Skip to main content
SpringerLink
Log in

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women.

Methods

This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection.

Results

Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59–2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02–1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13–1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02–1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59–0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29–0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48–0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96–0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height).

Conclusions

Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data Availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Sheba medical center.

References

  1. Ramm O, Woo VG, Hung YY, et al. Risk factors for the development of obstetric anal sphincter injuries in modern obstetric practice. Obstet Gynecol. 2018;131:290–6. https://doi.org/10.1097/AOG.0000000000002444.

    Article  PubMed  Google Scholar 

  2. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol. 2014;210:59.e1–6https://doi.org/10.1016/j.ajog.2013.08.043.

    Article  PubMed  Google Scholar 

  3. Meister MRL, Cahill AG, Conner SN, et al. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol. 2016;215:310.e1-310.e7. https://doi.org/10.1016/j.ajog.2016.02.041.

    Article  PubMed  Google Scholar 

  4. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Mode of delivery after obstetric anal sphincter injury and the risk of long-term anal incontinence. Am J Obstet Gynecol. 2016;214:733.e1–733.e13. https://doi.org/10.1016/j.ajog.2015.12.030.

    Article  PubMed  Google Scholar 

  5. Mous M, Muller SA, De Leeuw JW. Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG. 2008;115:234–8. https://doi.org/10.1111/j.1471-0528.2007.01502.x.

    Article  CAS  PubMed  Google Scholar 

  6. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308:887. https://doi.org/10.1136/bmj.308.6933.887.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. De Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC. Risk factors for third degree perineal ruptures during delivery. BJOG. 2001;108:383–7.

    PubMed  Google Scholar 

  8. Angioli R, Gómez-Marín O, Cantuaria G, O’Sullivan MJ. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol. 2000;182:1083–5. https://doi.org/10.1067/mob.2000.105403.

    Article  CAS  PubMed  Google Scholar 

  9. Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL. Risk factors for perineal injury during delivery. Am J Obstet Gynecol. 2003;189:255–60. https://doi.org/10.1067/mob.2003.547.

    Article  CAS  PubMed  Google Scholar 

  10. Loewenberg-Weisband Y, Grisaru-Granovsky S, Ioscovich A, et al. Epidural analgesia and severe perineal tears: a literature review and large cohort study. J Matern Fetal Neonatal Med. 2014;27:1864–9. https://doi.org/10.3109/14767058.2014.889113.

    Article  CAS  PubMed  Google Scholar 

  11. Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T. Obstetric Anal Sphincter Injuries at Vaginal Delivery: A Review of Recently Published National Guidelines. Obstet Gynecol Surv. 2018;73:695–702. https://doi.org/10.1097/OGX.0000000000000622.

    Article  PubMed  Google Scholar 

  12. Eisenberg VH, Valsky DV, Yagel S. Transperineal ultrasound assessment of the anal sphincter after obstetric anal sphincter injury (OASI). Ultrasound Obstet Gynecol. 2019;53:158–65. https://doi.org/10.1002/uog.19058.

    Article  CAS  PubMed  Google Scholar 

  13. Hersh SR, Emeis CL. Mediolateral episiotomy: technique, practice, and training. J Midwifery Womens Health. 2020;65:404–9. https://doi.org/10.1111/JMWH.13096.

    Article  PubMed  Google Scholar 

  14. Chitty LS, Altman DG, Henderson A, Campbell S. Charts of fetal size: 2. Head measurements. BJOG. 1994;101:35–43. https://doi.org/10.1111/j.1471-0528.1994.tb13007.x.

    Article  CAS  Google Scholar 

  15. Melamed N, Yogev Y, Danon D, et al. Sonographic estimation of fetal head circumference: how accurate are we? Ultrasound Obstet Gynecol. 2011;37:65–71. https://doi.org/10.1002/uog.7760.

    Article  CAS  PubMed  Google Scholar 

  16. Klokk R, Bakken KS, Markestad T, Holten-Andersen MN. Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian region: a case-control study. BMC Pregnancy Childbirth. 2022;22:1-277 https://doi.org/10.1186/S12884-022-04621-2.

  17. De Leeuw JW, De Wit C, Kuijken JPJA, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG. 2008;115:104–8. https://doi.org/10.1111/j.1471-0528.2007.01554.x.

    Article  PubMed  Google Scholar 

  18. Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG. 2007;114:1266–72. https://doi.org/10.1111/j.1471-0528.2007.01482.x.

    Article  CAS  PubMed  Google Scholar 

  19. Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis. Int Urogynecol J. 2016;27:1459–67. https://doi.org/10.1007/s00192-016-2956-1.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081.

    PubMed  Google Scholar 

  21. Levaillant M, Loury C, Venara A, et al. Is there still an indication for episiotomy? Results from a French national database analysis. Int J Gynaecol Obstet. 2023;160:880–885. https://doi.org/10.1002/IJGO.14385.

    Article  PubMed  Google Scholar 

  22. Kalis V, Laine K, De Leeuw JW, et al. Classification of episiotomy: towards a standardisation of terminology. BJOG. 2012;119:522–6.

    Article  CAS  PubMed  Google Scholar 

  23. Carroli G, Mignini. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081. cochranelibrary.com Accessed 19 October 2021

  24. Oladapo OT, Tunçalp Bonet M, et al. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. Bjog. 2018;125:918. https://doi.org/10.1111/1471-0528.15237.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Lee L, Dy J, Azzam H. SOGC clinical practice guideline: management of spontaneous labour at term in healthy women. J Obstet Gynaecol Canada. 2016;38:843–65. https://doi.org/10.1016/j.jogc.2016.04.093.

    Article  Google Scholar 

  26. Sartore A, De Seta F, Maso G, et al (2004) The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 103:669–673.  https://doi.org/10.1097/01.AOG.0000119223.04441.C9

  27. Nunes VD, Gholitabar M, Sims JM, Bewley S. Intrapartum care of healthy women and their babies: summary of updated NICE guidance. BMJ. 2014;349. https://doi.org/10.1136/BMJ.G6886.

  28. Fodstad K, Laine K, Staff AC. Different episiotomy techniques, postpartum perineal pain, and blood loss: an observational study. Int Urogynecol J Pelvic Floor Dysfunct. 2013;24:865–72. https://doi.org/10.1007/s00192-012-1960-3.

    Article  Google Scholar 

  29. Okeahialam NA, Wong KW, Jha S, et al. Mediolateral/lateral episiotomy with operative vaginal delivery and the risk reduction of obstetric anal sphincter injury (OASI): a systematic review and meta-analysis. Int Urogynecol J. 2022;33:1393–405. https://doi.org/10.1007/S00192-022-05145-1.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Lund N, Persson L, Jangö H, et al. Mediolateral/lateral episiotomy with operative vaginal delivery and the risk reduction of obstetric anal sphincter injury (OASI): a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;207:193–9.

    Article  PubMed  Google Scholar 

  31. Chill HH, Karavani G, Lipschuetz M, et al. Birthweight difference between deliveries and the risk of obstetric anal sphincter injury in parous women. Int Urogynecol J. 2022;33:3401–6. https://doi.org/10.1007/S00192-022-05207-4.

    Article  PubMed  Google Scholar 

  32. Ortega MV, Kim Y, Leung K, et al. Can sonographic fetal head circumference measurement help predict obstetric anal sphincter injury? Int J Gynaecol Obstet. 2022;159:279–83. https://doi.org/10.1002/IJGO.14098.

    Article  CAS  PubMed  Google Scholar 

  33. Meyer R, Rottenstreich A, Zamir M, et al. Sonographic fetal head circumference and the risk of obstetric anal sphincter injury following vaginal delivery. Int Urogynecol J. 2020;31:2285–90. https://doi.org/10.1007/S00192-020-04296-3.

    Article  PubMed  Google Scholar 

  34. Lindholm ES, Altman D. Risk of obstetric anal sphincter lacerations among obese women. BJOG. 2013;120:1110–5. https://doi.org/10.1111/1471-0528.12228.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sheba Medical Center at Tel Hashomer, Ramat-Gan and Sackler Faculty of Medicine, Tel Aviv University, 5265601, Tel Aviv-Yafo, Israel

    Uria Shani, Linor Klein, Hila Greenbaum & Vered H. Eisenberg

  2. Ministry of Health and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel

    Vered H. Eisenberg

Authors
  1. Uria Shani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Linor Klein
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hila Greenbaum
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vered H. Eisenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

U. Shani: data collection, data analysis, manuscript writing and editing; L. Klein: data collection, editing; H. Greenbaum: data collection, editing; V.H. Eisenberg: project development, data collection, data analysis, manuscript writing and editing.

Corresponding author

Correspondence to Uria Shani.

Ethics declarations

Conflicts of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shani, U., Klein, L., Greenbaum, H. et al. Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting. Int Urogynecol J 34, 2743–2749 (2023). https://doi.org/10.1007/s00192-023-05602-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-023-05602-5

Keywords

Search

Navigation