Int Urogynecol J

DOI 10.1007/s00192-012-2006-6

ORIGINAL ARTICLE

A prior cesarean section and incidence of obstetric anal

sphincter injury
Sari Risnen & Katri Vehvilinen-Julkunen &
Rufus Cartwright & Mika Gissler & Seppo Heinonen

Received: 12 September 2012 / Accepted: 12 November 2012

# The International Urogynecological Association 2012

Abstract
Introduction and hypothesis Obstetric anal sphincter injury
(OASIS) following birth may have serious, long-term
effects on affected women, including fecal incontinence,
despite primary repair.
Methods This was a retrospective population-based register
study. Women with OASIS grouped by order of vaginal
delivery and prior cesarean section (CS) were compared separately with women without OASIS using logistic regression
analysis. The aim was to assess an association between prior
CS and incidence of OASIS across groups of women categorized according to singleton first, second, and third vaginal
deliveries between 1997 and 2007 in Finland.
Results The incidence of OASIS was 1.8 % at a first vaginal
delivery after a prior CS compared with 1.0 % at a first
vaginal delivery without prior CS. After adjustment prior
CS was associated with a 1.42-fold risk of OASIS only at
the first vaginal delivery, with no further significant risk
after one or two previous vaginal deliveries. One centimeter
increase in maternal height was associated with a 2 % decrease in OASIS incidence at the first vaginal delivery.
S. Risnen (*)
Savonia University of Applied Sciences, P.O. Box 72,
74101 Iisalmi, Finland
e-mail: shraisan@student.uef.fi
K. Vehvilinen-Julkunen
Department of Nursing Science, University of Eastern Finland,
P.O. Box 1627, 70211 Kuopio, Finland
e-mail: Katri.VehvilainenJulkunen@uef.fi
K. Vehvilinen-Julkunen
Kuopio University Hospital, P.O. Box 1777,
70211 Kuopio, Finland
R. Cartwright
Institute of Reproductive and Developmental Biology,
Hammersmith Hospital, Du Cane Road,
London W12 0NN, UK
e-mail: r.cartwright@imperial.ac.uk

Conclusions Prior CS is a significant risk factor for OASIS

at the first vaginal delivery. This suggests that relative
fetopelvic disproportion leading to CS for a first delivery
also predisposes to OASIS at a first vaginal delivery since
40 % of the increased incidence of OASIS risk was
explained by birthweight and 4 % by maternal height.
Keywords Birth injuries . Delivery, obstetric . Episiotomy .
Perineum, injuries . Registries . Cesarean section

Introduction
Obstetric anal sphincter injury (OASIS) is a serious complication of vaginal delivery that may result in anal
incontinence in one third to two thirds of women [1].
There is a wide variation in the reported incidence of
OASIS between countries, ranging from 0.2 to 3.5 % in
2004 in Europe [2] and from 3.5 to 5.9 % in the USA
[3, 4]. An overall increased incidence has been reported
in recent decades, which may be partially explained by
M. Gissler
National Institute for Health and Welfare (THL),
P.O. Box 30, Lintulahdenkuja 4,
00271 Helsinki, Finland
e-mail: mika.gissler@thl.fi
M. Gissler
Nordic School of Public Health, Gothenburg, Sweden
S. Heinonen
Department of Obstetrics and Gynaecology, Kuopio University
Hospital, P.O. Box 1777, 70211 Kuopio, Finland
e-mail: seppo.heinonen@kuh.fi

S. Heinonen
University of Eastern Finland, P.O. Box 1627, 70211 Kuopio,
Finland

Int Urogynecol J

improvements in either diagnosis or routine registration

[5, 6].
Consistently identified risk factors for OASIS based on
previous studies include first vaginal birth [7, 8], high birthweight [9, 10], prolonged active second stage of birth [8],
assisted deliveries [7, 10], and midline episiotomy [3, 11,
12]. Data regarding mediolateral and lateral episiotomy are
less consistent, but large population-based studies demonstrate decreased risk of OASIS [8, 10, 13]. Lateral episiotomy, which is performed in the vaginal introitus 1 or 2 cm
lateral to the midline and directed downwards towards the
ischial tuberosity, is exclusively used in Finland [14]. Some
previous studies have considered an association between
previous cesarean section (CS) and incidence of OASIS. A
first vaginal delivery after a prior CS has been reported to be
associated either with a similar [15] or an increased incidence of OASIS [3, 7, 16] compared to a first vaginal
delivery without a prior CS. In addition, two studies from
the USA, where midline episiotomy is preferred, reported an
increased association between the incidence of OASIS and
first vaginal deliveries after a prior CS compared to first
vaginal deliveries [3, 16]. An excess risk from prior CS has
also been reported for second and subsequent vaginal deliveries [3], including for the subset of women delivering
spontaneously [7].
It has been clearly established that the risk of OASIS
declines with increasing parity, with some threshold effect,
evident at the first vaginal delivery [810]. Conclusions
from previous studies are limited, both by the absence of
comparisons right across the range of vaginal birth order and
risk of unmeasured confounding factors associated with CS
at the first birth. Accordingly, the aim of the present study
was to assess an association between prior CS and incidence
of OASIS across groups of women categorized according to
singleton first, second, and third vaginal deliveries between
1997 and 2007 in Finland.

Materials and methods

The data were gathered from the Finnish Medical Birth
Register with linkage to the Hospital Discharge Register
that are both maintained by the National Institute for Health
and Welfare (THL) in Finland. Permission to use the confidential register data in this study was granted 16 October
2008 by the THL in Finland (reference number 2777/605/
2007). The Medical Birth Register established in 1987
includes information on maternal and neonatal birth characteristics and perinatal outcomes concerning all live births or
stillbirths delivered after the 22nd gestational week or
weighing 500 g or more.
Information on OASIS was not collected in the Medical
Birth Register prior to 2004, so for the years 19972003, the

information about OASIS was taken from the Hospital

Discharge Register, based on the International Classification
of Diseases (ICD-10) codes O70.2 (third degree) and O70.3
(fourth degree). The Hospital Discharge Register established
in 1969 contains information on all aspects of inpatient care
and outpatient visits in Finnish hospitals; thus, we had also
information concerning all aspects of care during pregnancy
and birth such as medical interventions and surgical procedures. The two data sources were linked together using
encrypted unique personal identification numbers. Women
with only a first OASIS were included and those with
subsequent OASIS (n022) were excluded from analysis.
The use of a sensitive electronic health register for the
period from 1997 to 2007 required authorization by national
data protection legislation. Only anonymized data were used
and consequently the informed consent of the registered
individuals was not needed.
The data included all women with singleton first to third
vaginal deliveries (n0463,918) of which 6.2 % (n028,942)
had a prior CS. The deliveries were categorized into six
groups, which were first vaginal, first vaginal delivery after
a prior CS, second vaginal delivery, second vaginal delivery
after a prior CS, third vaginal delivery, and third vaginal
delivery after a prior CS in univariate analyses.
Statistical differences between the subjects and the reference group in the maternal and neonatal birth characteristics
and perinatal outcomes were evaluated by the chi-square
test. The differences between groups in the continuous variables were evaluated by Students t and by MannWhitney
U tests as appropriate. In multivariate analyses deliveries
were grouped and analyzed by order of vaginal delivery in
three groups (first, second, and third vaginal delivery). For
each vaginal delivery group logistic regression analyses
were used to calculate the odds ratio (OR) of OASIS by
adjusting for both clinically relevant and statistically significant factors (p<0.1) associated with OASIS. Furthermore,
in order to examine whether mode of delivery and background characteristics (maternal age, birthweight, maternal
height and weight) contributed to the risk of OASIS at the
first vaginal delivery with and without a prior CS, we
estimated the contribution of each of these factors by using
logistic regression for the years 20042007. Maternal
height, maternal weight, length of active second stage of
birth, and head circumference were available for inclusion in
logistic regression analyses for births that occurred after
2003. Each intervention or background characteristics were
added separately to model B (risk adjusted by a prior CS and
maternal age) and the contribution of each factor was measured by the percentage reduction in the OR of OASIS
compared to the model B (OR model BOR model C/D/E/
F)/(OR model B1) [17, 18].
The degree of OASIS was classified according to standard definitions: a third-degree rupture involves the external

Int Urogynecol J

anal sphincter and a fourth-degree rupture affects both the

anal sphincter and the anorectal mucosa [19]. In all of the
analyses, data on third- and fourth-degree OASIS were
pooled. Active second stage of birth was defined as commencement of active pushing until delivery of the infant.
Apart from birthweight, length of active second stage of
delivery, head circumference, maternal height, and pregravid body mass index (BMI), all other variables were categorical or dichotomous in multivariate analyses. BMI was
calculated by dividing body weight in kilograms by height
in meters squared. Differences were deemed to be significant if p<0.05. The data were analyzed using SPSS for
Windows 19.0 (Chicago, IL, USA).

Results
For women with a singleton vaginal delivery in 19972007,
the overall incidence of OASIS was 0.6 % (n02,786 of
463,086). As expected rates of OASIS declined across
groups of vaginal delivery from first to third. The incidence
of OASIS at a first vaginal delivery (women without a prior
CS) was 1.0 % compared with 1.8 % at a first vaginal
delivery after a prior CS (p0.001). There was no measurable absolute difference in subsequent deliveries, with an
OASIS incidence of 0.2 % at second vaginal deliveries
(without and with a prior CS, p00.33) and 0.1 % at third
vaginal deliveries (without and with a prior CS, p00.22)
(Tables 1, 2, and 3). Unadjusted OR and 95 % confidence
intervals (CI), with first vaginal delivery (including women
with prior CS) as the reference group, were OR 0.21 (95 %
CI 0.190.23) and OR 0.08 (95 % CI 0.060.10), respectively (data not shown).
After adjustment for confounders and mediators a prior
CS was associated with a 1.42-fold incidence of OASIS at
first vaginal deliveries (adjusted OR 1.42, 95 % CI 1.25
1.61), with no significant association at the second and the
third vaginal deliveries (adjusted ORs 0.91, 95 % CI 0.59
1.43 and 1.32, 0.483.63, respectively) as shown in Table 4.
Instrumental assisted delivery was associated with an increased incidence of OASIS at first and second vaginal
deliveries and high birthweight across all groups of vaginal
deliveries.
The use of lateral episiotomy was associated with a 25 %
(adjusted OR 0.75, 95 % CI 0.680.82) decreased incidence
of OASIS at first vaginal deliveries (without and with a
previous CS), whereas use of the procedure was associated
with a significantly increased incidence of OASIS at third
vaginal deliveries. The length of active second stage of birth
was associated with an increased incidence of OASIS at the
first and second vaginal deliveries, with a similar but nonsignificant trend at third vaginal deliveries, probably due to
the low number of cases. At first vaginal deliveries,

maternal height was significantly negatively associated with

the incidence of OASIS. One centimeter increase in maternal height was associated with a 2 % decrease in the incidence of OASIS (adjusted OR 0.98, 95 % CI 0.970.99),
such that a 10-cm increase in maternal height was associated
with a 20 % relative decreased incidence of OASIS. Further,
it appeared that the mean height (SD) of women at first
vaginal deliveries with a prior CS was lower than those
without it [165.2 cm (5.9) vs 166.0 cm (5.9), p0.001],
as shown in Table 5.
Furthermore, we measured the contribution of mode of
delivery and background characteristics to the incidence of
OASIS associated with a prior CS before a first vaginal
delivery using a percentage reduction in the OR, as shown
in Table 6. For example, the OR of OASIS adjusted by a
prior CS and maternal age was 1.53 (95 % CI 1.351.73)
and after birthweight was added to the model the OR decreased to 1.32 (95 % CI 1.171.49). This means that
39.7 % of the OASIS incidence at first vaginal delivery after
a prior CS can be explained by birthweight and 3.8 % by
maternal height.

Discussion
The present study aimed to assess an association between
prior CS and incidence of OASIS across groups of women
categorized according to singleton first, second, and third
vaginal deliveries between 1997 and 2007 in Finland. The
main finding was that a prior CS was associated with a 1.42fold increased risk of OASIS at the first vaginal delivery,
with no significant association in subsequent vaginal deliveries. The incidence of OASIS at first vaginal deliveries was
1.1 % (2,354 of 221,347) and declined substantially at
second (0.2 %, 368 of 165,960) and third deliveries
(0.1 %, 66 of 76,611). This inverse association between
incidence of OASIS and vaginal birth order confirmed the
results of previous large retrospective population-based
studies from the Netherlands and Norway. In both these
countries mediolateral episiotomy is preferred, and the overall incidence of OASIS is approximately twofold higher
than in Finland [7, 10].
The most important strength of this analysis was that the
data were gathered from two high-quality mandatory national registers, each of which provides excellent coverage of
the entire Finnish population with validated data quality [5,
20]. Nevertheless, it might be a concern that this kind of
register includes errors and missing values, because the data
are produced mainly for administrative and statistical purposes, not primarily for research. For the period 20062007,
we were able to compare our two data sources, when there
was independent recording of OASIS in both registers.
During this period the Hospital Discharge Register covered

Int Urogynecol J
Table 1 Delivery characteristics and interventions for singleton first vaginal delivery and first vaginal delivery after a prior CS for the first birth
(chi-square, Mann-Whitney U, marked with *, and Students t tests, marked with **)
Delivery intervention/characteristic,
% or mean (SD)

Mean maternal age, years (SD)

19
2029
3039
40
Mean maternal height, cm (SD)a
BMI (SD)a
Mode of delivery
Vaginal spontaneous
Breech
Forceps
Vacuum assistance
Mean length of active 2nd stage of
birth, min (SD)a
15
1630
3145
4660
61
Mean birthweight, g (SD)
<3,000
3,0003,499
3,5003,999
4,000
Mean head circumference, cm (SD)a
Induction
Augmentation with oxytocin
Episiotomy
Epidural analgesia
Nitrous oxide gas
Paracervical block

First vaginal delivery, n0204,104

p value

With OASIS
(1.0 %, n02,046)

Without OASIS

28.1 (4.8)
3.4
59.8
35.6
1.2
165.8 (5.9)
23.6 (4.2)

26.8 (5.1)
6.9
64.0
28.0
1.1
166.0 (5.9)
23.4 (4.3)

0.001
0.001

63.1
0.5
0.8
35.5
63.9 (57.2)

84.2
0.8
0.2
14.8
42.5 (42.5)

0.001

11.6
22.5
20.5
15.2
30.1
3,677.8 (445.6)
6.2
28.8
42.1
22.9
35.2 (1.4)
17.0
65.8
65.7
58.9
53.2
11.7

23.7
31.0
18.9
10.5
15.9
3,417.0 (445.7)
15.7
37.4
34.7
12.2
34.7 (1.6)
15.2
63.0
63.5
60.7
56.8
14.6

0.78
0.14

0.001

0.001
0.001

0.001
0.03
0.009
0.04
0.10
0.001
0.001

First vaginal delivery after a prior

CS for their first birth, n017,243

p value

With OASIS
(1.8 %, n0308)

Without OASIS

31.1 (4.1)
0.0
34.7
63.6
1.6
165.1 (5.6)
24.7 (4.7)

30.3 (4.7)
0.5
42.8
54.3
2.4
165.2 (5.9)
24.5 (4.7)

72.1
0.3
1.3
26.3
54.1 (49.3)

83.6
0.3
0.2
15.9
38.7 (40.7)

0.001

15.4
26.5
23.5
9.6
25.0
3,795.9 (448.8)
3.9
20.1
40.9
35.1
35.4 (1.4)
20.1
65.9
55.8
63.0
51.0
12.3

27.8
32.4
16.9
9.4
13.5
3,574.2 (514.5)
10.5
30.7
39.7
19.0
35.1 (1.6)
17.9
61.3
63.2
61.0
55.2
15.0

0.001

0.001**
0.008

0.95**
0.60**

0.001**

0.001*
0.001

0.03**
0.30
0.10
0.008
0.48
0.14
0.11

Maternal height, BMI, length of active 2nd stage of birth, and head circumference covered only for the years 20042007. Information for the years
20042007: n083,179 of which 6,568 had a prior CS, n OASIS01,379 of which 174 had a prior CS

95 % of OASIS cases recorded in the Medical Birth Register, which adds to our confidence in the reliability of case
ascertainment. For the period 20042007 we were able to
adjust for a wide range of potential confounders and mediators, including maternal height, BMI, length of active second stage of birth, and head circumference, which by means
of multivariate modeling strengthens the association between a prior CS and OASIS.
Among the possible limitations of this analysis were the
lack of data regarding the number of previous CS for women with three or more deliveries. Although a vaginal delivery after two CS is rarely and after three CS never

recommended in Finland, there might have been a few such

cases, in which we would have underestimated vaginal
parity. This would tend to bias away from the null results
we report for an effect of prior CS on second and third
vaginal deliveries. In the present study, there were 528 cases
with missing information on parity, which were excluded
from the data. This exclusion, however, is unlikely to have
affected our results, since their share was only 0.1 % of the
total population.
Our results pertaining to an association between a prior
CS and an incidence of OASIS confirmed the results of
previous studies and were of similar magnitude [3, 7, 16].

Int Urogynecol J
Table 2 Delivery characteristics and interventions for singleton second vaginal delivery and second vaginal delivery after a prior CS for the first
birth (chi-square and Mann-Whitney U)
Delivery intervention/characteristic

Second vaginal deliveries, n0157,317

p value Second vaginal delivery + prior CS, n08,296 p value

With OASIS (0.2 %, Without OASIS,

n0347), % or mean % or mean

With OASIS (0.3 %,

n021), % or mean
0.001 33.2 (3.7)
0.001 0.0
9.5

Without OASIS,
% or mean

Mean maternal age, years (SD)

19
2029

30.9 (4.6)
0.0
38.9

29.4 (4.8)
0.8
50.9

32.0 (4.5)
0.1
29.1

0.22*
0.19

3039
40
Mean maternal height, cm (SD)a
BMI (SD)a
Mode of delivery
Vaginal spontaneous
Breech
Forceps
Vacuum assistance
Mean length of active 2nd stage of
birth, min (SD)a
15
1630
3145
4660
61
Mean birthweight, g (SD)
<3,000
3,0003,499
3,5003,999
4,000
Mean head circumference, cm (SD)a
Induction
Augmentation with oxytocin
Episiotomy
Epidural analgesia
Nitrous oxide gas
Paracervical block

55.9
5.2
165.3 (5.8)
23.9 (3.9)

46.4
1.9
166.1 (5.9)
24.1 (4.5)

0.11
0.58

81.0
9.5
164.9 (4.1)
23.2 (2.3)

66.5
4.3
165.1 (5.7)
24.9 (4.7)

87.6
0.6
0.3
11.5
29.4 (34.2)

97.1
0.6
0.0
2.3
14.8 (19.7)

0.001 90.5
0.0
0.0
9.5
0.001 15.6 (16.5)

95.2
0.5
0.1
4.2
16.1 (21.9)

0.66

39.0
35.6
13.7
1.4
10.3
3,953.4 (472.3)
2.3
12.4
40.9
44.4
35.5 (1.4)
17.0
41.8
30.5
26.8
45.2
23.3

72.0
19.1
5.1
1.9
2.0
3,617.1 (499.0)
9.0
29.9
40.1
21.1
35.01 (1.4)
13.6
33.3
20.8
23.9
48.6
24.1

0.001 62.5
25.0
0.0
12.5
0.0
0.001 3,932.4 (441.7)
0.001 4.8
4.8
42.9
47.6
0.001 35.7 (1.8)
0.07
28.6
0.001 42.9
0.001 33.3
0.20
33.3
0.21
42.9
0.75
19.0

69.2
20.4
5.9
2.1
2.4
3,616.7 (560.5)
10.5
27.3
38.7
23.4
35.0 (1.8)
21.1
39.2
24.6
28.2
50.3
23.4

0.30

0.96
0.39

0.80

0.003
0.02

0.37
0.40
0.73
0.35
0.61
0.50
0.64

Maternal height, BMI, length of active 2nd stage of birth, and head circumference covered only for the years 20042007. Information for the years
20042007: n060,861 of which 3,088 had a prior CS, n OASIS0208 of which 13 had a prior CS

However, the same association in the second and third

vaginal deliveries was not in line with previous studies that
have suggested that a prior CS increased the risk of OASIS
regardless of the number of previous vaginal deliveries [3,
7]. Our results demonstrated that in the Finnish population a
prior CS was not associated with increased incidence of
OASIS at the second and third vaginal deliveries. These
findings could be explained by the fact that in the previous
studies the risk of OASIS was adjusted among the total
population, whereas in our study we were able to adjust
among strata of women with equal number of vaginal deliveries. Other differences may arise from wide variation in

obstetric practice with regard to CS. In 2004 CS rates in

Europe varied from 14.3 % in Slovenia to 37.8 % in Italy
[2], whereas in 2009 the CS rate in the USA was 32.9 %
[21]. In Finland, the annual CS rate has been quite constant
and varied from 15.2 to 16.2 % during the study period.
Differences in risk associated with prior CS may therefore
reflect a different risk profile in different settings.
Based on results of multivariate analyses we suggest that
increased incidence of OASIS after a prior CS at first
vaginal delivery might reflect relative fetopelvic disproportion. Such fetopelvic disproportion might predispose to CS
at a first delivery and subsequently contribute to increased

Int Urogynecol J
Table 3 Delivery characteristics and interventions for singleton third vaginal delivery and third vaginal delivery after a prior CS for the first birth
(chi-square and Mann-Whitney U)
Delivery intervention/
characteristic

Mean maternal age, years (SD)

19
2029
3039
40
Mean maternal height, cm (SD)a
BMI (SD)a
Mode of delivery
Vaginal spontaneous
Breech
Forceps
Vacuum assistance
Mean length of active 2nd stage of
birth, min (SD)a
15
1630
3145
4660
61
Mean birthweight, g (SD)
<3,000
3,0003,499
3,5003,999
4,000
Mean head circumference, cm (SD)a
Induction
Augmentation with oxytocin
Episiotomy
Epidural analgesia
Nitrous oxide gas
Paracervical block

Third vaginal deliveries, n073,347

p value

With OASIS (0.1 %,

n062), % or mean

Without OASIS,
% or mean

33.7 (4.6)
0.0
14.5
75.8
9.7
165.3 (7.0)
25.3 (4.6)

31.6 (4.7)
0.1
32.7
62.7
4.5
165.9 (5.8)
24.4 (4.7)

0.001
0.008

95.2
0.0
0.0
4.8
25.4 (25.4)

97.8
0.6
0.0
1.6
11.2 (15.8)

0.19

50.0
16.7
12.5
16.7
4.2
3,934.1 (519.9)
1.6
14.5
38.7
45.2
35.6 (1.3)
24.2
40.3
22.6
14.5
35.5
32.3

81.3
13.3
3.1
1.1
1.1
3,660.3 (515.7)
8.2
27.2
39.8
24.7
35.1 (1.4)
18.0
31.7
9.3
14.4
45.8
24.7

0.70
0.15

0.001
0.001

0.001
0.001

0.05
0.21
0.15
0.001
0.98
0.10
0.17

Third vaginal delivery + prior CS,

n03,264

p value

With OASIS (0.1 %,

n04), % or mean

Without OASIS,
% or mean

38.0 (3.7)
0.0
75.0
25.0
0.0
174.0
24.8

33.2 (6.6)
0.0
24.8
67.3
8.0
164.9 (5.7)
25.3 (4.9)

0.03
0.29

75.0
0.0
0.0
25.0
42.0

97.0
0.5
0.0
2.5
12.0 (16.9)

0.04

0.0
0.0
100.0
0.0
0.0
3,861.3 (375.6)
0.0
0.0
50.0
50.0

25.0
25.0
50.0
25.0
50.0
0.0

80.0
14.8
2.9
0.7
1.6
3,621.2 (580.8)
11.0
26.2
38.4
24.4
35.1 (1.6)
25.1
39.0
10.0
18.9
48.9
25.6

0.13
0.87

0.10
0.001

0.36
0.44

1.00
0.57
0.008
0.76
0.96
0.24

Maternal height, BMI, length of active 2nd stage of birth, and head circumference covered only for the years 20042007. Information for the years
20042007: n026,922 of which 1183 had a prior CS, n OASIS033 of which 2 had a prior CS

risk of OASIS. Because we had no direct information on

pelvic parameters or clinical suspicion of cephalopelvic
disproportion, we used maternal height as a surrogate
variable. Several studies have established maternal height
to be correlated to the size of the pelvis, and women
with cephalopelvic disproportion are shorter compared to
those with spontaneous vaginal deliveries.[2226] Indeed,
in this sample, the mean maternal height of women with
first vaginal delivery after a prior CS was 0.8 cm lower
than those without a prior CS. Furthermore, in multivariate analysis a 1 cm increase in maternal height was

associated with a 2 % decrease in the incidence of

OASIS. Thus, for example, a 5-cm increase in maternal
height was associated with a 10 % decrease on OASIS
rates. Although we were also able to adjust both for
birthweight and head circumference, cephalopelvic disproportion can never be predicted with certainty based
on either maternal or fetal measures, because it results
from diverse factors including malposition of the fetal
head as well as contraction frequency and strengths
[27]. So although we observed that women with a prior
CS had an increased unadjusted risk of OASIS, based on

Int Urogynecol J
Table 4 Adjusted OR of OASIS at first, second, or third singleton vaginal delivery between 1997 and 2007 in Finland (logistic regression
analyses)
Delivery intervention/characteristic

Maternal age
19
2029 (ref. 29 in multiparous)
3039
40
Maternal height, cma
BMIa
Mode of delivery
Vaginal spontaneous
Breech
Forceps
Vacuum assistance
Length of active 2nd stage of birth per 1 h increasea
Birthweight per 1,000 g increase
Head circumference, cma
Induction
Augmentation with oxytocin
Episiotomy
Epidural analgesia
Nitrous oxide gas
Paracervical block
Prior CS

First vaginal delivery

OR (95 % CI), n0221,347
(20042007, n040,022)

Second vaginal delivery

OR (95 % CI), n0165,892
(20042007, n029,366)

Third vaginal delivery

OR (95 % CI), n076,580
(20042007, n013,499)

1
1.71 (1.342.17)***
2.18 (1.702.78)***
1.68 (1.082.60)*

1
1.53 (1.231.91)***
3.43 (2.135.53)***

1
2.56 (1.255.21)**
4.70 (1.7312.76)**

0.98 (0.970.99)**
0.99 (0.971.01)

0.98 (0.951.02)
0.96 (0.761.10)

0.95 (0.871.03)
0.97 (0.871.09)

1
1.16 (0.642.11)
4.90 (3.157.64)***
2.90 (2.623.16)***
1.22 (1.121.33)***
2.62 (2.402.86)***
1.03 (0.961.10)
1.02 (0.911.13)
1.07 (0.971.17)
0.75 (0.680.82)***
0.78 (0.710.86)***
0.86 (0.740.94)**
0.67 (0.590.77)***
1.42 (1.251.61)***

1
1.66 (0.416.73)
8.97 (1.2166.16)***
3.81 (2.705.39)***
1.44 (1.121.84)***
3.95 (3.194.90)***
0.91 (0.751.12)
0.93 (0.721.21)
1.06 (0.841.33)
1.12 (0.891.42)
1.02 (0.801.30)

0.91 (0.591.43)

2.18
1.60
2.69
0.84
1.23
1.01
2.31

1.32

(0.766.23)
(0.843.06)
(1.644.43)***
(0.541.32)
(0.702.17)
(0.661.83)
(1.294.16)**

(0.483.63)

*p value<0.05; **p<0.01; ***p<0.001

a

Maternal height, BMI, length of active 2nd stage of birth, and head circumference adjusted only for the years 20042007

both measurable maternal and fetal factors (Table 5), we

conclude that there was also an excess risk resulting from
unmeasured but persistent above-mentioned common contributors both to CS and OASIS.
The results of the present study are applicable to
countries with a similar incidence of OASIS but may be
very different in countries with markedly lower or higher
OASIS or CS rates, or other differences in obstetric practice.

Table 5 Characteristics of
women with or without prior CS
at first singleton vaginal delivery
during 19972007 in Finland
(chi-square, Mann-Whitney U,
or Students t tests)
a

Maternal height, maternal

weight, and head circumference
were analyzed only for the years
20042007

In particular, low use of forceps and exclusive use of lateral

episiotomy may reduce generalizability.

Conclusions
A prior CS was associated with a 1.42-fold incidence of
OASIS at first vaginal deliveries, even after adjustment for a

Characteristic

Mean
Mean
Mean
Mean

maternal height, cm (SD)a

maternal weight, kg (SD)a
birthweight, g (SD)
head circumference, cm (SD)a

First vaginal delivery, n0221,347 (in 20042007, n0

49,32774,220)
With a prior CS

Without a prior CS

165.2
67.1
3577.7
35.1

166.0
64.7
3448.0
34.7

(5.9)
(13.6)
(515.1)
(1.6)

(5.9)
(12.7)
(502.7)
(1.6)

p value

0.001
0.001
0.001
0.001

The risk of OASIS at first vaginal deliveries with and without a prior CS was adjusted by maternal age only in model B. Each intervention or demographic characteristics were added separately to
model B, and the contribution of each factor was measured by the percentage reduction in the OR of anal rupture compared to model B (OR model BOR model C/D/E/F)/(OR model B1)

Model A 0 adjusted by a prior CS; model B 0 adjusted by a prior CS and maternal age; model C 0 adjusted by a prior CS, maternal age, and mode of delivery; model D 0 adjusted by a prior CS,
maternal age, and birthweight; model E 0 adjusted by a prior CS, maternal age, and maternal height; model F 0 adjusted by a prior CS, maternal age, and maternal weight

1.9
1.52 (1.281.80)
3.8
1.51 (1.281.80)
A prior CS

1.78 (1.582.01)

1.53 (1.351.73)

1.57 (1.391.77)

39.7
1.32 (1.171.49)

Diff. with B
(%)a
OR (95 % CI)
Diff. with B
(%)a
OR (95 % CI)
OR (95 % CI)
OR (95 % CI)

OR (95 % CI)

Diff. with B
(%)a
OR (95 % CI)
Diff. with B
(%)a

Model F
Model E
Model D
Model C
Model B
Model A

Table 6 OR for OASIS at first vaginal deliveries with and without a prior CS after adjustment by interventions and characteristics (n082,031) between 2004 and 2007 in Finland (logistic
regression)

Int Urogynecol J

wide range of risk factors for both CS and OASIS. At second

and third vaginal deliveries there was no significant association. Maternal height, which correlates with pelvic diameters,
and birthweight were strongly associated with incidence of
OASIS and in the order of 44 % of increased incidence of
OASIS at first vaginal deliveries after a prior CS. Thus, a prior
CS might reflect relative fetopelvic disproportion that persists
in subsequent deliveries and increases the risk of OASIS.
Conflicts of interest None.

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