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Reducing high-order perineal laceration

during operative vaginal delivery
Emmet Hirsch, MD; Elaine I. Haney, BS, MT; Trent E. J. Gordon, MS; Richard K. Silver, MD
OBJECTIVE: This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree)
perineal lacerations during operative vaginal delivery.
STUDY DESIGN: The following recommendations for clinical manage-

ment were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum
extraction over forceps delivery; (2) conversion of occiput posterior to
anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal
head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison
was encouraged by provision of individual and departmental statistics.
Clinical data were extracted from the labor and delivery database and
the medical record.

RESULTS: One hundred fifteen operative vaginal deliveries occurred in

the 3 quarters preceding the intervention, compared with 100 afterward

(P ! .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P ! .02), coincident with increased use of
vacuum (16% vs 29% of operative vaginal deliveries, P ! .02); fewer
high-order lacerations after episiotomy (63% vs 22%, P ! .003); a
nonsignificant reduction in performance of episiotomy (30% vs 23%,
P ! .22); and a nonsignificant increase in mediolateral episiotomy
(14% vs 30% of episiotomies, P ! .19).
CONCLUSION: Introduction of formal practice recommendations and

performance review was associated with diminished high-order perineal injury with operative vaginal delivery.
Key words: forceps, operative vaginal delivery, perineal injury,
vacuum extraction

Cite this article as: Hirsch E, Haney EI, Gordon TEJ, et al. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008;198:
668.e1-668.e5.

aginal birth frequently causes

perineal laceration. These lacerations are typically categorized in 4 degrees, with third-degree lacerations involving, in addition to the vaginal
epithelium and tissues of the perineal
body, a partial or complete tear of the
anal sphincter complex. In fourth-degree perineal lacerations, the above tissues are disrupted along with the rectal
mucosa. In general, these high-order
From the Department of Obstetrics and
Gynecology (Drs Hirsch and Silver, Ms
Haney and Mr Gordon), Evanston
Northwestern Healthcare, Evanston, IL, and
the Feinberg School of Medicine (Drs Hirsch
and Silver), Northwestern University,
Chicago, IL.
Presented in part at the 74th Annual Meeting of
the Central Association of Obstetricians and
Gynecologists, Chicago, IL, Oct. 17-20, 2007.
Received July 7, 2007; revised Nov. 20, 2007;
accepted Feb. 4, 2008.
Reprints not available from the authors.
0002-9378/$34.00
2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.02.002

668.e1

(third- and fourth-degree) perineal injuries are associated with greater risks
of dysfunction than lower order lacerations. For example, the risk of reported fecal incontinence 6 months
postpartum in primiparous women is
2-fold higher after a recognized
sphincter tear than after a vaginal birth
without such a tear (17.0% vs 8.2%, adjusted odds ratio [AOR], 1.9; 95% confidence interval [CI], 1.2 to 3.2).1
In addition to fecal and flatal incontinence, high-order perineal lacerations
are associated with pain (acute and
chronic), dyspareunia, and rectovaginal
fistula.1-3 In recent years, perineal laceration has been viewed as a proxy for
quality of care in obstetrics by the Joint
Commission (formerly JCAHO)4 and
the Agency for Healthcare Research
and Quality (AHRQ, http://www.
qualityindicators.ahrq.gov).5 Data on
third- and fourth-degree lacerations
will soon be available to third-party
payers and to the public on the Internet. Also, functional impairment after
perineal laceration continues to be a
significant impetus for legal claims.6

American Journal of Obstetrics & Gynecology JUNE 2008

Given these considerations, it follows

that reducing high-order perineal laceration while preserving maternal and fetal
outcomes should be an important goal in
clinical obstetrics. In this observational
study, we report the outcomes of a department-wide intervention, the objective of which was to reduce the rate of
high-order perineal laceration in the setting of operative vaginal delivery (OVD)
(vacuum and forceps). This intervention, which focused on clinical practice
recommendations, education of physicians, and performance review, was instituted as a quality improvement effort
when it became apparent that perineal
injury with OVD in our hospital exceeded national benchmarks. Physicians
were encouraged to adopt evidencebased practices that have been shown to
reduce the rates of severe perineal
trauma in published studies or are generally accepted best practices based
primarily on authoritative opinion. Outcomes from the 9-month period before
the quarter in which the intervention
was initiated were compared with results
from the 9 months after.

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TABLE 1

Recommended practices to
diminish the occurrence of highorder perineal laceration

Use a vacuum device instead of forceps

where feasible.
Convert occiput posterior to anterior
position before traction.
Consider a mediolateral episiotomy
rather than a midline incision if
episiotomy is performed.
Select the appropriate type of vacuum
cup, apply vacuum and forceps
correctly to the fetal head and use
proper axis traction during the delivery.
Disarticulate forceps and remove from
the fetal head before expulsion.
Use only the minimal necessary
maternal effort at expulsion.

Hirsch. Reducing high-order perineal laceration

during operative vaginal delivery. Am J Obstet
Gynecol 2008.

M ATERIALS AND M ETHODS

Evanston Hospital is a level III teaching
hospital affiliated with the Feinberg
School of Medicine of Northwestern
University. The conduct of this study
was approved by the Institutional Review Board of the hospital. Commencing
in October 2005, an educational initiative focusing on methods of reducing
high-order perineal laceration with
OVD was instituted. This initiative resulted from analysis of outcome data
provided by the National Perinatal Information Center (NPIC Quarterly Report V.05.1 [April 1, 2004 to March 31,
2005], Providence, RI), which demonstrated a rate of perineal laceration with
OVD in our hospital that was 1.5-fold
higher than the 19.2% average of similar
teaching hospitals contributing to the
NPIC database.
The following practices were advocated as part of the initiative (Table 1):
1. Use a vacuum device instead of forceps when feasible. This recommendation was based on data demonstrating an increased risk of
high-order laceration with obstetric forceps in comparison with vacuum deliveries.7-10 A preliminary
analysis in our center had shown
that the ratio of forceps delivery to
vacuum extraction was 5:1, which
contrasts with the national trend

(only 22% of OVDs in the NPIC

teaching hospital group were conducted with forceps). Because of
the apparent tendency to choose
forceps over vacuum in our department, manuscripts and training
manuals addressing vacuum technique were distributed to all physicians. Didactic lectures and a
hands-on workshop with inanimate patient models were also held
as part of the educational effort.
2. Convert occiput posterior to anterior positions before traction. The
evidence linking occiput posterior
position with higher rates of perineal injury in OVD11-13 and the
mechanism underlying this association (ie, the larger fetal diameter
presenting to the maternal pelvis in
occiput posterior positions) were
reviewed. Techniques for conversion from occiput posterior to occiput anterior position, including
digital, manual, and instrumental
rotations (ie, Kiellands forceps and
the Scanzoni maneuver) were suggested in appropriately selected patients for clinicians with adequate
training and experience with these
techniques.
3. Consider mediolateral rather than
midline episiotomy when episiotomy is deemed necessary. Prospective randomized clinical trials have
identified a cause-and-effect relationship between episiotomy and
high-order perineal injury and
sphincter dysfunction for spontaneous vaginal birth, whereas
retrospective evidence of a similar
relationship exists for OD.14-18
Therefore, the use of episiotomy in
OVD was not encouraged. In 1 prospective randomized trial comparing midline with mediolateral episiotomy in which forceps delivery
was performed in 17% of patients, a
2.7-fold lower rate of sphincter injury was associated with mediolateral compared with midline
episiotomy (24% vs 9%, respectively).15 Therefore, the recommendation made was to use mediolateral rather than midline
episiotomy if episiotomy was

deemed necessary. Given the relative weakness in the quality of the

evidence, this recommendation
was presented as a consideration,
rather than a practice firmly supported by data.
4. Use proper technique. This recommendation included selection of
the proper vacuum device (ie, a cup
designed for the occiput posterior
position when appropriate7), appropriate positioning of vacuum
cups and forceps blades to promote
flexion of the fetal head, and maintenance of axis traction.19,20
5. Disarticulate forceps prior to expulsion (ie, after delivery is assured
and before passage of the widest diameter of the head through the introitus) to minimize distension of
the perineum.
6. Use the minimal necessary maternal effort at the time of expulsion
(ie, allow the contraction by itself
to complete delivery or instruct the
mother to push with an open glottis
or with submaximal effort).
These practice recommendations were
reinforced through multiple departmental presentations; distribution of review
articles and technical manuals; letters to
clinicians reiterating key recommendations; and prominent display of an instructional poster adjacent to the labor
and delivery unit. Vacuum extraction
training with inanimate human models
was provided for house staff and attending physicians. Educational offerings
were complemented by the provision of
individual and departmental birth and
OVD statistics to every physician and
midwife in the department. All of the
above measures were designed to be positively reinforcing and educational in
nature.
Data from all operative vaginal deliveries during the 3 quarters preceding the
intervention (period 1, Jan. 1-Sept. 30,
2005) were compared with the 3 quarters
after the initiation of the intervention
(period 2, Jan. 1-Sept. 30, 2006). It was
believed that a 9-month observational
period was sufficiently long to assess the
short-term staying power of any influences on practice patterns attributable to

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668.e2

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TABLE 2

Practice patterns and outcomes associated with OVD in the 9 months preceding the intervention
(period 1, Jan. 1, 2005-Sept. 30, 2006) and the 9 months after (period 2, Jan. 1, 2006-Sept. 30, 2006)
Period 1

Period 2

Total deliveries

2626

2584

SVDs

1775

1732

P value

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Third-/fourth-degree lacerations with SVD

32 (1.8%)

39 (2.3%)

.35

................................................................................................................................................................................................................................................................................................................................................................................

Cesarean sections (rate)

708 (27.0%)

725 (28.1%)

.38

Primary

432 (16.5%)

410 (15.9%)

.57

Repeat

276 (10.5%)

315 (12.2%)

.06

115 (4.4%)

100 (3.9%)

.36

47 (41%)

26 (26%)

.02

39 of 97 (40%)

20 of 71 (28%)

.11

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

Number of OVDs (% of all deliveries)

................................................................................................................................................................................................................................................................................................................................................................................

Third-/fourth-degree laceration with OVD

.......................................................................................................................................................................................................................................................................................................................................................................

Third-/fourth-degree laceration with forceps

.......................................................................................................................................................................................................................................................................................................................................................................

Third-/fourth-degree laceration with vacuum

8 of 18 (44%)

6 of 29 (21%)

.08

................................................................................................................................................................................................................................................................................................................................................................................

Vacuum extraction (percent of OVD)

18 (16%)

29 (29%)

.02

Episiotomy

35 (30%)

23 (23%)

.22

Third-/fourth-degree laceration with episiotomy

22 of 35 (63%)

5 of 23 (22%)

.003

Mediolateral episiotomy (% of all episiotomies)

5 of 35 (14%)

7 of 23 (30%)

.19

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Malpositions (occiput posterior or transverse)

27 (23%)

26 (26%)

.75

................................................................................................................................................................................................................................................................................................................................................................................

Purposeful rotation of #45-degrees from occiput posterior

(% of posterior positions)

2 (7.4%)

4 (15.4%)

.42

................................................................................................................................................................................................................................................................................................................................................................................

SVD, spontaneous vaginal delivery.

Hirsch. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008.

the program. Data were extracted from

the labor and delivery database, which is
maintained in real time by nurses entering primary data immediately following
delivery into a Microsoft Access software
program file (Microsoft Corporation,
Redmond, WA). Additional postnatal
maternal and neonatal data were extracted from the electronic medical
record for each birth. Maternal information included route of delivery; type of
anesthesia; whether forceps or vacuum,
or neither was used; fetal position at delivery, whether purposeful rotation was
performed and how rotation was accomplished; whether an episiotomy was cut
and, if so, which type (midline or mediolateral); degree of perineal laceration (for
the purposes of this study, this was
classified dichotomously either third/
fourth degree or not third/fourth degree); hemoglobin level on admission
and at nadir; and whether maternal
transfusion occurred. Neonatal outcomes included admission to the neonatal intensive care unit; 1- and 5-minute
Apgar scores; whether transfusion was
668.e3

performed; and any additional diagnoses

(including birth injuries).
Categorical data were analyzed by !2
testing, with Fisher exact testing as indicated. Continuous data were analyzed by
Student t test for normally distributed
data or by Mann-Whitney U test for
nonnormally distributed data. A P value
of less than .05 was considered significant. Multivariable logistic regression
was conducted with the use of the SAS
software package (SAS Institute, Cary,
NC).

R ESULTS
There were 2626 births in period 1 and
2584 in period 2 (Table 2). Of these, the
mode of delivery was by cesarean section
in 27% and 28% of births, respectively (P
! .38). OVD with either forceps or vacuum occurred in 115 (4.4%) and 100
(3.9%) cases in periods 1 and 2, respectively (P ! .36). The mean gestational
ages in weeks of these OVDs were 39.0 "
2.2 in period 1 and 39.6 " 1.4 in period 2
(P ! .17). The mean birthweights in

American Journal of Obstetrics & Gynecology JUNE 2008

grams were 3293 " 611 and 3366 " 459,

respectively (P ! .33). Epidural anesthesia was used in 90% and 91% of cases,
respectively (P ! .7).
There was no change in the rate of
high-order perineal laceration with
spontaneous (ie, nonoperative) vaginal
delivery between periods 1 and 2 (1.8%
vs 2.3%, P ! .35). In contrast, there was
a significant reduction in the number of
third- and fourth-degree lacerations occurring with OVD in period 2 (26% of all
OVDs, of which 30% were fourth-degree
lacerations) compared with period 1
(41% of OVDs, of which 19% were
fourth-degree lacerations, P ! .02 for
comparison of high-order lacerations).
This reduction occurred for both forceps
and vacuum deliveries. In addition, there
was a statistically significant increase in
the use of the vacuum extractor as the
device of choice. There was a nonsignificant reduction in the use of episiotomy
with OVD and a significantly diminished
likelihood of experiencing a third- or
fourth-degree laceration if an episiotomy was cut. There was a doubling of the

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TABLE 3

Maternal and neonatal outcomes associated with OVD in the 9 months

preceding the intervention (period 1, Jan. 1, 2005-Sept. 30, 2006)
and the 9 months after (period 2, Jan. 1, 2006-Sept. 30, 2006)
Number of OVDs

Period 1

Period 2

115

100

P value

..............................................................................................................................................................................................................................................

Drop in maternal hemoglobin from

admission to nadir

21%

18%

.11

..............................................................................................................................................................................................................................................

Maternal blood transfusion

#.99

..............................................................................................................................................................................................................................................

Admission to neonatal intensive

care unit

18 (16%)

16 (16%)

#.99

..............................................................................................................................................................................................................................................

Neonatal transfusion

#.99

..............................................................................................................................................................................................................................................

1-min Apgar score $6

15 (13%)

17 (17%)

.44

5-min Apgar score $6

0 (0%)

2 (2%)

.22

Intraventricular hemorrhage

1 (grade 1)

1 (grade 1)

#.99

Brachial plexus injury

#.99

Facial nerve palsy

#.99

Scalp abrasion (all mild)

1 (1%)

3 (3%)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

.34

Hirsch. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008.

use of mediolateral rather than midline

episiotomy; however, this did not
achieve statistical significance.
There was a nonsignificant doubling of
purposeful rotation of the fetal head in occiput posterior positions (to 15.4% of all
occiput posterior presentations in period 2
from 7.4% in period 1). In no case was
there a high-order laceration after successful rotation (n ! 6 over periods 1 and 2
combined), compared with a 47% rate of
third- and fourth-degree laceration in
malpositioned fetuses delivered in the occiput posterior position (n ! 47, P ! .035).
In the multivariable analysis examining delivery device, use and type of episiotomy, purposeful rotation, birthweight, and use of epidural anesthesia,
only instrument selection (ie, vacuum or
forceps) was significantly different between periods 1 and 2 (P ! .02).
There were no differences between periods 1 and 2 in the drop in maternal hemoglobin from admission to postpartum nadir or in maternal blood
transfusion. There were no differences in
admissions to the neonatal intensive care
unit, neonatal transfusion, 1- and
5-minute Apgar scores, intraventricular
hemorrhage, brachial plexus injuries, facial nerve palsies, or scalp injuries (Table
3). There were no reported cases of

cephalohematoma, retinal hemorrhage,

or subgaleal hemorrhage, and the incidence of neonatal jaundice was no different between the 2 periods.

C OMMENT
The 37% reduction in third- and fourthdegree perineal lacerations with OVD
described in this article resulted from an
intervention instituted in response to
perineal injury rates that were outside
the range of those observed in similar
teaching hospital departments. Because
the excess high-order lacerations were
confined to OVDs, the intervention focused on reducing perineal laceration in
these cases only. The clinical practice
recommendations were based on objective evidence from the literature supplemented by accepted best practices
when level I or II evidence was not available. In addition, self-examination by
practitioners was reinforced by providing feedback in the form of individual
statistics in the context of departmental
performance.
The improvement in perineal injury
was statistically associated with changes
corresponding to 2 of the recommended
clinical practice principles: increased use
of vacuum and better performance with

episiotomy. In addition, there was a favorable, though not statistically significant, change with respect to a third recommendation: purposeful rotation
from occiput posterior to anterior position. We were unable to measure behaviors related to the other 3 recommendations (operative technique and vacuum
cup selection, disarticulation of forceps,
and diminished maternal effort at expulsion). Although it was not emphasized in
the intervention reported in the current
article, other considerations are important as well. Enhancement of both safety
and efficacy can be expected by choosing
forceps designed specifically for various
clinical circumstances, such as the presence or absence of caput succedaneum
and asynclitism. Operators should also
carefully consider other important clinical variables, such as estimated fetal
weight, pelvic dimensions, length of the
second stage, and the presence or absence of diabetes.
It is possible that a change in behavior
was induced by observation alone (ie,
Hawthorne effect) or that underreporting of perineal injury in period 2 contributed to the observed improvement.
However, the similar rates of high-order
laceration reported with spontaneous
(ie, nonoperative) vaginal delivery over
the same 2 periods (1.8% and 2.3%, respectively) argues against such effects.
There was no substantial turnover of departmental personnel over the study period. Neither did the alternative of cesarean section appear to have displaced
OVD in our population. Finally, although our study was not powered to detect differences in neonatal outcomes,
there were no serious neonatal complications of OVD in either time period or
with either technique, suggesting that
improvement in maternal laceration
rates was not accompanied by an increased number of adverse fetal
outcomes.
This was a retrospective analysis and as
such, a causal relationship between the
recommended interventions and the improved clinical outcome cannot be
proven. Although prospective, randomized trials testing each of the components
of the program might have dealt more
effectively with potential confounders

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668.e4

CAOG Papers
and might have identified which of the
recommendations had the most meaningful impact, 1 of the strengths of the
current report is that it reflects a real
world response to a quality need. Our
experience may serve as a model for
other departments dealing with performance outcomes falling short of established parameters.
To assess whether the observed improvements were transient, we conducted a follow-up analysis of the labor
and delivery database in the first 4
months of 2007 (after the issue of perineal laceration had ceased to be a primary focus of quality improvement activities in the department). The
incidence of high-order laceration with
OVD remained low (12/52 cases; 23%);
with a majority of these deliveries using a
vacuum device (28/52 cases; 54%); and
with episiotomies performed in a minority of cases (7/52 cases; 13%).
We consider the reduction of perineal
injury to be a matter of high importance
for practitioners who wish to preserve
OVD as a viable option. However, inducing behavioral changes in physician
practice patterns is challenging, as can be
illustrated by the persistent failure of
many practitioners to adopt the 1988
American College of Obstetrician and
Gynecologists (ACOG) definition of fetal station.21 Highly focused and intensive interventions may be required to induce such behavioral changes. For
example, a dedicated, experienced, and
proactive teacher stationed in the labor
and delivery unit of a teaching hospital
successfully enhanced resident experience and practice with respect to forceps
delivery.22
The alternative to operative vaginal
birth (ie, cesarean section) has its own
short- and long-term maternal morbid-

668.e5

www.AJOG.org
ities, especially when performed repeatedly, as has become increasingly likely in
women who have had a first cesarean
section. Maximizing the options for safe
vaginal birth should help to reduce these
f
morbidities.
ACKNOWLEDGMENT
We thank Ms Brittany Bettendorf for assistance
with data extraction.

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