Risk Factors for Anal Sphincter Tear During Vaginal Delivery

FitzGerald, Mary P. MD1; Weber, Anne M. MD, MS2; Howden, Nancy MD, MS3; Cundiff, Geoffrey W. MD4; Brown, Mort B. PhD5; for the Pelvic Floor Disorders Network

doi: 10.1097/01.AOG.0000242616.56617.ff
Original Research

OBJECTIVE: To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women.

METHODS: We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age.

RESULTS: We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9–23.2) and episiotomy (OR 5.3, 95% CI 3.8–7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2–62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5–124.4).

CONCLUSION: Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions.

LEVEL OF EVIDENCE: II

Instrumental delivery and episiotomy are strong, potentially modifiable risk factors for anal sphincter tear at the time of vaginal delivery.

From 1Loyola University Medical Center, Maywood, Illinois; 2National Institute of Child Health and Human Development, Bethesda, Maryland; 3Western Carolina Women’s Specialty Center, Asheville, North Carolina; 4Johns Hopkins School of Medicine, Baltimore, Maryland; and 5University of Michigan, Ann Arbor, Michigan.

* For members of the Pelvic Floor Disorders Network, see the Appendix.

Supported by grants from the National Institute of Child Health and Human Development (U01 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, and U10 HD41267) and the National Institute of Diabetes, Digestive and Kidney Diseases (K24 DK068389).

The authors thank Dr. Robert Park, the Chair of the Pelvic Floor Disorders Network Steering Committee, for his advisory role in the development of the project.

Corresponding author: Mary P. FitzGerald, MD, Loyola University Medical Center, Division of Female Pelvic Medicine and Reconstructive Surgery, 2160 South First Avenue, Building 103, Room 1004, Maywood, IL 60153; e-mail: Mfitzg8@lumc.edu.

© 2007 The American College of Obstetricians and Gynecologists