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DOI: 10.1111/1471-0528.


General obstetrics


Third- and fourth-degree perineal tears among

primiparous women in England between 2000
and 2012: time trends and risk factors
I Gurol-Urganci,a,b DA Cromwell,a LC Edozien,c TA Mahmood,b EJ Adams,d DH Richmond,b,d
A Templeton,b JH van der Meulena
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, b Office for Research and
Clinical Audit, Lindsay Stewart R&D Centre, Royal College of Obstetricians and Gynaecologists (RCOG), London, c Maternal and Fetal Health
Research, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, d Department of Urogynaecology, Liverpool
Womens NHS Foundation Trust, Liverpool, UK
Correspondence: Dr Ipek Gurol-Urganci, Department of Health Services Research and Policy, London School of Hygiene and Tropical
Medicine, 1517 Tavistock Place, London, WC1H 9SH, UK. Email ipek.gurol@lshtm.ac.uk

Accepted 17 May 2013. Published Online 3 July 2013.

Objective To describe the trends of severe perineal tears in

England and to investigate to what extent the changes in related

risk factors could explain the observed trends.
Design A retrospective cohort study of singleton deliveries from a

national administrative database.

Setting The English National Health Service between 1 April 2000

and 31 March 2012.

Population A cohort of 1 035 253 primiparous women who had a

singleton, term, cephalic, vaginal birth.

Methods Multivariable logistic regression was used to estimate

the impact of financial year of birth (labelled by starting year),

adjusting for major risk factors.
Main outcome measure The rate of third-degree (anal sphincter

is torn) or fourth-degree (anal sphincter as well as rectal mucosa

are torn) perineal tears.

Results The rate of reported third- or fourth-degree perineal tears

tripled from 1.8 to 5.9% during the study period. The rate of
episiotomy varied between 30 and 36%. An increasing proportion
of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental
deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A
higher risk of third- or fourth-degree perineal tears was associated
with a maternal age above 25 years, instrumental delivery (forceps
and ventouse), especially without episiotomy, Asian ethnicity, a
more affluent socio-economic status, higher birthweight, and
shoulder dystocia.
Conclusions Changes in major risk factors are unlikely

explanations for the observed increase in the rate of third- or

fourth-degree tears. The improved recognition of tears following
the implementation of a standardised classification of perineal
tears is the most likely explanation.
Keywords Episiotomy, instrumental delivery, severe perineal
trauma, trends, vaginal delivery.

Please cite this paper as: Gurol-Urganci I, Cromwell D, Edozien L, Mahmood T, Adams E, Richmond D, Templeton A, van der Meulen J. Third- and
fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120:15161525.

Recent population-based studies from Scandinavian countries and Canada have identified an increase in the occurrence of severe obstetric anal sphincter injuries.15 In the
UK, a study from a single unit reported that the combined
rate of third-degree (anal sphincter is torn) and fourthdegree perineal tears (anal sphincter as well as rectal
mucosa are torn) increased from 1.3% in 2001 to 4.6% in
2010.6 One possible reason for this trend is the rise in
maternal age at first birth and maternal weight, which are


linked to a higher birthweight and risk of perineal tears.

Other reasons include increased awareness and training,
which is likely to result in a better case detection and
recording of obstetric injuries, and changes in the management of the second stage of labour.1,5
The aim of this study was to describe the time trends in
obstetric anal sphincter injuries in England, recorded in a
large population-based database that includes all maternity
admissions in the English National Health Service (NHS).
We also investigated risk factors for these injuries
and explored to what extent changes in these relevant risk

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Third- and fourth-degree perineal tears in England

factors and in obstetric practice were linked to the observed


We used the Hospital Episode Statistics (HES) database to
identify all deliveries that took place in English NHS Trusts
(acute hospital organizations) from April 2000 to March
2012. HES is a data warehouse that includes records of all
inpatient admissions and day cases in English NHS Trusts.
The data are extracted from local patient administration
systems, and undergo a series of validation and cleaning
processes before being made available for analysis.7
The HES database contains patient demographics, clinical information, and administrative data for each inpatient
episode of care. Diagnostic information is coded using the
International Classification of Diseases 10th revision
(ICD10),8 and operative procedures are coded using the
UK Office for Population Censuses and Surveys classification, fourth revision (OPCS4).9 For maternity episodes, the
HES database has supplementary fields known as the
maternity tail, which captures parity, birthweight, gestational age, method of delivery, and pregnancy outcome.
The accuracy and completeness of diagnostic and procedures data are high.10 The maternity tail is not compulsory,
and the level of data completeness varies across Trusts. For
example, birthweight and parity are available in 79 and
65% of the delivery episodes, respectively.
The study included only primiparous women aged 15
45 years, who had a singleton, term, cephalic, vaginal birth.
We confined the analysis to NHS Trusts that had parity
information recorded in at least half of the deliveries, and
that had a proportion of primiparous women between 25
and 55% (overall about 40% of women giving birth are
primiparous in England and Wales). The quality of parity
data was evaluated for each year of the study.
Cases of perineal tears were identified by ICD10 codes
O70.0 (first-degree perineal laceration), O70.1 (second
degree), O70.2 (third degree), and O70.3 (fourth degree).
Mode of delivery was defined using information in the
OPCS4 procedure codes, and we distinguished between
vaginal (OPCS4 codes R23 and R24), forceps (R21), and
ventouse (R22), or if not defined using OPCS4 codes, by
the delivery method specified in the maternity tail. These
three modes were further stratified by whether or not an
episiotomy had been performed (OPCS4 code R27.1).
We identified the following potential risk factors. Maternal demographic factors were age (<20, 2024, 2529, 30
34, 35 years), ethnicity (white, Asian, black, other), and
socio-economic deprivation of the mothers area of residence 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,

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social, and housing indicators).11 Factors associated with

labour were mode of delivery, birthweight, prolonged
labour, and shoulder dystocia. 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 the ICD10 code O66.0
(obstructed labour as a result of shoulder dystocia).
We present the unadjusted trends for all degrees of perineal tears for all singleton, term, cephalic, vaginal first
births. We used multiple logistic regression models to estimate the crude and adjusted effect of the financial year of
delivery (labelled by starting year) on the risk of observing a
third- or fourth-degree tear, with the aim of assessing to
what extent the magnitude of the calendar time effect is
mitigated by controlling for the other risk factors. The logistic regression model was defined with random intercepts at
the NHS Trust level to take account of organisational clustering. All analyses were performed in STATA/SE 11.

There were 6 621 439 singleton term deliveries in 146 English NHS Trusts between April 2000 and March 2012.
Among these, 39.1% took place in NHS Trusts that had
poor-quality parity data, and the records for these NHS
Trusts were omitted. The median number of NHS trusts
included in each year was 81 (interquartile range: 7985).
Omitting episodes with missing parity data left 3 559 687
deliveries, of which 1 358 072 (38.6%) were first births.
Among these primiparous women, 23.1% of deliveries were
by caesarean section, and 0.2% were vaginal breech deliveries. A further 0.6% of records were missing maternal age or
deprivation data. Excluding these left 1 035 253 deliveries
for analysis.
The trends in unadjusted rates of reported obstetric tears
at first births, by degree of tear, are given in Figure 1. The
rate of third- or fourth-degree tears tripled between 2000
and 2011, whereas the rate of second-degree tears increased
by 23.5%. In 2011, the rate of third- or fourth-degree tears
was 5.9 per 100 deliveries.
During the same period, the use of forceps among all
vaginal primiparous deliveries increased from 9.0 to 16.1%,
and the rate of ventouse deliveries decreased from 17.5 to
13.9% (Figure 2). Only 83.2% of forceps deliveries were
facilitated by episiotomy, with the rate increasing from 82.2
to 87.7% over the study period. The proportion of ventouse deliveries facilitated by episiotomy increased from
67.8% in 2000 to 78.6% in 2011. The use of episiotomy in
non-instrumental deliveries decreased over the study period
from 19.1 to 15.1%.
Over half of the women included in the study were
between 20 and 29 years of age (Table 1). The risk of a
third- or fourth-degree tear increased with maternal age.


Gurol-Urganci et al.


Cases of tears, per 100 births















Second degree

First degree






Third/Fourth degree

Figure 1. Trends in the rate of obstetric tears. Rates are expressed per 100 singleton, term, cephalic, vaginal first births.


















Normal % with episiotomy

Ventouse % with episiotomy

Forceps % with episiotomy

Figure 2. Trends in the rates of forceps, ventouse, and non-instrumental deliveries. Rates are expressed per 100 singleton, term, cephalic, vaginal
first births.

Women older than 25 years were reported to have a thirdor fourth-degree tear at least twice as often as teenage
mothers. Women living in the least deprived communities,
and those with non-white ethnicities were also more likely
to have a severe obstetric tear. Asian women had a risk of
a third- or fourth-degree tear that was more than twice as
high as women from a white ethnic background (adjusted
OR 2.27, 95% CI 2.142.41).
Women who had an episiotomy were less likely to experience a severe perineal tear, regardless of the mode of
delivery. Across the different modes of delivery, women


who had a non-instrumental or a ventouse delivery with an

episiotomy had the lowest rates of third- or fourth-degree
tears. Use of forceps increased the risk of a tear, with a forceps delivery without an episiotomy increasing the odds of
a tear six-fold compared with a vaginal delivery without an
episiotomy. The adjusted risk of third- or fourth-degree
tears increased with birthweight and shoulder dystocia, but
was not associated with the duration of labour.
Figure 3 shows the time trends within risk groups
according to maternal age, ethnicity, mode of delivery, and
shoulder dystocia. The rate of obstetric tears increased in

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Third- and fourth-degree perineal tears in England

Table 1. Rate of third- or fourth-degree perineal tears in 1 035 253 singleton, term, cephalic, vaginal first births according to maternal and
obstetric risk factors
Prevalence of risk factor (%)
Year of delivery (Financial years)
Maternal age (years)
Q1: Most deprived
Least deprived
Mode of delivery
Normal w/o episiotomy
Normal w/episiotomy
Forceps w/o episiotomy
Forceps w/episiotomy
Ventouse w/o episiotomy
Ventouse w/episiotomy
Birthweight (g)
Prolonged labour
Shoulder dystocia

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Rate of tear per 100 births (%)

Crude OR (95% CI)











Adjusted OR (95% CI)



























1.49 (1.41.59)

0.99 (0.941.04)



3.15 (2.93.43)

1.90 (1.722.08)







Gurol-Urganci et al.


Cases of tears, per 100 births

Cases of tears, per 100 births


2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

20 to 24

25 to 29

30 to 34




Cases of tears, per 100 births

Cases of tears, per 100 births




2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

N + Epi

F orceps

F + Epi


V + Epi

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Dystocia: No

Dystocia: Yes

Figure 3. Trends in the rate of obstetric tears by risk factors. Rates are expressed per 100 singleton, term, cephalic, vaginal first births: (A) by
maternal age categories; (B) by ethnicity; (C) by mode of delivery 9 episiotomy; (d) by shoulder dystocia.

all groups, with the largest absolute increase in women

undergoing a forceps delivery without an episiotomy (Figure 3c) and in women with an Asian ethnic background
(Figure 3b).

We found a three-fold increase in the rate of reported
third- or fourth-degree perineal tears in England, with the
rate rising from 1.8% in 2000 to 5.9% in 2011. An
increased risk of a severe tear was associated with a maternal age above 25 years, forceps and ventouse delivery, especially without episiotomy, Asian ethnicity, a more affluent
socio-economic status, higher birthweight, and shoulder
dystocia. The use of an episiotomy was protective; however,
the increase in the rate of severe perineal injury over the
study period could not be explained by temporal changes
in the major risk factors.
Using HES data has several advantages for trying to
describe patterns of maternity care. First, over 96% of all
deliveries in England occur in NHS Trusts, and are therefore captured by HES,12 which gives large sample sizes for
outcomes that are relatively rare, such as third- or fourth-


degree perineal tears. Second, the availability of data since

1997 allows for the analysis of patterns of care over time.
Finally, the data are able to capture multiple procedures
and diagnoses at an individual level, and so provide a rich
description of the patient case mix.
A weakness of administrative data sets is that the coding
of the diagnoses and procedures is potentially inaccurate;
however, studies have demonstrated that the majority of
NHS Trusts submit good-quality data to HES that conforms with national recommendations.1315 A recent systematic review of discharge coding accuracy in the UK
concluded that routinely collected data are sufficiently
robust to support their use for research and managerial
decision-making.10 The richness of the data also makes it
possible to develop coding frameworks and data quality
criteria to identify hospitals with divergent coding practices
by combining diagnosis, procedure, and administrative
codes.16 A number of recent publications have demonstrated that when analysed carefully, HES is a valuable
source of data to explore patterns of care as well as supporting epidemiological studies related to childbirth.1719
This study included half of all vaginal singleton term
births in primiparous women who delivered in an NHS

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Third- and fourth-degree perineal tears in England

hospital over a 12year period. We focused on primiparous

women, as earlier studies had concluded that birth order
and a perineal tear in an earlier birth are important risk
factors.2026 Excluding NHS Trusts with poor data quality
may have introduced bias, as the risk-adjusted tear rates at
these hospitals may be different from the rates observed in
hospitals with better data quality. However, the effect size
of selection bias is likely to be small because the distributions of outcome and risk factors in both groups were similar (Table S1). This finding is in agreement with a recent
study that concluded that using birth cohorts from hospitals with high completeness of recording is likely to be
valid and nationally representative.27 A second method to
identify parity is to examine the womens obstetric history.
In a sensitivity analysis, we constructed a data set of primiparous women, using 10 years of obstetric history, covering a study period from April 2007 to March 2012. The
adjusted estimates of risk of obstetric tears from this data
set were compared with the results from the data set generated using high-quality parity information for the same
period. Both methods yielded comparable results (data not
We were unable to control for a number of risk factors,
such as the type of anaesthetic used, that might have influenced our results. Data on intrapartum anaesthetic use is
available in HES, but this information is contained in the
maternity tail, and was missing in about one-third of all
patient records. Therefore, we omitted this variable from
the analysis. In the subsample of records for whom this
information was available, the adjusted effect of epidural
analgesia was OR 1.10 (95% CI 0.941.29), and the inclusion of epidural in the logistic regression model did not
significantly modify the effect size of other risk factors. This
result is consistent with other studies on the impact of an
epidural anaesthetic on third- or fourth-degree tears.28,29
We were also unable to control for perineal protection
techniques applied during the second stage of labour, or
the experience or preferences of the birth attendant.30,31
Similarly, the angle and size of an episiotomy is likely to
influence the risk of tears,3234 but this information was
not available in our data set.

Comparison with previous literature

The rate of reported third- or fourth-degree tears in singleton, term, cephalic, vaginal first births in England was
5.9% in 2011. This rate of clinically recognised anal sphincter injuries falls within the wide range of figures reported
elsewhere. In large population-based studies using birth
registry or administrative hospital data, the incidence was
1.8% in Finland,5 3.64.2% in Norway, Denmark, and Sweden,1,2 and 4.55.4% in the USA.20,35 It is known that the
actual rate of anal sphincter lacerations is significantly
higher than the reported rates. Studies using endoanal

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ultrasonography have found clinically occult anal sphincter

defects in up to one-third of vaginal deliveries.36
We found that the risk of perineal tears was lower in
younger women. The risk of a severe perineal injury in
teenage primiparous women was less than half the risk in
women older than 25 years, which corresponds to the rates
in Norway.1 However, maternal age was not always identified as a risk factor for severe tears.28,37,38
Differences in risk for ethnicity have been demonstrated in
studies from Norway, Sweden, UK, and the USA.1,2,20,3840 It
has been suggested that differences in the anatomy of the
perineum, such as perineal body length and thickness among
different ethnic groups, may be contributing factors.39
Mode of delivery is a key determinant of the risk of perineal tears, with studies consistently demonstrating that
women with instrumental deliveries have higher rates of
anal sphincter tears,2,23,28,37 and that forceps deliveries carry
the highest risk of third- or fourth-degree perineal tears.
The risk of having a severe perineal injury has been
reported to be 1.514.0 times higher with forceps, and up
to four times higher with ventouse, than with spontaneous
vaginal delivery.2123,38,41,42
We considered it more informative to analyse combinations of mode of delivery and use of episiotomy in contrast
to analysing both as separate risk factors, which has been
the case in most studies. This allows for the effect of episiotomy to vary by delivery mode. Midline episiotomies are
known to increase the risk of third- or fourth-degree perineal tears.21,22,41,42 For mediolateral episiotomies, although
the evidence is not conclusive,43,44 most studies suggest that
this technique protects against severe tears.20,23,28,29,32,37,41,4547
The results of studies that analysed specific combinations
of mode of delivery and episiotomy use were consistent
with ours. These studies found that mediolateral episiotomy reduced the risk of tears in instrumental vaginal deliveries.1,46,47
Our findings on shoulder dystocia and birthweight confirms the results of previous studies, which found that
shoulder dystocia and birthweights higher than 4000 g double the risk of perineal tears.2023,45,48 An increase in the
incidence of these risk factors could contribute to a higher
rate of tears. However, the distribution of birthweights in
our population did not change over the study period. In
fact, the use of episiotomy in instrumental deliveries for
babies with birthweights over 4000 g increased from 77.5%
in 2000 to 85.6% in 2011, which is likely to reduce the risk
of severe tears for this group. We did not find evidence that
a longer duration of labour increases the risk of severe tears,
which is in contrast to a number of other studies.23,37,45,48

Possible explanations for the observed trends

It is important to monitor trends in the incidence of thirdor fourth-degree perineal tears, and the underlying explana-


Gurol-Urganci et al.

tions, because severe perineal trauma is listed as an index

of quality of care in the RCOG Maternity Dashboard,49
and by Australian,50 European,51 and US national quality
accreditation systems.52 These nationally reported trends
can be used for benchmarking. A trend towards an increasing incidence of third- or fourth-degree perineal tears, as
found in this study, does not necessarily indicate poorquality care. It may indicate, at least in the short term, an
improved quality of care through better detection and
The most likely explanation for the rising rate of
reported severe perineal injury is improved recognition.
This would be a result of two recent developments: the
introduction of a standardised classification of perineal
tears, and better training of staff in recognising and repairing perineal tears.54 The Royal College of Obstetricians and
Gynaecologists published evidence-based guidelines for the
management of third- or fourth-degree perineal tears in
2001 (second edition in 2007).55 All maternity units in
England should now have written policies on the diagnosis
and management of tears.56 Prior to the introduction of
the standardised classification, some clinicians will have
classified injuries to the anal sphincter as second-degree
tears.31,55,57 In the last decade, specific training in the identification and repair of perineal tears has become established as an essential component of postgraduate training
and continuing professional development for doctors and
midwives. Studies in the UK that have evaluated the implementation of the documentation proforma and auditable
standards recommended in the new guideline,58,59 and in
training interventions,60 confirm that the increased awareness and appropriate examination have increased the likelihood of perineal tears being detected.61
Another possible explanation is a gradual improvement
in the coding of tears in the English HES database. However, better coding is unlikely to have had a major impact
as the completeness and accuracy of data coding of thirdor fourth-degree perineal tears were found to be high in
databases in the USA, Norway, and Australia.6264 In all
these countries the sensitivity of coding of third- or fourthdegree tears was higher than 90%, and the majority of discrepancies occurred in the coding of first- and seconddegree tears.62
Our results and those of other studies demonstrate
that changes in the main risk factors do not explain the
observed increase in the rates of severe perineal tears.13,5,35
However, there have been significant changes in the management of the second stage of labour in the last decade. In
the 1990s, ventouse was advocated as the instrument of
first choice for instrumental vaginal delivery.65,66 As the
rate of failed instrumental delivery increased, clinical guidelines moved to recommending the use of the instrument
best suited to the individual circumstances.67 The National


Institute for Clinical Excellence (NICE) Guidelines for intrapartum care also recommended that routine episiotomy
should not be performed during spontaneous vaginal birth,
but that it should be used with any forceps delivery.67
These changes, as well as the fact that an episiotomy was
not performed in one or two of every ten forceps deliveries
in our study population, may have contributed to the
increase in the rates of third- or fourth-degree tears in England.
Changes in the application of perineal protection techniques may also have played a role.6871 The implementation of manual assistance and perineal protection
techniques during the second stage of labour have significantly reduced the incidence of perineal tears in Norway.72,73 Antenatal perineal massage reduces the
likelihood of perineal trauma (mainly episiotomies), but
is not routinely practiced in the UK.74 Wider application
of the hands-poised approach, combined with the reluctance to use episiotomies, could have resulted in a
higher risk of a third- or fourth-degree tears.3,75,76 Also,
women are increasingly encouraged to use their preferred
birth positions, which may have reduced perineal protection.5,48

This study found that, between April 2000 and March
2012, the rate of reported third- or fourth-degree perineal
tears for first births tripled in England. This trend mirrors
those reported from other developed countries such as Finland, Norway, and Canada. The most likely explanation for
the increasing rate is improved diagnosis through the introduction of a standardised classification of perineal tears
and the better training of staff. Changes in the patterns of
maternal risk factors and modes of delivery are unlikely

Disclosure of interests

Contribution to authorship
IGU, LCE, TAM, LA, and JHvdM conceived the study.
IGU and DAC contributed to its design and conducted the
analyses. IGU wrote the article, and DAC, LCE, TAM, LA,
DR, AT, 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.

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Third- and fourth-degree perineal tears in England

IG-U is supported by the Royal College of Obstetricians
and Gynaecologists.

We thank the Department of Health for providing the HES
data used in this study.

Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Maternal and obstetric risk factors in singleton, term vaginal births: comparison of included and
excluded episodes. &

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