European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review article

Risk factors for severe perineal trauma during childbirth: An updated

meta-analysis
Vasilios Pergialiotisa,b,* , Ioannis Bellosa , Maria Fanakia , Nikolaos Vrachnisb ,
Stergios K. Doumouchtsisa,c,d
a
Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece
b
Second Department of Obstetrics and Gynecology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece
c
Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, United Kingdom
d
St George's University of London, London, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Several studies have investigated the importance of maternal, fetal factors and intrapartum character-
Received 6 January 2020 istics in predicting severe perineal lacerations. The purpose of the present systematic review is to
Received in revised form 11 February 2020 accumulate current evidence and provide estimated effect sizes for the various risk factors described. We
Accepted 13 February 2020
reviewed Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials
CENTRAL and Google Scholar for published studies in the field for observational studies as well as
Keywords: randomized controlled trials. Two researchers independently assessed the included studies and
Perineal trauma
documented outcomes. Data extraction was performed using a modified data form that was based in
Perineal lacerations
Obstetric trauma
Cochrane`s data collection form for intervention reviews for RCTs and non-RCTs. Forty-three articles were
OASIS selected for inclusion in the present systematic review. The analyzed population reached 716,031
Sphincter trauma parturient of whom 22,280 (3,1%) sustained third- and fourth-degree perineal lacerations. Several risk
Meta-analysis factors were identified. Instrumental delivery [RR 3.38 (2.21, 5.18)], midline episiotomy [RR 2.88 (1.79,
4.65)] and a persistent occiput posterior position [RR 2.73 (2.08, 3.58)] were associated with the higher
risk of developing severe perineal lacerations. Mediolateral episiotomy did not increase, but was also not
protective against perineal lacerations [RR 1.55 (0.95, 2.53)]. Several factors contribute to the
development of severe perineal lacerations. The present meta-analysis presents accumulated data that
may help physicians estimate risks and provide appropriate patient counseling.
© 2020 Elsevier B.V. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Selection of outcomes and data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Assessment of risk of bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Primary statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Secondary statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Meta-regression analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Prediction intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Outcomes that were not included in the quantitative synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

* Corresponding author at: 6, Danaidon str., Halandri, 15232, Greece.

E-mail address: pergialiotis@yahoo.com (V. Pergialiotis).

https://doi.org/10.1016/j.ejogrb.2020.02.025
0301-2115/© 2020 Elsevier B.V. All rights reserved.
 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100 95

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Strengths and limitations of the study . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Implications for current clinical practice and future research in the field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Contribution to authorship . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Ethics statement . . . . . . . . . . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Introduction Central Register of Controlled Trials CENTRAL (1999–2019) and

The unprecedented rise in cesarean section rates renders it a
global epidemic and the latest Lancet report suggests that the rates of
this procedure risen the past 15 years reaching a steep 21 % [1]. The
World Health Organization (WHO) statement on cesarean section
rates supports that cesarean section rates above 10–15 % are
unjustified, regardless the region and population they refer to [2]. At
2018 FIGO issued a position paper that aims to support professional
organizations, women`s groups and other stakeholders to support
normal labor [3]. The most important reason behind these state-
ments is the increased morbidity that accompanies cesarean
sections. Despite the lower rates of maternal and neonatal morbidity
that seem to be associated with normal labor, perineal trauma
remains still common at childbirth, affecting 53–79 % of women [4].
Perineal lacerations are classified in four distinct degrees, with third
and fourth degree being usually referred as severe forms as they are
accompanied by increased rates of immediate and long term
morbidity that significantly affects women`s quality of life (QoL) [5].
Despite these critical issues, to date, significant discrepancies exist
in an international level, concerning the optimal preventive manage-
ment of severe perineal lacerations, often referred to as OASIS
(obstetric anal sphincter injury) [6]. The incidence of OASIS varies
between 3 and 7 % of normal deliveries and according to the findings of
recent cohort study that was based in 75,000 deliveries, current
preventive strategies have reached a plateau; therefore, further
decline of the incidence of sphincter injurycannot be anticipated using
existing measures. Identification of risk factors that increase the odds
of developing OASIS is a matter of primary importance and estimation
of the actual effect size may help future studies combine this evidence
to enhance the diagnostic accuracy of algorithms that can target
women at risk of developing OASIS. In a previous meta-analysis that
included 22 studies, Pergialiotis et al. observed that various factors
increase the risk of developing severe perineal lacerations, including
increased birthweight, use of episiotomy and labor augmentation [7].
Since then, several articles were published in this field, rendering
necessary an update. In the present systematic review and meta-
analysis, we updated our research, adding more evidence in the field
and also enhanced our analysis in order to evaluate the contribution of
potential confounders in our analysis.
Materials and methods
Study design
The present meta-analysis was designed according to the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines and has been registered in
PROSPERO (CRD42019139612) [8]. Eligibility criteria were pre-
determined by the authors.
Sources
We used the Medline (1966–2019), Scopus (2004–2019),
Clinicaltrials.gov (2008–2019), EMBASE (1980–2019), Cochrane
Google Scholar (2004–2019) databases in our primary search along
with the reference lists of electronically retrieved full-text papers
(snowballing). The date of last search was set at August 30th 2019.
The search strategy included the words “perineal lacerations;
perineal trauma; perineal tear; childbirth trauma; birth trauma;
obstetric trauma; obstetric anal sphincter injury; OASIS; third degree
tear; fourth degree tear” and is in accordance to that performed in a
previous article [9]. The PRISMA flow diagram presented in Fig. 1
summarizes the search process for article retrieval.
Study selection
Two authors (V.P. and M.F.) were responsible for the electronic
search and study selection process. Language, country or date
restrictions were avoided to minimize the possibility of potential
article losses. The process for article retrieval was divided in three
consecutive stages. During the first stage, and following dedupli-
cation of retrieved studies, we screened the titles and abstracts to
evaluate the potential eligibility of articles. Those that were
presumed to meet the criteria for selection were retrieved in full
text, read thoroughly and snow-balling of references was also
conducted to evaluate the eligibility of articles that could have been
potentially missed in our electronic search (step 2). In the final stage,
all observational (both prospective and retrospective) studies as well
as randomized controlled trials (including quasi-randomized trials)
that reported outcomes relevant to the development of severe
perineal lacerations among women with and without risk factors
included in our previous systematic review were considered as
eligible for inclusion. Conference proceedings and abstracts were
also considered to be eligible, provided that the outcome of interest
was available within their context. When studies with duplicate or
overlapping referral, populations were retrieved the ones with the
most complete dataset were included in the meta-analysis. Animal
studies, case reports, case series and review articles were excluded
from the present meta-analysis. When discrepancies arose between
the two authors concerning article eligibility, assessment of risk of
bias and selection of statistical analysis they were resolved by the
consensus of all authors.
Selection of outcomes and data extraction
Outcomes retrieved in the present meta-analysis were based in
the findings of the previous meta-analysis published in this field
[7]. Data extraction was performed using a modified data form that
was based in Cochrane`s data collection form for intervention
reviews for RCTs and non-RCTs [10].
Assessment of risk of bias
The methodological quality of included studies was indepen-
dently assessed by two authors (M.F. and N.V.) using the
Newcastle-Ottawa Scale (NOS), which evaluates the selection of
the study groups, the comparability of the groups and the
ascertainment of the exposure or outcome of interest [11].
96 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100
Fig. 1. PRISMA search plot diagram.
Primary statistical analysis
Meta-analysis of risk ratios (RR) and mean differences (MD)
was performed with the RevMan 5.3 software (Copenhagen: The
Nordic Cochrane Centre, The Cochrane Collaboration, 2011).
Confidence intervals were set at 95 %. The DerSimonian–Laird
random effect model was selected to calculate the reported RRs
as well as 95 % confidence intervals (CI), due to the significant
heterogeneity of the methodological characteristics of included
studies that was expected to arise, given the results of the
previous meta-analysis [7,12]. Publication bias was evaluated for
the sum of studies included in our primary analysis using funnel
plots constructed with the Review manager software and the
Begg and Mazumdar rank correlation as well as the Egger`s
regression intercept were calculated using the regtest function in
R [13].
Secondary statistical analysis
Meta-regression analysis, sensitivity analysis and trial sequen-
tial analysis were performed to control for potential confounders
that could affect the results of the primary analysis.
Meta-regression analysis
Univariate meta-regression was performed with Open Meta-
Analyst statistical software [14]. We sought to investigate the
influence of the year of publication, study type (prospe ctive vs
retrospective), patient number (using a cut-off of 1000 patients per
group of patients), origin of the study (per continent assigned as 0:
North America, Europe and Australia, 2: rest of the world) and
parturient care (midwife vs physician). Following retrieval of
articles, we observed that meta-regression analysis for parturient
care was not possible due to insufficient data that could not
preclude the possibility of erroneous interpretation of the type of
care administered. Similarly, meta-regression analysis for study
type and origin of study were of no use as the vast majority of
published articles were retrospective and research was almost
unanimously published from researchers from countries of the
North America, European and Australia.
Sensitivity analysis
The potential impact of individual studies on the overall
outcome of the primary analysis was investigated with leave-one-
out analysis; one study was sequentially omitted at a time to
evaluate its effect in the outcome of the meta-analysis using the
Open Meta-Analyst software.
Prediction intervals
Furthermore, prediction intervals were calculated as they
provide an estimation of the effects to be expected by future
studies in the field. More specifically, prediction intervals take into
account the inter-study variation of the results and express the
existing heterogeneity at the same scale as the examined outcome.
As proposed by IntHout et al. [15], prediction intervals are
calculated in the logarithmic scale as logOR
t  SDPI , where OR
represents the meta-analytic odds ratio, t the two-sided critical t-
value and SDPI the standard deviation of the prediction interval. It
 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100 97

Table 1
Results of the quantitative analysis.

Assessed variable Number of studies Parturient number (severe lacerations/controls) Effect estimate (95 % CI)
Asian ethnicity 11 146,584 (6,950/139,634) RR 1.87 (1.46, 2.39)
Primiparity 29 613,989 (13,253/600,736) RR 1.59 (1.45, 1.75)
Duration of second stage 7 43,095 (1,148/41,947) MD 28.46 (22.44, 34.48)
Induction of labour 15 501,863 (9,924/491,939) RR 1.05 (0.97, 1.15)
Augmentation of labour 13 76,467 (3,536/72,931) RR 1.46 (1.32, 1.62)
Epidural 23 294,373 (8,047/286,326) RR 1.21 (1.08, 1.36)
Occiput posterior 12 369,427 (8,013/361,414) RR 2.73 (2.08, 3.58)
Mediolateral episiotomy 12 564,247 (12,043/552,204) RR 1.55 (0.95, 2.53)
Midline episiotomy 11 475,545 (13,531/462,014) RR 2.88 (1.79, 4.65)
Any type of episiotomy 29 659,640 (17,080/642,560) RR 1.54 (1.27, 1.86)
Vacuum delivery 17 554,580 (10,890/543,690) RR 2.60 (1.78, 3.79)
Metallic forceps 14 509,398 (13,293/496,105) RR 3.15 (1.91, 5.19)
Instrumental delivery (any) 25 637,150 (16,128/621,022) RR 3.38 (2.21, 5.18)
Neonatal birthweight 13 257,130 (4,960/252,170) MD 163,71 (115.37, 212.06)

RR: risk ratio, MD: mean difference, CI: confidence intervals.

Mean difference in duration of second stage of labor in minutes, mean difference in neonatal birthweight in grams.

should be noted that t is estimated at k-1 degrees of freedom, with
k indicating the number of studies included in the meta-analysis.
Calculation of SDPI is performed according to the following
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
formula: SDPI ¼ t 2 þ SE2 , where t 2 represents the existing
heterogeneity and SE the standard error of logOR. Exponentiation
of the limits provides the prediction intervals at the OR scale.
Moreover, the probability that the true effect would be on the other
side of the null was estimated using the one-tail cumulative t-
distribution with k-1 degrees of freedom.
Results
Overall, 43 articles were selected for inclusion in the present
systematic review [16–58]. The analyzed population reached
716,031 parturient of whom 22,280 (3,1%) sustained third- and
fourth-degree perineal lacerations. The methodological assess-
ment of included studies revealed that they were at least adequate
(mean Newcastle-Ottawa score for case control studies 6.72
0.89,
Appendix S1 and for cohort studies 7
0.79, Appendix S2). The
differences of mean values between the two type of studies that
were included were not significant (p = .296) after performing non-
parametric analysis using the Mann-Whitney U test
The meta-analysis of investigated factors revealed that nearly
all of them increased the risk of developing obstetric anal sphincter
injury (3rd or 4th degree perineal lacerations) (Table 1), with the
exception of induction of labor and use of mediolateral episiotomy.
It is worth mentioning, however, that the implemention of
mediolateral episiotomy does not actually prevent the risk of
severe perineal lacerations but rather tends to increase it, although
the overall effect does not reach statistical significance (p = .08).
The mildest increase in the observed risk ratios was that developed
by the introduction of epidural anesthesia, whereas the biggest risk
was associated, as pathophysiologically expected, with instrumen-
tal delivery and particularly metallic forceps delivery. Neonatal
birthweight was also found increased, although it remains unclear
whether this is clinically relevant, as the difference was only 160 g.
Appendix S3 summarizes the results of the publication bias
analysis (funnel plot analysis), the meta-regression analysis and
the leave-one-out meta-analysis. The symmetrical funnel plots
indicated that the possibility of publication bias among investi-
gated risk factors was not detected. Similarly, the results of the
leave-one-out meta-analysis suggested that no individual study
conferred significantly to the findings of the primary analysis, as
the statistical significance remained unchanged (using a cut-off
value of 95 % for beta. A negative association between the year of
publication of each individual study and the risk of developing
severe perineal lacerations following the introduction of epidural
anesthesia was observed. Similarly, a negative association between
the year of publication was observed when performing meta-
regression of outcomes concerning the impact of metallic forceps
delivery. On the other hand, a positive association was observed
when analyzing the year of publication and use of mediolateral
episiotomy, indicating that in the future the marginally not
reached statistical significance that was observed in the primary
analysis could actually change in the future. Concerning the case of
persistent occiput posterior position, we observed that publica-
tions that included more than 1000 parturient in each arm severe

Table 2
Results of the prediction intervals analysis.

Outcome Standard error t2 Estimate (95% prediction intervals)

Asian ethnicity 0.16 0.22 2.09 (0.70, 6.30)
Primiparity 0.11 0.28 3.33 (1.09, 10.07)
Labor induction 0.05 0.01 1.06 (0.83, 1.34)
Labor augmentation 0.11 0.03 1.94 (1.23, 3.03)
Epidural anesthesia 0.13 0.31 1.46 (0.45, 4.76)
Birth weight 0.04 0.01 0.32 (0.09, 0.55)
Second stage duration 0.06 0.01 0.36 (0.07, 0.64)
Occiput posterior position 0.15 0.11 2.91 (1.27, 6.69)
Episiotomy 0.31 2.47 2.85 (0.11, 75.9)
Mediolateral episiotomy 0.35 1.38 1.83 (0.12, 27.4)
Median episiotomy 0.32 0.98 4.46 (0.44, 45.6)
Instrumental delivery 0.18 0.74 4.82 (0.79, 29.37)
Vacuum delivery 0.22 0.73 2.71 (0.42, 17.64)
Metallic forceps 0.26 0.84 4.54 (0.57, 36.23)

Estimation of 95 % prediction intervals.

Odds ratio for categorical variables and standardized mean difference for continuous variables.
98 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100
perineal lacerations vs no or minor degree perineal lacerations
tended to report a decreased degree of the actual RR of developing
severe perineal lacerations.
The results of the prediction intervals analysis (Table 2) showed
a significant outcome regarding primiparity (OR: 3.33, 95 % PI:
[1.09, 10.07]), birth weight (SMD: 0.32, 95 % PI: [0.09, 0.55]),
duration of the second stage of labor (SMD: 0.36, 95 % PI: [0.07,
0.64]) and occiput posterior fetal position (OR: 2.91, 95 % PI: [1.27,
6.69]), implying that a statistically significant effect is to be
expected by future studies. Prediction intervals of the rest
outcomes were wide due to the high between-study heterogeneity.
Outcomes that were not included in the quantitative synthesis
Information relevant to the impact of obesity on the risk of
developing OASIS remain still scarce in the literature. Differences in
body mass index were evaluated in only one study since the
publication of the previous meta-analysis and they were not
clinically significant (26.9
3.2 in OASIS vs 26.6
3.4 in no
lacerations) [41]. On the other hand, Garretto et al. reported that the
presence of obesity (BMI  30 kg/m2 was protective against perineal
lacerations (adjusted odds ratio 0.75, 95 % CI 0.58, 0.98)) [45].
Discussion
The findings of our updated meta-analysis are based in a nearly
double number of articles compared to those of the previous meta-
analysis published in this field (43 vs 22 articles) [7]. Most of the
investigated outcomes that were associated in the previous meta-
analysis with severe perineal lacerations, did also in the present
study. An exception to this observation was the use of labor
induction which was found marginally significant in the previous
meta-analysis (OR 1.08, 95 % CI, 1.02, 1.14). The actual reason behind
this finding cannot be explored, however, we may speculate that
stricter criteria for labor induction could have been applied since
then, given the novel classification system that was proposed at
2015 by Nippita et al. [59]. A significant observation that was
observed in the meta-regression analysis of our study was the
increasing trend of the risk of developing OASIS among studies
investigating the impact of mediolateral episiotomy. Until recently,
mediolateral episiotomy was considered an actual protective
measure against OASIS, however, the previous meta-analysis
clearly showed that this was not scientifically proven.
Strengths and limitations of the study
The present systematic review is based in a meticulous review
of the literature which resulted in an almost 100 % increase of
included studies, compared to the previous meta-analysis that was
conducted in this field [7]. The large number of parturient that was
included in each analyzed index permits safe interpretation as the
sample size that was reached is adequate. Moreover, the use of
several secondary analysis helps minimize the possibility of bias
that arises from potential confounders, including the impact of
individual studies, of year of publication and used sample size
using an arbitrary cut-off of 1000 patients per study group.
Furthermore, the methodological quality of included studies was
at least acceptable, and in several cases, optimal, therefore
minimizing the possibility for selection bias.
On the other hand, several parameters that deserve further
investigation in future studies were not available to perform the
quantitative analysis, including the impact of obesity, type of
attendant (physician vs midwife), angle of episiotomy as well as
age of parturient (using established WHO classifications for
adolescent and advanced maternal age gravidae). Moreover, sub-
stratification of parturient as primi- or multiparas was not possible
as the majority of included studies did not provide data that would
permit separate analysis based in this information.
Implications for current clinical practice and future research in the
field
The importance of identifying and quantifying the effect size of
the various risk factors that seem to be associated with obstetric
trauma is underlined by a recent study conducted by Jangö et al.
who observed that the introduction of prevention programs
focusing on perineal protection is important [60]. In this study the
authors underlined the fact that cases with known risk factors,
including episiotomy and forceps delivery, had comparable risk of
developing OASIS. Identification of women that are prone to
develop perineal lacerations, prevention of modifiable factors
(such as excessive weight gain during pregnancy) and appropriate
patient counseling based in accurate data is important in modern
medicine. The results of our meta-analysis are directly applicable
in current clinical practice and physicians should keep in mind that
the introduction of several risk factors could further increase the
risk of perineal lacerations. Therefore, pregnant women that
undergo induction and augmentation of labor, combined with
epidural anesthesia and who are subjected to episiotomy could
have an even higher risk for developing perineal lacerations,
compared to that expected from the univariate analysis of our
study. Taking in mind this consideration it would be prudent to
consider the adoption of a restricted episiotomy policy in order to
minimize the possibility of severe perineal tearing. Maximal effort
to ensure the perineal integrity should be given as well by
supporting the perineum and by maximizing the angle of
episiotomy whenever this maneuver is considered necessary
(ex. in forceps delivery).
Future studies are needed to help elucidate factors that were
not available, or were poorly investigated, as stated in the
limitations section. Stratification according to the number of risk
factors that are present at delivery could also help construct robust
algorithms with the use of classification and regression trees as
well as with intelligent hybrid systems such as neuro-fuzzy
networks that combine the artificial intelligence of neural
networks (ANNs) with the fuzzy interference environment that
permit reasoning of the imprecise information that are collected
from the ANN analysis [61].
Conclusions
Several factors are associated with perineal lacerations and the
present meta-analysis provides accurate risk estimates that may
help physicians during patients counseling. The results of the
present study may also be used as evidence to help establish
preventive plans that will help minimize the risk of severe perineal
lacerations and particularly OASIS in the future.
Contribution to authorship
VP and SD conceived the idea and wrote the manuscript, VP and
MF performed the literature search and wrote the manuscript, MF,
IB and NV tabulated the data and wrote the manuscript, VP and IB
performed the analysis. MF and NV contributed to the quality
assessment of studies. All authors wrote and critically revised the
manuscript.
Funding
The authors did not receive funding for the present work.
 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100
Ethics statement
the present systematic review is based on outcomes already
published from previous trials in the field. The study is based on
aggregated patient data and no IRB approval was required.
Declaration of Competing Interest
The authors report that they have no conflicts of interest to
disclose.
Appendix B. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ejogrb.2020.02.025.
References
[1] The L. Stemming the global caesarean section epidemic. Lancet 2018;392:1279.
[2] Betran A, Torloni M, Zhang J, Gülmezoglu A, Section tWWGoC. WHO statement
on caesarean section rates. Bjog Int J Obstet Gynaecol 2016;123:667–70.
[3] Visser GHA, Ayres-de-Campos D, Barnea ER, de Bernis L, Di Renzo GC, Vidarte
MFE, et al. FIGO position paper: how to stop the caesarean section epidemic.
Lancet 2018;392:1286–7.
[4] Practice bulletin No. 165: prevention and management of obstetric lacerations
at vaginal delivery. Obstet Gynecol 2016;128:e1–e15.
[5] Leeman L, Rogers R, Borders N, Teaf D, Qualls C. The effect of perineal lacerations
on pelvic floor function and anatomy at 6 months postpartum in a prospective
cohort of nulliparous women. Birth (Berkeley, Calif) 2016;43:293–302.
[6] Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T. Obstetric anal sphincter
injuries at vaginal delivery: a review of recently published national guidelines.
Obstet Gynecol Surv 2018;73:695–702.
[7] Pergialiotis V, Vlachos D, Protopapas A, Pappa K, Vlachos G. Risk factors for
severe perineal lacerations during childbirth. Int J Gynaecol Obstet
2014;125:6–14.
[8] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The
PRISMA statement for reporting systematic reviews and meta-analyses of
studies that evaluate health care interventions: explanation and elaboration. J
Clin Epidemiol 2009;62:e1–34.
[9] Ghai V, Pergialiotis V, Jan H, Duffy JMN, Doumouchtsis SK. Obstetric anal
sphincter injury: a systematic review of information available on the internet.
Int Urogynecol J 2019;30:713–23.
[10] Zhang J, Klebanoff MA, DerSimonian R. Epidural analgesia in association with
duration of labor and mode of delivery: a quantitative review. Am J Obstet
Gynecol 1999;180:970–7.
[11] Wells GA, Shea B, O`Connel D, Peterson J, Welch V, et al. The Newcastle-Ottawa
Scale (NOS) for assessing the quality of nonrandomized studies in meta-
analysis. 2011. www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
[12] Egger M, Smith G, O`Rourke K. Why and how sources of heterogeneity should
be investigated. In: Group BP, editor. Systematic reviews in health care.
London: BMJ Publishing Group; 2001. p. 157–75.
[13] Botrel TE, Clark O, Pompeo AC, Bretas FF, Sadi MV, Ferreira U, et al.
Immunotherapy with Sipuleucel-T (APC8015) in patients with metastatic
castration-refractory prostate cancer (mCRPC): a systematic review and meta-
analysis. Int Braz J Urol 2012;38:717–27.
[14] Wallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH. Closing the
gap between methodologists and end-users: R as a computational back-end. J
Stat Softw 2012;1(5) 2012.
[15] IntHout J, Ioannidis JPA, Rovers MM, Goeman JJ. Plea for routinely presenting
prediction intervals in meta-analysis. BMJ Open 2016;6:e010247.
[16] Anthony S, Buitendijk SE, Zondervan KT, van Rijssel EJ, Verkerk PH.
Episiotomies and the occurrence of severe perineal lacerations. Br J Obstet
Gynaecol 1994;101:1064–7.
[17] Labrecque M, Baillargeon L, Dallaire M, Tremblay A, Pinault JJ, Gingras S.
Association between median episiotomy and severe perineal lacerations in
primiparous women. CMAJ 1997;156:797–802.
[18] Klein MC, Janssen PA, MacWilliam L, Kaczorowski J, Johnson B. Determinants
of vaginal-perineal integrity and pelvic floor functioning in childbirth. Am J
Obstet Gynecol 1997;176:403–10.
[19] Robinson JN, Norwitz ER, Cohen AP, McElrath TF, Lieberman ES. Episiotomy,
operative vaginal delivery, and significant perinatal trauma in nulliparous
women. Am J Obstet Gynecol 1999;181:1180–4.
[20] Jones KD. Incidence and risk factors for third degree perineal tears. Int J
Gynaecol Obstet 2000;71:227–9.
[21] Samuelsson E, Ladfors L, Wennerholm UB, Gareberg B, Nyberg K, Hagberg H.
Anal sphincter tears: prospective study of obstetric risk factors. BJOG
2000;107:926–31.
[22] Angioli R, Gomez-Marin O, Cantuaria G, O’Sullivan MJ. Severe perineal
lacerations during vaginal delivery: the University of Miami experience. Am J
Obstet Gynecol 2000;182:1083–5.
99
[23] de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC. Risk factors for third
degree perineal ruptures during delivery. BJOG 2001;108:383–7.
[24] Jander C, Lyrenas S. Third and fourth degree perineal tears. Predictor factors in
a referral hospital. Acta Obstet Gynecol Scand 2001;80:229–34.
[25] Bodner-Adler B, Bodner K, Kaider A, Wagenbichler P, Leodolter S, Husslein P,
et al. Risk factors for third-degree perineal tears in vaginal delivery, with an
analysis of episiotomy types. J Reprod Med 2001;46:752–6.
[26] Riskin-Mashiah S, O’Brian Smith E, Wilkins IA. Risk factors for severe perineal
tear: can we do better? Am J Perinatol 2002;19:225–34.
[27] Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal
pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol
2004;191:1199–204.
[28] Eogan M, Daly L, O’Connell PR, O’Herlihy C. Does the angle of episiotomy affect
the incidence of anal sphincter injury? BJOG 2006;113:190–4.
[29] Hudelist G, Gelle’n J, Singer C, Ruecklinger E, Czerwenka K, Kandolf O, et al.
Factors predicting severe perineal trauma during childbirth: role of forceps
delivery routinely combined with mediolateral episiotomy. Am J Obstet
Gynecol 2005;192:875–81.
[30] Sheiner E, Levy A, Walfisch A, Hallak M, Mazor M. Third degree perineal tears
in a university medical center where midline episiotomies are not performed.
Arch Gynecol Obstet 2005;271:307–10.
[31] Aukee P, Sundstrom H, Kairaluoma MV. The role of mediolateral episiotomy
during labour: analysis of risk factors for obstetric anal sphincter tears. Acta
Obstet Gynecol Scand 2006;85:856–60.
[32] Dahlen HG, Ryan M, Homer CS, Cooke M. An Australian prospective cohort
study of risk factors for severe perineal trauma during childbirth. Midwifery
2007;23:196–203.
[33] Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and
subsequent anal sphincter lacerations: a comparison of cohorts by parity and
prior mode of delivery. Am J Obstet Gynecol 2007;196(344):e1–5.
[34] Kudish B, Blackwell S, McNeeley SG, Bujold E, Kruger M, Hendrix SL, et al.
Operative vaginal delivery and midline episiotomy: a bad combination for the
perineum. Am J Obstet Gynecol 2006;195:749–54.
[35] Hornemann A, Kamischke A, Luedders DW, Beyer DA, Diedrich K, Bohlmann
MK. Advanced age is a risk factor for higher grade perineal lacerations during
delivery in nulliparous women. Arch Gynecol Obstet 2010;281:59–64.
[36] Groutz A, Cohen A, Gold R, Hasson J, Wengier A, Lessing JB, et al. Risk factors for
severe perineal injury during childbirth: a case-control study of 60
consecutive cases. Colorectal Dis 2011;13:e216–9.
[37] Groutz A, Hasson J, Wengier A, Gold R, Skornick-Rapaport A, Lessing JB, et al.
Third- and fourth-degree perineal tears: prevalence and risk factors in the
third millennium. Am J Obstet Gynecol 2011;204(347):e1–4.
[38] Hauck YL, Lewis L, Nathan EA, White C, Doherty DA. Risk factors for severe
perineal trauma during vaginal childbirth: a Western Australian retrospective
cohort study. Women Birth 2015;28:16–20.
[39] Schmitz T, Alberti C, Andriss B, Moutafoff C, Oury JF, Sibony O. Identification of
women at high risk for severe perineal lacerations. Eur J Obstet Gynecol
Reprod Biol 2014;182:11–5.
[40] Hirsch E, Elue R, Wagner Jr A, Nelson K, Silver RK, Zhou Y, et al. Severe perineal
laceration during operative vaginal delivery: the impact of occiput posterior
position. J Perinatol 2014;34:898–900.
[41] Hsieh WC, Liang CC, Wu D, Chang SD, Chueh HY, Chao AS. Prevalence and
contributing factors of severe perineal damage following episiotomy-assisted
vaginal delivery. Taiwan J Obstet Gynecol 2014;53:481–5.
[42] Ampt AJ, Roberts CL, Morris JM, Ford JB. The impact of first birth obstetric anal
sphincter injury on the subsequent birth: a population-based linkage study.
BMC Pregnancy Childbirth 2015;15:31.
[43] Gauthaman N, Walters S, Tribe IA, Goldsmith L, Doumouchtsis SK. Shoulder
dystocia and associated manoeuvres as risk factors for perineal trauma. Int
Urogynecol J 2016;27:571–7.
[44] Vale de Castro Monteiro M, Pereira GM, Aguiar RA, Azevedo RL, Correia-Junior
MD, Reis ZS. Risk factors for severe obstetric perineal lacerations. Int
Urogynecol J 2016;27:61–7.
[45] Garretto D, Lin BB, Syn HL, Judge N, Beckerman K, Atallah F, et al. Obesity may
Be protective against severe perineal lacerations. J Obes 20169376592 2016.
[46] Gossett DR, Gilchrist-Scott D, Wayne DB, Gerber SE. Simulation training for
forceps-assisted vaginal delivery and rates of maternal perineal trauma. Obstet
Gynecol 2016;128:429–35.
[47] Kwon HY, Park HS. Episiotomy and the risk of severe perineal injuries among
Korean women. J Matern Neonatal Med 2017;30:1745–9.
[48] Frigerio M, Manodoro S, Bernasconi DP, Verri D, Milani R, Vergani P. Incidence
and risk factors of third- and fourth-degree perineal tears in a single Italian
scenario. Eur J Obstet Gynecol Reprod Biol 2018;221:139–43.
[49] Gundabattula SR, Surampudi K. Risk factors for obstetric anal sphincter
injuries (OASI) at a tertiary centre in south India. Int Urogynecol J
2018;29:391–6.
[50] Djakovic I, Ejubovic E, Bolanca I, Markus-Sandric M, Becic D, Djakovic Z, et al.
Third and fourth degree perineal tear in four-year period at sestre milosrdnice
university hospital center, Zagreb, Croatia. Open Access Maced J Med Sci
2018;6:1067–71.
[51] Segal D, Baumfeld Y, Yahav L, Yohay D, Geva Y, Press F, et al. Risk factors for
obstetric anal sphincter injuries (OASIS) during vacuum extraction delivery in
a university affiliated maternity hospital. J. Maternal-Fetal Neonatal Med.
2018;1–5.
[52] Wilkie GL, Saadeh M, Robinson JN, Little SE. Risk factors for poor perineal
outcome after operative vaginal delivery. J Perinatol 2018;38:1625–30.
100 V. Pergialiotis et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 247 (2020) 94–100
[53] Tunestveit JW, Baghestan E, Natvig GK, Eide GE, Nilsen ABV. Factors associated
with obstetric anal sphincter injuries in midwife-led birth: a cross sectional
study. Midwifery 2018;62:264–72.
[54] Sano Y, Hirai C, Makino S, Li X, Takeda J, Itakura A. Incidence and risk factors of
severe lacerations during forceps delivery in a single teaching hospital where
simulation training is held annually. J Obstet Gynaecol Res 2018;44:708–16.
[55] Ramm O, Woo VG, Hung YY, Chen HC, Ritterman Weintraub ML. Risk factors for
the development of obstetric anal sphincter injuries in modern obstetric
practice. Obstet Gynecol 2018;131:290–6.
[56] D’Souza JC, Monga A, Tincello DG. Risk factors for perineal trauma in the primiparous
population during non-operative vaginal delivery. Int Urogynecol J 2019.
[57] Gommesen D, Nohr EA, Drue HC, Qvist N, Rasch V. Obstetric perineal tears: risk
factors, wound infection and dehiscence: a prospective cohort study. Arch
Gynecol Obstet 2019;300:67–77.
[58] Chen SJ, Chen CP, Sun FJ, Chen CY. Factors associated with obstetric anal
sphincter injuries during vacuum delivery among Chinese women. Int J
Gynaecol Obstet 2019;145:354–60.
[59] Nippita T, Khambalia A, Seeho S, Trevena J, Patterson J, Ford J, et al. Methods
of classification for women undergoing induction of labour: a systematic
review and novel classification system. Bjog Int J Obstet Gynaecol
2015;122:1284–93.
[60] Jango H, Westergaard HB. Changing incidence of obstetric anal sphincter
injuries-A result of formal prevention programs? Acta Obstet Gynecol Scand
2019;98:1455–63.
[61] Gupta MM. Fuzzy logic and neural networks. IEEE Trans Neural Netw 1992;3
(5):636–9.