Dr David Richmond, RCOG President, writes…
We know that around 90% of women tear during childbirth; however some women can suffer from more severe forms of tearing, which can significantly damage the anal sphincter, the muscle that controls the anus.
Unfortunately, it is not always possible to predict or prevent these types of tears. There are certain risk factors to look out for, for example, shoulder dystocia, if the second stage of labour is longer than expected, if it is your first vaginal birth, if you have a large baby, if your labour needs to be induced or if you have an assisted birth.
In terms of prevalence, previous research I was involved in, published in BJOG, analysed the trends of perineal tearing in all NHS hospitals in England and highlighted a three-fold increase in the rate of reported third or fourth degree perineal tears (the most severe types), with the rate rising from 1.8% in 2000 to 5.9% in 2011 among first time mothers.
The most recent BJOG study, published this week, examined the mode of delivery and recurrence rate in pregnancies following a third or fourth degree perineal tear. The paper found that among women who had a vaginal delivery at second birth, the rate of a severe tear was 7.2% in women with a previous tear, compared to 1.3% in women without, a more than five-fold increase.
So why are we seeing this increase and what does it mean for women?
It is important to emphasise that a trend towards an increasing incidence of third or fourth degree perineal tears does not necessarily indicate poor-quality care. Tearing is an incredibly complex issue which could be influenced by a range of factors. One possible reason for this trend is the rise in maternal age at first birth and maternal weight, which are linked to a higher birthweight and risk of perineal tears.
The increase may also be down to better detection and reporting. This is a result of two recent developments: the introduction of a standardised classification of perineal tears, and better training of staff in recognising and repairing perineal tears. We also published evidence-based guidelines for the management of third- or fourth-degree perineal tears in 2001 which will be revised next year and all maternity units in England should now have written policies on the diagnosis and management of tears.
As you can imagine, severe tearing can affect many aspects of a woman’s life longer term, including her physical and mental health, as well as future pregnancies. In the short term, there can be problems with looking after a newborn whilst recovering from the birth. Longer term, women may feel that they cannot go through a vaginal birth again and it may be a contributing factor to the rising caesarean section rate. Some women may also have longer term issues with incontinence.
The College, along with the RCM, are currently planning joint work to improve the awareness of third and fourth degree tears’ among health professionals involved in maternity care and develop tools to improve the prevention and management of severe perineal tearing.
We are optimistic that our forthcoming work will assist in reducing national rates and associated morbidity, significantly improving the quality of life and experience of giving birth for women in the UK.