Open Journal of Obstetrics and Gynecology, 2012, 2, 304-310 OJOG Published Online September 2012 (
Third degree perineal lacerations—How, why and when?
A review analysis
Angelos Daniilidis1, Vasilis Markis1, Menelaos Tzafetas1, Panagiotis Loufopoulos1, Pan agiotis Hatz is 1,
Nikolaos Vrachnis2, Konstantinos Dinas1
1Department of Obstetrics and Gynecology, Hippokratio General Hospital, Aristotle University of Thessaloniki, T hessaloniki, Gre ece
2Department of Ob s tetrics and Gynaec ology, Ateraieio Hospital, Athens, Greece
Received 28 March 2012; revised 30 April 2012; accepted 13 May 2012
Aim: The aim of this article is to present the know-
ledge of current literature regarding epidemiology
and predisposing factors, classification and surgical
treatment of third degree perineal tears. Materials
and Methods: We reviewed current articles in Eng-
lish language from medline and Pub-Med using as
key words “vaginal repair, third degree tear, episi-
otomy and vaginal delivery”. We summarized litera-
ture regarding predisposing factors, epidemiology,
prevention and surgical treatment of third degree
perineal tears. Results: it is demonstrated today by
several studies that widespread episiotomy is respon-
sible for the increasing frequency of 3rd degree la-
cerations of the perineum which are significantly as-
sociated with forceps and the use of gynecological
chair (boom) for vaginal delivery. Primipa rou s wo m e n
with babies weighting > 4 kgr, are at greater risk.
Two types of surgical repair: end-to-end approxima-
tion and overlapping of torn ends of the anal sphinc-
ter, are both related to the functional outcome of the
repair. Conclusion: Episiotomy is an important risk
factor for severe lacerations after vaginal delivery.
Midline episiotomy and assisted vaginal delivery should
be avoided whenever possible, especially in the pre-
sence of a large baby. Recent evidence suggests that
there is no significant advantage between overlap re-
pair and approximation technique, with regard to
fecal incontinence.
Keywords: Vaginal Repair; Third Degree Tear;
Episiotomy; Vaginal Delivery
Third degree perineal lacerations are known since the
time of Hippocrates. They involve a tear in the vagina,
skin, muscles between the vagina and anus (perineal skin
& perineal muscles) and anal sphincter. Directly under-
neath the layer of squamous epithelium and vaginal mu-
cosa lies the perineal body which is triangular in shape
and is the join connection between bulbospongiosus,
superficial transverse perineal and anal sphincter muscles.
The anal sphincter consists of two separate muscles: the
internal and the external anal sphincter. A tear can be
through one or both of these muscle s (Figure 1).
The classification system establishes a framework for
evaluation, discussion of the degree of injury, appropriate
treatment and rehabilitation research. In the USA, a clas-
sification system of four levels is used, in contract to a
three level system used in Europe (Europe’s third level
corresponds to the fourth level of America) (Table 1).
Perineal tears occur more frequently in the presence of
median episiotomy or in operative vaginal deliveries. In
developed countries the incidence of third-degree peri-
neal tears ranges between 0.5% and 1% of all vaginal de-
liveries [1]. Proper assessment and rehabilitation is neces-
sary to prevent complications. The degree of laceration is
Figure 1. Third degree lacer ation.
A. Daniilidis et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 304-310 305
Table 1. Classification of perineal tears.
Degree of laceration
First degree Superficial laceration of the vaginal mucosa or perineal body.
Second degree Laceration of the vaginal mucosa and/or perineal skin and deeper subcutaneous tissues.
Third degree incomplete Second degree laceration with la ce ration of the capsule and pa rt (but not all) of the a n a l sp h i n c t er muscle.
Third degree complete As above with comple t e laceration of the anal sphincter muscle.
Fourth degree Complete third degree laceration with laceration of the rectal mucosa.
graded and determines the method of repair, the tech-
nique of which has changed little over the past 50 years.
Episiotomy is the overriding determinant of third-degree
lacerations [2].
The aim of this article is to review the current litera-
ture regarding epidemiology, predisposing factors, clas-
sification and surgical treatment of third degree perineal
1.1. Predisposing
The first proposal for episiotomy was made by Ould in
1742 to facilitate the 2nd stage of labour. It was not until
1920 when Delle and Pomeroy publish ed several articles
suggesting that the wide use of routine episiotomy to
primiparous women, provide protection from the 3rd de-
gree perineal lacerations. In 1948 the Kaltreider and
Dixon [3] noted the high incidence of rectal lacerations
with median episiotomy and created the question of the
effectiveness in practice [3]. The widespread episiotomy
today is demonstrated through studies to be responsible
for the increasing frequency of 3rd degree lacerations.
The medio-lateral episiotomy seems to have an advan-
tage in comparison to median episiotomy. The trend is
that it should be used only when necessary [1,3-5]. A
conservative approach to the use of mediolateral episi-
otomy consists a reasonable solution in order to prevent
third-degree lacerations [6]. Reduction in episiotomy
results in less posterior perineal trauma, less aggregation
and fewer complications, but there is no difference in the
degree of pain and severe vaginal and perineal trauma.
On the contrary there seems to be an increased risk of
anterior wall trauma.
The use of gynecological chair (boom) for vaginal de-
livery, increases the risk of third degree perineal tears.
In cases of spontaneous births the use of episiotomy is
limited to 1 in 5 spontaneous deliveries There is a sig-
nificant association between third degree perineal lacera-
tions and the use of forceps [1,6]. Evidence shows that in
operative delivery methods, vacuum extractor has an
advantage over the use of metallic forceps regarding the
risk for third degree tears. The same applies for the pre-
vention of faecal incontin ence [7,8]. Following this com-
plication about 44% of the patients remain symptomatic
Third-degree tears are significantly more common in
primigravidae and mothers with high birth-weight babies
[9]. Primiparous women who have delivered babies with
weight > 4 kgr, have a greater risk for third degree per-
ineal lacerations. There are also reports and studies ac-
cording to which multiparous women following opera-
tive delivery and episiotomy are at increased risk com-
pared to wom e n wh o del i ver spontane o usl y (Table 2).
Gestational age, marital status, weight before preg-
nancy, weight gain during pregnancy, height, education,
labour or physical condition are factors which don’t seem
to be associated with this type of injuries. Factors that
could increase perineal integrity are: spontaneous or va-
cuum assisted delivery, rather than forceps, also avoiding
episiotomy, allowing time for perineal thinning and per-
ineal massage during the weeks before childbirth in nul-
liparous women.
Before treatment we have to focus on contradictory
preventive strategies. It might seem that restrictive episi-
otomy has been shown to result in less posterior perineal
trauma, less suturing and fewer complications, but there
is no difference for severe vaginal or anterior wall
trauma [1,3,5].
1.2. Surgical Techniques for Repairing Third
Degree Perineal Tear
A cooperative patient is of very high importance for good
exposure and adequate repair. Anesthesia should be al-
ways used and epidural anesthesia is considered to be the
Table 2. Risk factors associated with third-degree
perineal tears [1].
Routine episiotomy (midline > mediolatera l)
Delivery with stirrups (delivery table, lithotomy)
Operative delivery (metal forceps > vacuum extractor)
Experience of delivering provider
Prolonged second stage of labor
Occipital posterior or occipital transverse position
Anesthesia (local or epidural)
Age of pregnant women (less than 21 years)
Use of oxytocin
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A. Daniilidis et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 304-310
gold standard type. When regional anaesthesia, epidural
or spinal are not available, an adequate pudendal block
and inhalation anaesthetic or general anesthesia remain
the option. Ten milliliters of a local anesth etic (lidocaine,
chloroprocaine, bupivacaine) should be injected below
the ischial spines bilaterally and at least ten more to the
laceration area. Enough care should be taken to make
sure that the rectal sphincter is anesthetized prior to the
It is essential that the full extent of the laceration is
discerned, including extension of the laceration and
“button holes” defecting into the rectal mucosa. A careful
rectal examination should be performed with the use of
index finger by elevating the anterior rectal wall into the
vagina. The rectal glove should be changed before con-
tinuing with the repair. It is often useful to place a pad
(usually a long pack of gauze pad) high into the vagina to
prevent blood from the uterus of obscuring the view.
Sometimes the anatomy is not clear and it becomes more
apparent as the wound is being repaired. If the tear is
complex, a more experienced operator may be required.
In order to decrease dead space and strengthen the
rectovaginal septum, three to four interrupted or running
00-polyglycolic acid sutures should be placed into the
internal anal sphincter and rectovaginal fascia. Of course
care should be taken to prevent entry into the rectal lu-
men [1,10].
Where the internal anal sphincter can be identified, it
is advisable to be repaired separately with interrupted
sutures. The size of suture must be such as 3-0 PDS and
2-0 Vicryl which may cause less irritation and discomfort
Regarding repair of the external anal sphincter there
are two surgical techniques, the overlapping and the end
to end (approximation) method. The ends of the sphinc-
ter must be clearly identified and grasped with Alis
The end-to-end technique is used to bring the ends of
the sphincter together at each quadrant (12, 3, 6, and 9
o’clock) using interrupted sutures placed through the
capsule and muscle (Figure 2) [12,13].
Allis Clamps are placed on each end of the external
anal sphincter. Monofilament sutures such as polydiaxa-
none (PDS) or modern braided interrupted sutures such
as polyglactin (Vicryl) are placed at “posterior, inferior,
superior and anterior” side of sphincter. Recent evidence
suggests that end-to-end repairs have poorer anatomic
and functional outcomes than was previously believed
An alternative technique is overlapping repair of the
external anal sphincter. It brings together the ends of the
sphincter with mattress sutures (Figure 2) and results in
a larger surface area of tissue contact between the two
torn ends. Dissection of the external anal sphincter from
Figure 2. Over lap (a) and end to end technique (b).
the surrounding tissue with Metzenbaum scissors may be
required to achieve adequate length for the overlapping
of the muscles. The suture is passed from top to bottom
through the superior and inferior flaps, then from bottom
to top through the inferior and superior flaps. The proxi-
mal end of the superior flap overlies the distal portion of
the inferior flap. Two more sutures are placed in the
same manner. After all three sutures are placed, they are
each tied snugly, but without strangulation. When tied,
the knots are on the top of the overlapped sphincter ends.
Care must be taken to incorporate the muscle capsule in
the closure [15- 17].
A recent randomized controlled study of one hundred
and twenty-eight patients with grade three tears, included
119 (end-to-end 60, overlap 59) which received the allo-
cated treatment. The obtained information concerning
fecal incontinence from 101 (85%) patients shows that
one patient in the end-to-end group and none in the
overlap group reported leakage of solid stool once a
week or more. Fourteen patients in the end-to-end group
and 10 in the overlap group reported flatus incontinence
(p = 0.48). Defect of external sphincter was found in
2/46 in the end-to-end group compared to 0/41 in the
overlap group (NS). There was no difference in anal
manometry findings in both groups. Compendiously
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A. Daniilidis et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 304-310 307
there was no significant advantage between overlap re-
pair and approximation technique with regard to fecal
incontinence at 1 year [18].
Current RCOG (Royal College of Obstetricians and
Gynecologists) classification of obstetrics perineal trauma
pintpoints that the anatomic structures together with the
physiological functions of tissue involved in ano-rectal
continence should always be respected [11]. Experience
of the surgeon, operating theatre and its equipment,
asepsis, lighting, operating instruments, anesthesia, ma-
terial and type of suture as well as medication, are related
with the effectiveness of the repair. A delay up to 8 - 12
hours in primary repair does not seem to be detrimental
to the functional outcome of the procedure [19].
1.3. Complications of Third Degree Tears and
Treatment Methods
Several studies give an estimation of 15% of complica-
tions of third degree laceration repairs. The most com-
mon complications are: wound dehiscence, hematoma,
rectovaginal fistula, rectocutaneus fistula, perineal ab-
scess, anal incontinence, dyspareunia. The most common
et i ol o gies for these k inds of complications are summar i ze d
in Table 3. These complications occur in patients with
insulin-dependent diabetes, cancer, or an immunosup-
pressive disorder. Multiple bacterial pathogens are re-
sponsible for necrotizing fasciitis and the wound should
be recognized of the cyanotic discoloration and the loss
of sensation. This situations should be usually managed
with surgical debridement and allowance of broad spec-
trum antibiotics [1,16,20]. In a retrospective study of 27
women with 140 days follow up the feasibility of an
overlapping anal sphincter repair instead of end to end
repair was evaluated [21]. The study includes women
who delivered vaginally between June 1995-November
1996 complicated by a third degree perineal tear (Table
4). The internal sph incter was repaired separately and the
torn ends of the external sphincter were overlapped and
sutured with 3/0 PDS sutures (Ethicon, Edinburgh, UK).
Table 3. Etiology of complications.
Poor tissue approximation (poor surgical technique)
Poor perineal hygiene
Blunt or penetrating tra uma
Forceful coitus
Cigarette smoking
Inflammatory bo wel disease
Connective tissue disease
Prior pelvic radiation
Hematologic disease
Table 4. Bowel symptoms, anal manometry and endosonogra-
phy in women with overlap sphincter repair (n = 27). Values are
given as n (%) [21].
Symptoms Percent
Incontinence of flatus 8%
Anal endosonography
External sphincter 15%
Internal sphincter 44%
Bowel symptoms
Faecal ur gency 15%
The conclusion of this study was that there are reserva-
tions regarding the feasibility of the overlap versus end
to end repair technique. Another retrospective cohort
study included 626 primiparous women with three and
six months follow up, after vaginal delivery [22]. 209 of
them received an episiotomy, 206 did not but experi-
enced a second, third, or fourth degree spontaneous per-
ineal laceration and 211 had no laceration or a first de-
gree perineal laceration. This study concluded that mid-
line episiotomy is not effective in protecting the per-
ineum and sphincters during childbirth and may impair
anal continence (Table 5). A new study [23] was per-
formed to evaluate the prevalence of anal incontinence
(AI) in primiparous women five years after their first
delivery. It included 242 primiparous women in order to
evaluate the prevalence of anal incontinence (AI) in five
years after their first delivery. Women with sphincter tear
(n = 36) at their first delivery were compared to women
without such injury (n = 206). Anal incontinence in-
creased significantly after the 5-year follow-up. Among
women with sphincter tears, 44% reported anal inconti-
nence at nine months and 53% at five years (p = 0.002).
Risk factors for anal incontinence at five years were age
(OR 2.2, 95% CI 1.0; 4.6), sphincter tear (OR 2.3, 1.1;
5.0) and subsequent childbirth (OR 2.4, 1.1; 5.6) (Table
6). In this cohort study thirty-six (15%) of the women
had a sphincter tear. After 9 months, 68/242 women
(28%) reported anal incontinence symptoms and after 5
years 85/242 women (35%) reported symptoms of anal
incontinence (p < 0.0001) (Ta b l e 7 , Figure 3). Another
systematic review on the method of repair of third-de-
gree tears [24] included three trials of 279 women. This
review reported that there was no significant difference
in perineal pain (RR0.08, 95% CI 0.00 - 1.45), dyspare-
unia (RR 0.62, 95% CI 0.11 - 3.39), flatus incontinence
(RR 0.93, 95% CI 0.2 - 3.31) and faecal incontinence
(RR 0.07, 95% CI 0.00 - 1.21), between the two repair
techniques at 1 year, but there was a significantly lower
incidence in faecal urgency (RR 0.12, 95% CI 0.02 -
0.86). Some studies report anal incontinence symptoms
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Copyright © 2012 SciRes.
Table 5. Risk of anal incontinence three and six months after childbirth for varying degrees of perineal injury. Figures are numbers
(percentage) of women [22].
Outcome Intact/1st degree tear
(intact grou p) 2nd
degree tea r3rd/4th
degree tea r2nd/3rd/4th degree
tear (tear group)Episiotomy
(episiotomy g roup) Episiotom y with
no extension
Faecal incontinence
At 3 months 5/205 (2.4) 5/154 (3.3) 2/50 (4.0) 7/204 (3.4) 20/203 (9.9) 13/147 (8.8)
At 6 months 3/201 (1.5) 3/152 (2.0) 0/49 (0) 3/201 (1.5) 8/195 (4.1) 6/141 (4.3)
Flatus incontinence:
At 3 months 40/192 (20.8) 27/144 (18.8)9/48 (18.8) 36/192 (18.8) 63/187 (33.7) 39/137 (28.5)
At 6 months 20/188 (10.6) 18/142 (12.7)5/47 (10.6) 23/189 (12.2) 42/181 (23.2) 26/133 (19.6)
Table 6. Type of delivery and sphincter tear [23].
Number and type of delivery No sphincter tear (n = 206) Sphincter tear (n = 36)
No subsequent childbirth 44 9
One subsequent vaginal delivery 134 20
Two subsequent vaginal deliveries 20 3
Three subsequent vaginal deliveries 1 0
One subsequent c-section 8* 1
Two subsequent c-sections 0 3
*One woman had both a c - section and a v aginal deli very.
Table 7. Degree of fecal incontinence and involuntary flatus [23].
Symptoms Sphincter tear No sphincter tear
9 mo after delivery 5 yrs after delivery 9 mo after delivery 5 yrs after delivery
No incontinence 56% (20/36) 47% (17/36) 75% (154/206) 68% (140/206)
Fecal incontinence
<1/week 0 11% (4/36)** 1% (3/206)* 4% (9/206)***
>1/week 0 0 0 0.5% (1/206)****
Daily 0 0 0 0
Involuntary flatus
<1/week 33% (12/ 3 6 ) 25% (9/36) 16% (33/206) 22% (45/206)
>1/week 11% (4/36) 22% (8/36) 7% (14/206) 7% (15/206)
Daily 0 6% (2/36) 1% (3/206) 2% (5/206)
*One woman also had incontinence to flatus; **All women were also incontinent to flatus; ***All but one woman were also incontinent to flatus; ****The women
also were incontinent to flatus.
in 20% - 67% of women with primary third-degree tear
repair. The type of incontinence is mainly flatus (up to
59%) with leakage of liquid and solid stool in up to 11%,
while faecal urgency occurred in 26% of these women.
In one study, there were symptoms of anal incontinence
after four years of follow-up (17% - 42%) [11,25]. These
studies used different questionnaires to assess anal incon-
tinence symptoms and it is not easy to compare studies’
outcomes [11]. Several randomised controlled studies
since 2000 comparing overlap and end-to-end techniques
of EAS repair, report low incidences of anal incontinence
symptoms in both sides, describing as asymptomatic
60% - 80% of women at 1 year 11. A randomized con-
trolled trial study investigates the association between
endoanal ultrasonography and anorectal manometry in
relation to anal incontinence after primary repair of ob
A. Daniilidis et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 304-310 309
Figure 3. Anal incontinence at 9 months and 5 years in relation to subsequent childbirth [26]. Sphincter refers to
tear or no tear at the index delivery.
stetric sphincter injury in primiparous, premenopausal
women. It included 108 women who had previously been
part of a delayed primary repair of obstetric sphincter
injuries, and 12 months after the repair, they had been
evaluated by anorectal manometry and endoanal ultra-
sound. Impaired rectal sensation at anorectal manometry
and a scar at endoanal ultrasonography are associated
with anal incontinence 12 months after primary sphincter
repair in primiparous women [26].
Studies using endoanal ultrasound as follow-up show
persistent defects in 54% - 88% of women after primary
repair of third-degree tears. More recently, randomised
controlled trials have reported fewer residual defects
(about 19% - 36% overall). The clinical relevance of
asymptomatic defects demonstrated by ultrasound is cur-
rently unclear [11,26].
Although episiotomy is an important risk factor for se-
vere lacerations after vaginal delivery, there are other
significant independent risk factors, such as maternal age,
birth weight, and assisted vaginal delivery, which should
be considered in counseling and making decisions re-
garding delivery modality. Older patients who deliver
their first child are at higher risk for severe laceration.
Midline episiotomy and assisted vaginal delivery should
be avoided in this population whenever possible, espe-
cially in the presence of a large baby. Recent evidence
suggests that no significant advantage between overlap
repair and approximation technique exists with regard to
fecal incontinence.
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