scholar
  11. 11.
    Laine K, Skjeldestad FE, Sandvik L, Staff AC. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open. 2012;2(5):e001649. doi: 10.1136/bmjopen-2012-001649.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    McPherson KC, Beggs AD, Sultan AH, Thakar R. Can the risk of obstetric anal sphincter injuries (OASIs) be predicted using a risk-scoring system? BMC Res Notes. 2014;7:471. doi: 10.1186/1756-0500-7-471.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Aasheim V, Nilsen A, Lukasse M, Reinar L. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2011;12:CD006672. doi: 10.1002/14651858.CD006672.pub2.Google Scholar
  14. 14.
    Hals E, Oian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol. 2010;116(4):901–908. doi: 10.1097/AOG.0b013e3181eda77a.CrossRefPubMedGoogle Scholar
  15. 15.
    Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S. High episiotomy rate protects from obstetric anal sphincter ruptures: a birth register-study on delivery intervention policies in Finland. Scand J Public Health. 2011;39(5):457–463. doi: 10.1177/1403494811404276.CrossRefPubMedGoogle Scholar
  16. 16.
    Karbanova J, Rusavy Z, Betincova L, Jansova M, Parizek A, Kalis V. Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy. Int J Gynaecol Obstet. 2014;124(1):72–76. doi: 10.1016/j.ijgo.2013.07.011.CrossRefPubMedGoogle Scholar
  17. 17.
    O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev. 2010;11:CD005455. doi: 10.1002/14651858.CD005455.pub2.Google Scholar
  18. 18.
    de Vogel J, van der Leeuw-van Beek A, Gietelink D, Vujkovic M, de Leeuw JW, van Bavel J, et al. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol. 2012;206(5):4040–4045. doi: 10.1016/j.ajog.2012.02.008.CrossRefGoogle Scholar
  19. 19.
    Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med. 2002;6(47):5.Google Scholar
  20. 20.
    McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. BJOG. 1998;105(12):1262–1272.CrossRefGoogle Scholar
  21. 21.
    Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J. 2011;22(10):1279–1285. doi: 10.1007/s00192-011-1454-8.CrossRefPubMedGoogle Scholar
  22. 22.
    National Institute for Health and Clinical Excellence. Intrapartum care for healthy women and babies. Clinical guideline 190. London: National Institute for Health and Clinical Excellence; 2014.Google Scholar
  23. 23.
    East CE, Lau R, Biro MA. Midwives׳ and doctors׳ perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey. Midwifery. 2015;31(1):122–131.CrossRefPubMedGoogle Scholar
  24. 24.
    Bulchandani S, Watts E, Sucharitha A, Yates D, Ismail KM. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG. 2015;122(9):1157–1165. doi: 10.1111/1471-0528.13431.CrossRefPubMedGoogle Scholar
  25. 25.
    Ismail K, Paschetta E, Papoutsis D, Freeman R. Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey. Acta Obstet Gynecol Scand. 2015;94(2):165–174. doi: 10.1111/aogs.12547.CrossRefPubMedGoogle Scholar
  26. 26.
    Royal College of Midwives. Report of a survey exploring the position of midwives’ hands during the birth of the baby’s head. London: Royal College of Midwives; 2012. Accessed 5 Oct 2016.
  27. 27.
    Taithongchai A, Naidu M, Sultan A, Thakar R. Survey of current practice on perineal support among United Kingdom obstetric and gynaecology trainees. BJOG. 2015;122:55–6. doi: 10.1111/1471-0528.13384.
  28. 28.
    Jansova M, Kalis V, Lobovsky L, Hyncik L, Karbanova J, Rusavy Z. The role of thumb and index finger placement in manual perineal protection. Int Urogynecol J. 2014;25(11):1533–1540. doi: 10.1007/s00192-014-2425-7.CrossRefPubMedGoogle Scholar
  29. 29.
    Royal College of Obstetricians and Gynaecologists. The OASI Care Bundle Project. London: Royal College of Obstetricians and Gynaecologists; 2015. Accessed 5 Oct 2016.

Copyright information

© The International Urogynecological Association 2016

Authors and Affiliations

  1. 1.Croydon University HospitalCroydonUK

Personalised recommendations