Journal of Obstetrics and Gynaecology, February 2009; 29(2): 119122

OBSTETRICS

Risk factors for 3rd and 4th degree perineal tear

O. ESKANDAR & D. SHET

Departments of Obstetrics and Gynaecology, North Devon District Hospital, Barnstaple, UK

Summary
We reviewed 3,038 deliveries at our hospital, over a period of 2 years (2005 and 2006) to identify risk factors for 3rd and 4th
degree perineal tear. We used the hospital database and labour ward registry book and reviewed patients record notes. After
excluding elective and emergency caesarean sections, 2,278 women had delivered vaginally, from which 36 patients had 3rd/
4th degree perineal tears as defined by the RCOG Green top guidelines No 29 (2007). A total of 2,242 women who delivered
vaginally without 3rd/4th degree perineal tears were used as controls in this study. The rate of 3rd/4th degree perineal tear
was 1.18% for all deliveries and 1.58% for vaginal deliveries. Occiptoposterior position during delivery (OR: 69.8),
primigravida (OR: 5.8), and high birth weight (OR: 1.19) are risk factors for anal sphincter tear. However, induction of
labour (OR: 0.71), use of medio-lateral episiotomy (OR: 0.35), epidural analgesia (OR: 0.88) and instrumental delivery of
occipitoanterior position (OR: 0.77) reduced the risk of severe perineal tear. Primipara and occipitoposterior position (OP)
during delivery are the only statistically significant risks for the occurrence of severe perineal damage. High birth weight is a
risk factor but it is not statistically significant. Instrumental delivery of OP position is a highly statistically significant risk
factor. On the other hand, induction of labour (IOL), epidural analgesia and instrumental delivery for occipitoanterior
position are protective factors against anal sphincter injury, although they did not reach statistical significance.
Keywords
Perineal tear, third degree, fourth degree, risk factors

Introduction
A 3rd-degree perineal tear is defined as a partial or complete
disruption of the anal sphincter muscles, which may involve
either or both the external (EAS) and internal anal sphincter
(IAS) muscles. A 4th-degree tear is defined as a disruption
of the anal sphincter muscles with a breach of the rectal
mucosa (RCOG 2007).
Immediate recognition and repair of anal sphincter tear is
very important and associated with a favourable outcome.
However, approximately 44% of women who are subject to
anal sphincter damage during labour are symptomatic after
repair; faecal incontinence may develop in 2957% of
patients (Hudelist et al. 2005) and 75% of the women have
evidence of anal sphincter defect on ultrasound (Williams
2003).
There is a great deal of controversy about the risk factors
for 3rd/4th degree perineal tears. For example some studies
showed that episiotomy may increase the risk of severe
perineal tear (Hudelist et al. 2005; Barbier et al. 2007), and
some others revealed the opposite (Lam et al. 2006; Eogan
et al. 2006; De Leeuw et al. 2008). Similarly, there is no
agreement, among studies, regarding the other risk factors
such as use of epidural analgesia during labour, IOL, birth
weight, fetal presentation and position and mode of delivery.

The aim of this study is to recognise the variable risk

factors that potentially influence the occurrence of anal
sphincter damage during vaginal delivery to identify high
risk patients.

Material and methods

A total of 3,038 women were included in this study, which
represent the number of deliveries at the North Devon
Hospital in the years 2005 and 2006. We identified the
patients who had 3rd and 4th degree perineal tears, from
the hospital database and the labour ward registry. The
study included women who had vaginal delivery, and those
who had caesarean section were excluded. The study
population included 2,278 cases. Only 3rd/4th degree
perineal tears were the outcome of interest, which was
defined and diagnosed according to the Green Top
Guidelines No. 29. A total of 36 patients had a 3rd/4th
degree perineal tear and 2,242 women who delivered
vaginally without a 3rd/4th degree perineal tear were used
as controls in this study.
Cases and controls records were reviewed for: parity, use
of epidural anaesthesia, use of medio-lateral episiotomy,
instrumental delivery, IOL, birth weight and position of the
head during delivery.

Correspondence: O. Eskandar, 57 Westaway Heights, Barnstaple, Devon EX31 1NR, UK. E-mail: oeskandar@yahoo.com
ISSN 0144-3615 print/ISSN 1364-6893 online ! 2009 Informa Healthcare USA, Inc.
DOI: 10.1080/01443610802665090

120

O. Eskandar & D. Shet

SSPS version 15 was used for statistical analysis. A

p value 5 0.5 was used as a statistically significant cut-off.
Odds ratio (OR) with 95% confidence interval (CI) was
used to compare cases and controls. The post hoc statistical
power of the study was 84.5% for 36 cases and 2,242
controls with a 0.5 effect size.

Results
The incidence of the 3rd/4th degree perineal tear was
1.58% of vaginal deliveries. The mean age of women who
sustained a 3rd/4th degree perineal tear was 27.74 years
with a standard deviation (SD) of 6.037 (CI: 25.6329.84).
Out of the 36 cases of 3rd/4th degree perineal tear, 16
women delivered during the daytime shift (between 0700
hours and 1900 hours) and 18 of them delivered during the
night shift (between 1900 hours and 0700 hours) and no
data were found in two cases (Figure 1). The time of
delivery does not seem to be a risk factor. Furthermore, the
length of the second stage was inversely proportional to the
frequency of occurrence of the severe perineal tear
(Figure 2). This may be due to having a slower and more
controlled second stage with less expulsive uterine force.
However, the relative risk of the effect of the length of the
second stage on the risk of occurrence of severe perineal
tear has not been calculated in this study.
Table I summarises the data obtained from the cases of
the perineal tears. None of the cases had had a history of
previous severe perineal tear. Table II shows the association of 3rd/4th degree perineal tear with different variables,
including parity, onset of labour, mode of delivery, position
of the fetal head at delivery, birth weight and using epidural
analgesia during labour and episiotomy during delivery.
Primipara was a risk factor for anal injury compared with
higher parity. The OR was 5.8 (CI 95%, 2.712). Direct
occipitoposterior position of the fetal head during delivery
increased the risk significantly with a relative risk of 35 (CI
95%, 1335) and all of them had instrumental deliveries.
None of the cases of the severe perineal tear had a breech,
brow, face or any other malpresentation or malposition.
Birth weight of a 44 kg baby was found to be associated
with anal injury with an OR of 1.19 (CI 95%, 0.453.1),
albeit statistically non-significant.
IOL reduced the risk of 3rd/4th degree perineal tear, the
OR was 0.71 (CI 95%, 0.242.0). Instrumental deliveries
also reduced the rate of the anal injury with an OR of 0.77

(CI 95%, 0.232.5). The use of epidural analgesia during

labour was associated with a reduction in the rate of 3rd/4th
degree perineal tear and the OR was 0.88 (CI 95% 0.36
2.1).
In the study population, 319 episiotomies were performed, giving a rate of 14% of the vaginal deliveries and all
of them were medio-lateral. Medio-lateral episiotomy
protected against severe perineal tear with an OR of 0.35
(CI 95%, 0.081.4).

Discussion
There are conflicting data regarding the relation between
episiotomy and severe perineal tear. The controversy is due
to comparing unlike with unlike, for example, midline
episiotomy adversely affects the rate of anal sphincter
damage, although mediolateral episiotomy reduces such
risk. Furthermore, not all mediolateral episiotomies are
actually mediolateral, and the angle of episiotomy affects
the incidence of anal sphincter injury (Eogan et al. 2006;
Andrews et al. 2005, 2006). The rate of episiotomy in this
study was 14% which is lower than the national rate in the
UK (24%) (Redshaw et al. 2006), however, it is still
protecting against severe perineal tear. In this study, the use
of medio-lateral episiotomy reduced the risk of severe
perineal tear by 65% and the absolute risk reduction was
1.1% which means that 90 episiotomies are needed to
prevent one severe perineal tear. Therefore, if the rate of
the use of episiotomy is selectively increased, the rate of the
severe perineal tear would have been significantly reduced.
This result is consistent with various previous trials and
observational studies (Lam et al. 2006; De Leeuw et al.
2008; Andrews et al. 2006; Anthony et al. 1994).
Delivering a baby with a birth weight 44 kg increased
the risk of 3rd/4th degree perineal tear by 19%, but the
absolute risk is small, and thus every 333 deliveries of a
baby weighing 44 kg contribute to one more case of anal
sphincter damage.
Instrumental delivery of occipitoanterior position reduced the chance of having anal sphincter damage by 23%.
In contrast to results of previous studies, instrumental
delivery in this study protected against anal damage. The
reason for that could be because an episiotomy is routinely
performed with almost all instrumental deliveries in the
hospital, and these instrumental deliveries are performed
by consultants or senior middle-grade staff with significant

Figure 1. The time of delivery in relation of the occurrence of 3rd/4th degree perineal tear. A total of 16 cases delivered during the daytime
shift (between 0700 hours and 1900 hours) and 18 cases delivered during the night shift (between 1900 hours and 0700 hours) and ND: no
data in two cases. The time of delivery does not seem to be a risk factor.

Risk factors for severe perineal tear

121

Figure 2. The length of the second stage in relation to the number of cases of severe perineal tear. ND: no data in three cases.

Table I. Summary of some variables among the cases of 3rd/4th degree perineal tear.
The variable

Mean

Range

SD

CI 95%

Age (years)
Gestational age (weeks)
Birth weight (kg)
Head circumference (cm)
Length of 1st stage (h)
Length of 2nd stage (min)

27.74
39.7
3.460
34.6
6.8
69

1739
3642
2.3004.400
3137
217
10180

6.037
1.42
471
1.65
3.86
46.5

25.6329.84
39.2440.23
3.2933.627
34.0135.22
5.48.2
5386

Table II. Summary of the risk factors for 3rd/4th degree perineal tear.
Risk factor
Onset of labour
Spontaneous
Induction
Episiotomy
No episiotomy
Mediolateral epis.
Epidural in labour
Epidural
No epidural
Mode of delivery
Instrumental
NVD
Parity
Primigravida
Multigravida
Position at delivery
Occipitoposterior
Occipitoanterior
Birth weight
54 kg
44 kg

n/N

Total

(%)

OR

CI 95%

RR

32/1,904
4/338

1,936
342

1.6
1.2

0.71

0.242.0

0.71

0.252.0

0.42

34/1,925
2/317

1,959
319

1.7
0.6

0.35

0.081.4

0.36

0.081.4

0.21

6/430
30/1,812

436
1,842

1.4
1.6

0.88

0.362.1

0.88

0.362.1

0.9

3/240
33/2,002

243
2,035

1.2
1.6

0.77

0.232.5

0.77

0.232.5

0.87

24/800
10/1,444

824
1,454

2.9
0.7

5.8

2.712

5.67

3/3
33/2,239

6
2,272

50
1.45

69.8

1484

29/1,957
5/287

1,986
292

1.5
1.7

1.19

0.453.1

35

1.19

95% CI

p value

2.711.8

50.0001

1335

50.0001

0.463

0.9

n, number of cases with 3rd or 4th perineal tear; N, number of deliveries with no 3rd or 4th perineal tear; OR, odds ratio; RR, relative risk;
CI, confidence interval; epis., episiotomy; NVD, normal vaginal delivery.

experience in obstetrics. Nevertheless, in line with previous

studies, there was a 35-fold increase in the risk of having
severe perineal tear with instrumental delivery of direct OP
position without a prior rotation of the head before delivery
(Andrews et al. 2006; Moller et al. 1992; Poen et al. 1997).
Therefore, if the rate of anal sphincter injury is to be
reduced, careful assessment of the position of the fetal head
before embarking on instrumental delivery is essential, and

appropriate rotation of the head must be conducted or

otherwise caesarean section should be considered.
Although IOL reduced the risk of anal sphincter injury
by 29%, this result was not statistically significant. It might
be confounded by other factors, such as parity, need of
augmentation during labour, use of epidural and birth
weight. It does not seem to be an independent factor to
reduce or increase the risk of severe perineal tear.

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O. Eskandar & D. Shet

In keeping with all previous studies, primigravidas are six

times more prone to sustain a higher degree of perineal
tears than multiparas. Lack of elasticity of the perineal
tissue in primiparas is the main factor, as previous
deliveries may make the perineal tissues more stretchable
and less susceptible to injury during delivery.
The effect of using epidural analgesia during labour on the
occurrence of perineal tear is complex, as there are many
confounding factors. There is evidence that primiparous
women use epidural analgesia at a statistically significant
higher rate than parous women; women use epidural
analgesia demonstrate a prolonged second stage of labour;
an increased use of augmentation of labour; and more use of
epidural analgesia with OP position may increase the risk of
anal sphincter damage (Bodner-Adler et al. 2002; Albers
et al. 2007). On the other hand, women undergoing epidural
analgesia have a higher rate of episiotomy and epidural
analgesia make the women more relaxed and under control
with a slower and more controlled second stage that might
reduce the risk (Bodner-Adler et al. 2002). However,
epidural analgesia has reduced the rate of severe perineal
tear by 12% in this study.
One of the drawbacks of this study is that the sample size,
in the exposed cohort, was relatively small because 3rd/4th
degree perineal tear is a rare complication of labour;
therefore some of the clinically important outcomes were
not as statistically significant. For example, delivering a
baby with birth weight 44 kg increased the risk of 3rd/4th
degree perineal tear by 19% but it did not reach statistical
significance. A total of 49,663 patients with 3rd/4th degree
perineal tear and a similar number of controls are needed
to have a statistically significant result. However, we
increased the number of women in the control group
(unexposed sample size) by including the whole deliveries
in the hospital in 2 years, to increase the power of the study.

Conclusion
Being a primigravida is a risk factor for developing severe
perineal tear during delivery, especially if the estimated
weight of the baby is 44 kg and particularly if instrumental
delivery is performed for direct occipitoposterior position
of the fetal head. On the other hand, having a true mediolateral episiotomy is a major protective measure against
3rd/4th degree perineal tear. In addition, the use of
epidural analgesia makes the patient and the person
conducting delivery more in control. Rotating the head
before delivery is essential, to prevent severe perineal tear,
when conducting instrumental delivery for OP position,
otherwise caesarean section should be considered.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.

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