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Int Urogynecol J. 2019 Feb 11. doi: 10.1007/s00192-019-03887-z. [Epub ahead of print]

The impact of variations in obstetric practice on maternal birth trauma.

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Sydney Medical School Nepean, The University of Sydney, Sydney, Australia.
Department of Obstetrics & Gynecology, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000, Kuala Lumpur, Malaysia.
Sydney Medical School Nepean, The University of Sydney, Sydney, Australia.
Liverpool Clinical School, University of Western Sydney, Sydney, Australia.



Forceps delivery and length of second stage are risk factors of maternal birth trauma, i.e., levator ani muscle (LAM) avulsion and anal sphincter trauma. The cesarean section (CS) rate has recently become the key performance indicator because of its increase worldwide. Attempts to reduce CS rates seem to have led to an increase in forceps deliveries and longer second stages. This study aimed to determine the association between variations in obstetric practice (between hospitals) and maternal birth trauma.


This was a retrospective ancillary analysis involving 660 nulliparous women carrying an uncomplicated singleton term pregnancy in a prospective perinatal intervention trial at two Australian tertiary obstetric units. They had been seen antenatally and at 3-6 months postpartum for a standardized clinical assessment between 2007 and 2014. Primary outcome measures were sonographically diagnosed LAM and external anal sphincter (EAS) trauma.


The incidence of LAM avulsion (11.5% vs. 21.3%, P = 0.01) and composite trauma, i.e., LAM avulsion ± EAS injury (29.2% vs. 39.7%, P = 0.03) were higher in one of the two hospitals, where the forceps delivery rate was also higher (10.9% vs. 2.6%, P < 0.001). BMI (OR 0.9, P = 0.02), length of second stage (OR 1.01, P = 0.02) and forceps delivery (OR 5.24, P < 0.001) were significant predictors of the difference in LAM avulsion incidence between the hospitals. Maternal age (OR 1.06, P < 0.04) and forceps delivery (OR 8.66, P < 0.001) were significant predictors for composite trauma.


A higher incidence of LAM avulsion and composite trauma in one of the two hospitals was largely explained by a higher forceps delivery rate.


Anal sphincter trauma; Forceps delivery; Levator avulsion; Levator trauma; Maternal birth trauma; OASIS


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