Hoque et al.

Trends, incidence and risk factors of perineal injuries

ORIGINAL RESEARCH ARTICLE

Incidence, trends and risk factors for perineal injuries of low-risk

pregnant women: Experience from a midwife run obstetric unit,
South Africa
DOI: 10.29063/ajrh2021/v25i4.6

Akm M. Hoque1*, Muhammad E. Hoque2 and Guido V. Hal3

Medical Manager, Kwadabeka Community Health Centre, KwaZulu-Natal, South Africa1; Management College of
Southern Africa Durban, South Africa2; Social Epidemiology and Health Policy, University of Antwerp
Antwerp, Belgium3

*For Correspondence: Email: [email protected], Phone: +27 31 7143704

Abstract
Pregnant women experience perineal injuries during childbirth. The objectives of this cross-sectional retrospective study were to
estimate the incidence, trends, and risk factors for perineal injuries of women who had childbirths from January 2013 to December
2017. We used logistic regression to identify risk factors for all injuries, episiotomy, and obstetric anal sphincter injury (OASI)
measured by odds ratios (OR). A total of 5547 women showed gradual decreases of episiotomy from 17.6% in 2013 to 7.6% in 2017
(p<0.05). Perineal injuries were reduced from 33.3% in 2013 to 28.9% in 2017 (p<0.05). The risk factor for any perineal injury were
younger ages, term pregnancy, and nil parity (p,0.05). Advanced gestational age, nil parity, and previous vaginal births were risk
factors for episiotomy. However, birth weight of baby was significantly associated with OASI. Episiotomy and overall perineal
injury rates were commendable. Training to midwives is needed to improve perineal care and maintain good practices during
delivery. (Afr J Reprod Health 2021; 25[4]: 52-62).

Keywords: Episiotomy, labour management, obstetric anal sphincter injury

Résumé
Les femmes enceintes subissent des blessures périnéales lors des accouchements. Les objectifs de cette étude rétrospective
transversale étaient d'estimer l'incidence, les tendances et les facteurs de risque de blessures périnéales chez les femmes qui ont
accouché de janvier 2013 à décembre 2017. Nous avons utilisé la régression logistique pour identifier les facteurs de risque pour
toutes les blessures, l'épisiotomie et l'obstétrique. lésion du sphincter anal (OASI) mesurée par les rapports de cotes (OR). Au total,
5 547 femmes ont présenté une diminution progressive de l'épisiotomie de 17,6 % en 2013 à 7,6 % en 2017 (p<0,05). Les blessures
périnéales ont été réduites de 33,3% en 2013 à 28,9% en 2017 (p<0,05). Le facteur de risque de toute lésion périnéale était un âge
plus jeune, une grossesse à terme et une parité nulle (p, 0,05). L'âge gestationnel avancé, la parité nulle et les accouchements vaginaux
antérieurs étaient des facteurs de risque d'épisiotomie. Cependant, le poids de naissance du bébé était significativement associé à
l'OASI. Les taux d'épisiotomie et de lésions périnéales globales étaient louables. La formation des sages-femmes est nécessaire pour
améliorer les soins périnéaux et maintenir les bonnes pratiques lors de l'accouchement. (Afr J Reprod Health 2021; 25[4]: 52-62).

Mots-clés: Épisiotomie, gestion du travail, lésion obstétricale du sphincter anal

Introduction fourth-degree perineal injuries are considered major

or extensive and are collectively known as obstetric
Pregnant women experience varying degrees of anal sphincter injuries (OASI). The overall rates of
perineal injuries during childbirth. Perineal injuries OASI are reported with great variations from
are classified as (i) first degree: when the injury different reports between 0.7% and 10.2% (Norway,
involves perineal skin, (ii) second degree: perineal Denmark, Sweden, Iceland, USA, and UK) at
muscles and skin are involved, (iii) third degree: different periods3 -7. A recent study of a systemic
injury involving anal sphincter complex, and (iv) review of meta-analysis on “Birth-Related Trauma
fourth degree: involving the anal sphincter complex, in Low-and middle-Income Countries (LMIC)”
epithelium, and rectal mucosa1,2. The third- and reported that the overall episiotomy, second degree

African Journal of Reproductive Health August 2021; 25 (4):52

Hoque et al. Trends, incidence and risk factors of perineal injuries
injury, and OASI rates were 46%, 24%, and 1.4% episiotomy is found when women had childbirth on
respectively8. However, this report excludes first left lateral position compared to lithotomy
degree injuries as a result of incomplete data from position24. Therefore, the left lateral position of
the published reports. The study further identifies women at the time of childbirth is considered
other limitations such as definition, reporting, and protective for perineal injuries.
outcomes of perineal injuries, the use of episiotomy The known maternal risk factors for
(routine versus selective) to prevent OASI and or to perineal injuries are age, parity, precipitated labour
facilitate childbirths, and suggestions made for and very narrow introitus (foetal passage) lead to
improvement on monitoring and reporting of cephalo-pelvic disproportion (CPD) and foetal
perineal injuries from different health facilities of factors such as large foetus, occipito-posterior
LMIC8. High incidence of all perineal injuries was position of the vertex (foetal head), and or
reported between 70 to 85% from high income malpresentation. The known obstetric factors are
countries where the monitoring and reporting uncontrolled or precipitated delivery (labour),
systems are of high quality and included all assisted deliveries, episiotomy, vacuum extraction,
injuries9, 10. A study from Sweden reported that and extended episiotomy in emergency lead to
perineal injuries are lower among planned home perineal injuries25. A study from USA hospitals in
childbirths than hospital births11. Higher incidences 2011 on “third- and fourth-degree perineal tears
of overall perineal injuries were reported from prevalence and risk factors” reported that occipito-
England (90.4%) and Iran (84.3%)12-13. The lowest posterior position being the presenting part, parity
incidence of 64% perineal injury was reported from and excessive birth weight of the new-born) were
Brazil among low-risk pregnancies14. significant predictors of the cause of OASI26.
It is reported that perineal injuries are Another study on “risk factors for OASI during
related to pelvic floor disorders even after 10 years vaginal delivery from a referral hospital” in Cape
of delivery15. The incidence of episiotomy and Town, South Africa (SA), identified primipara,
OASI are also considered as obstetric care assisted childbirths (use of forceps and vacuums),
indicators12,16-17. Detection and repair of extensive malpresentation, mothers negative HIV status, and
perineal injuries involving anal sphincter are thus shoulder dystocia were significantly associated with
important for maternity care. Therefore, it is perineal injuries27. In that hospital, midwives only
universally recommended that the perineum is conducted uncomplicated childbirths while
supported during the time of delivery of the foetal complicated births were assisted and conducted by
presenting part that causes stretching of the medical professionals under Obstetrician’s
perineum as standard obstetric care and is found to supervision and used mediolateral episiotomies
prevent injuries18,19. There are controversies on when necessary. Similarly, a report from two
manual support to prevent perineal injuries. For regional hospitals of Durban in SA found a rate of
example, a report from a meta-analysis of 16.2% spontaneous perineal injuries28. The same
randomised controlled trials (RCTs) finds no study found race, the time required for childbirths,
protective effect but non-randomised studies find and the use of epidural analgesia were significantly
significant protection for OASI20. Studies report associated with perineal injuries. Episiotomy was
from Norway that training of doctors and midwives found to be a protective factor for OASI28. There is
on the traditional method of manual support with limited information from low-income countries and
significant reductions on the incidences of OASI, more so from the midwife obstetric unit (MOU)
overall spontaneous and operative vaginal where women give births. Therefore, it is important
deliveries21,22. A randomised control trial on to understand the magnitude, classification, risk
primiparous women from Brazil reports that the left factors of perineal injuries from different settings.
lateral position during childbirth resulted in low risk The objectives of this study are to estimate the
of OASI23. A similar reduction of perineal injuries incidence, trends, and risk factors for perineal
including injuries of women who gave childbirths at a MOU.

African Journal of Reproductive Health August 2021; 25 (4):53

Hoque et al. Trends, incidence and risk factors of perineal injuries

Methods signs of foetal distress in the second stage of labour,

breech delivery, history of previous third- or fourth
Study design degree perineal injuries, or preterm delivery where
the perineum is tight. A standard right mediolateral
A cross-sectional retrospective study was episiotomy is undertaken using local anaesthetic.
undertaken to target all women who had However, there is no induction of labour and
spontaneous singleton vaginal childbirths at instrumental deliveries using forceps or vacuum
Kwadabeka community health center (KCHC) from extractor at this MOU by the midwives. A rectal
January 2013 to December 2017. examination after suturing the episiotomy or
second-degree injury is performed by the delivering
Study setting and data collection midwife to check for any stitches placed in the
rectum.
The setting of the study has been explained
elsewhere as this was part of a comprehensive study Referral criteria of pregnant women from
that investigated the problems and outcomes of KCHC to hospitals during labour29
pregnant women experienced during the time of
delivery28. However, the study was undertaken at Pregnant women attended KCHC in labour with the
KCHC, a Primary Health Care (PHC) facility in following conditions were referred to hospitals:
Durban, SA, for the residence of Kwadabeka and primipara women aged ≥37 years, grand multiparity
Clermont communities with over 150,000 The (parity ≥5), had previous caesarean section or
maternity services at this MOU are available 24 surgery of the uterus, cervix, vagina, bladder or
hours a day and are run by trained midwives using pelvic floor, previous postpartum haemorrhage
SA National protocol29. requiring blood transfusion, serious medical
disorder (e.g. cardiac disease, current TB infection,
Care and management of perineum during the currently symptomatic asthma, epilepsy), anaemia
second stage of labor29 (Hb <10 g/dL), hypertension (≥140/90 mmHg),
multiple pregnancies, breech presentation or
The second stage of labour is defined when the transverse lie, estimated foetal weight <2 kg,
cervix is fully dilated and ends with the delivery of rupture of the membranes before the onset of labour,
the baby. Usually, two hours are allowed for the maternal pyrexia ≥37.5 degrees Celsius,
foetal head or the presenting part to descend onto vulvovaginal blisters or ulcers, extensive
the pelvic floor if there is no foetal distress and vulvovaginal warts that may obstruct delivery,
CPD. The bladder is emptied using a catheter, if antepartum haemorrhage, suspected foetal distress,
necessary, as usual practice for easy descent of the thick meconium staining liquor, offensive liquor,
presenting part of the foetus. Delivery of the foetus cord prolapse, prolonged latent phase (≥8 hours) of
is usually undertaken in lithotomy position as a labour, poor progress in the active phase (first stage)
routine practice at the facility. Efforts to bear down of labour (> 8 hours) and prolonged second stage of
the foetus by the mothers are only encouraged when labour (>2 hours).
the foetal head starts to distend in the perineum with
uterine contractions and the woman has an urge to Definition of terms
push. When the woman is ready to bear down the
baby, the woman is encouraged to bearing down APGAR score stands for "Appearance, Pulse,
only during contractions of the uterus (experience of Grimace, Activity, and Respiration" for the
pain by the mother). To protect the perineum, newborn babies in 1 and 5 minutes. Five indicators
midwives use a perineal guard when the foetal head were used to check the health of the baby. Each
crowns. An episiotomy is considered and indicator was scored on a scale of 0 to 2, with 2
undertaken on selective cases such as thick or rigid being the best score. Preterm or premature babies
perineum that seems to prevent delivery and may were defined when babies were born < 37 weeks of
prolong the second stage of labour. The other gestation, or they can be small for their gestational
maternal and foetal conditions for episiotomy are age (37 weeks of gestation but baby weight < 2500
African Journal of Reproductive Health August 2021; 25 (4):54
Hoque et al. Trends, incidence and risk factors of perineal injuries
grams). Preterm delivery was considered when (Table 1). Nearly all of them were at term gestation
mothers delivered a baby between 28 weeks and 36 (97%), the majority (73.1%) had parity between 1
weeks of gestational age and the baby weights and 4, previous vaginal deliveries (73.3%), and
above 1000g. The “term delivery” was considered received antenatal care (93.6%). The low-birth-
between 37 and 41 weeks of gestation. Any delivery weight delivery rate (< 2.5 kg) was 7.8% and most
that occurred at 42 completed weeks or afterward of the delivered babies (92.2%) had birth weight
was considered as “post-term delivery”. between 2.5 to 4.0 Kg. APGAR scores (over > 7)
of the babies in 1 and 5 minutes were 92.3% and
Data analysis 96.2% respectively.
The summary of all five years birth data
We entered data into Microsoft Excel for Windows showed (Table 1) that more than one fifth (21.1%)
and imported it into Statistical Package for Social of the pregnant women had spontaneous perineal
Sciences (IBM SPSS) version 22.0 software for injuries while 11.3% had episiotomy making a total
coding and analysis. We analysed the following of 32.4%. Among spontaneous perineal injuries, the
variables: (a) maternal factors: age in years, parity incidences of first- and second-degree injuries were
(nil, 1-4 & >5), and previous vaginal birth, antenatal 17.6% and 3.3% respectively. Only a few had third
care history; (b) obstetric factors: gestational age in degree (0.2%) while none had fourth-degree
weeks, episiotomy undertaken and (c) foetal factors: perineal injuries. Those who had undergone
weight of the new-born (baby) in kilogram (Kg), episiotomy did not have further third- or fourth-
gender of the new-born (male or female) and degree injuries. Table 1 also depicted the cross-
APGAR score at 1 and 5 minutes. Primary outcome table analysis with Chi-Square (X2) and p-values.
measures of the current study were perineal injuries There was a significantly higher (32.5%) rate of
first categorized into a) induced injury (episiotomy) spontaneous perineal injuries among teenagers
and b) spontaneous injuries. Spontaneous injuries (p<0.01) compared to older women. A significantly
were further categorized as i) first ii) second ii) third higher rate (24.2%) of perineal injury was found
and iv) fourth degree injuries. The demographic, among those women who had term pregnancy
baseline dependent, and outcome variables of (gestational age > 37 weeks)) compared to preterm
women were summarized using descriptive (12.6%) (p=0.002). A higher rate (25.8%) of
summary measures: expressed as mean with perineal injury was found among those women that
standard deviation for continuous variables. We delivered babies weighing between 3-3.49 kg
used percent for categorical variables. Cross-table compared to lower birth weight categories (p<0.05).
analysis of independent and dependent variables Figure 1 showed the trends of perineal
was undertaken using Chi-square test (X2) to injury rates over the study period. At the base year
identify the factors significantly associated with (2013) the total (all types) injury rate was higher of
outcome variables. We used binary logistic 33.3% and was found to decrease significantly to
regression analysis to determine possible predictors 28.9% (p<0.05) in 2017. The overall reduction of all
for outcome variables (separately for total, perineal injuries was 13%. The episiotomy rates
episiotomy, and OASI) and the results were were also decreased from 17.6% in 2013 to 7.6% in
expressed with adjusted odds ratios (OR) with 2017 (p<0.05) with a reduction of 57%. However,
corresponding two-sided 95% confidence intervals the spontaneous perineal injuries were increased
(95% CI) and associated p-values. P-values <0.05 significantly from 15.7% in 2013 to 21.3% (p<0.05)
were considered significant. in 2017 with the highest rate of 25.2% in 2016.
Binary logistic output (Table 2) on all perineal
Results injuries showed that the younger pregnant women
A total of 5547 pregnant women had delivered had higher risk of perineal injuries. We found that
singleton babies during 2013-2017 and thus formed teenage age (< 20 years) and ages between 20-29
our study sample. The mean age was 24.67 (SD= years were 6 (p<0.05), and 3.8 times (p<0.05)
5.89) years ranging from 13 to 47 years. Most of respectively more likely to have perineal injuries
them (60%) belonged to the age group 20-29 years than the older women.

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Hoque et al. Trends, incidence and risk factors of perineal injuries
Table 1: Baseline variables with cross-table analysis with outcome variables of the study population
Variables Frequency % Spontaneous P-value Episiotomy P-value OASI P value
Injury (%) (%) (%)
Age (n=5542)
<20 years 1068 19.2 5.5 0.000 4.3 0.000 0.1 0.010
20-29 years 3332 59.9 14.7 6.1 0.1
30- 39 years 1082 19.4 3.5 0.9 0.0
>40 years 51 0.9 0.0 0.1 0.0
Gestation age (n= 5508)
Term (37 -40 weeks) 5338 96.9 23.4 0.001 11.2 0.000 0.2 0.298
Preterm (<36 weeks) 170 3.1 0.4 0.1 0.0
Parity (n= 5471)
Nil parity 1386 25.3 7.6 0.000 5.6 0.000 0.1 0.845
1-4 parity 3996 73.1 16.1 5.6 0.2
>5 parity 89 1.6 0.2 0.1 0.0
Previous vaginal deliveries (n=5547)
Yes 4073 73.3 6.1 0.449 3.6 0.001 0.1 0.919
No 1474 26.7 17.7 7.7 0.2
Antenatal booking (n=5547)
Yes 5181 93.6 1.3 0.011 0.3 0.000 0.0 0.367
No 357 6.4 22.6 10.9 0.2
Sex of baby (n=5500)
Male 2759 49.6 12.4 0.014 5.8 0.043 0.1 0.999
Female 2741 49.4 11.4 5.4 0.1
Birth weight (n= 4874)
< 3 Kgs 1748 31.4 6.2 0.00 3.3 0.189 0.0 0.000
3- 3.99 Kgs 3711 66.8 17.3 7.8 0.1
> 4.00 Kgs 99 1.8 0.4 0.1 0.1
Length (n=5210)
<50 cm 4167 80 19.7 0.542 9.3 0.120
>51 cm 1043 20 4.8 2.0
APGAR score (n=5547)
<7 in 1 minutes 425 7.7 0.8 0.003 0.7 0.162 0.0 0.440
> 7 in 1 minutes 5122 92.3 23.3 10.7 0.2
< 7 in 5 min 212 3.8 0.0 0.001 0.1 0.462 0.0 0.740
> 7 in 5 min 5351 96.2 24.1 11.4 0.2
Perineal injuries (n= 5545)
Intact perineum 3747 67.6
1-degree injury 978 17.6
2-degree injury 184 3.3
3-degree injury 11 0.2
Episiotomy 625 11.3

Table 2: Logistic regression output of all perineal injuries

Odds Ratio 95% C.I. for OR
Variables Sig. (OR) Lower Upper
Age coded .000
Age < 20 years .001 5.927 2.084 16.861
Age 20-29 years .011 3.866 1.369 10.920
Age 30-39 years .085 2.506 .882 7.120
Gestational age >37 weeks .003 2.046 1.286 3.256
Parity .000
Parity nil .000 3.919 2.021 7.600
Parity 1-2 .072 1.817 .948 3.484
Birth weight of the baby .000
Birth weight < 3 kgs .868 .960 .592 1.555
Birth weight 3-3.99 Kgs .242 1.327 .826 2.130
ANC booking (Yes) .008 .689 .524 .905
Constant .000 .024

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Hoque et al. Trends, incidence and risk factors of perineal injuries

35

30

25

20 Episiotomy
Spontenious injury
15
Total injury
10

0
2013 2014 2015 2016 2017

Figure 1: Trends of different types of perineal injuries from 2013 to 2017 at KCHC

Table 3: Logistic regression output for episiotomy

Odds Ratio95% C.I. for OR

Variables Sig. (OR) Lower Upper
Age coded .000
Age < 20 years .176 2.303 .689 7.701
Age 20-29 years .711 1.254 .378 4.159
Age 30-39 years .534 .679 .200 2.301
Gestational age > 37 weeks .000 6.226 2.250 17.232
Parity coded .000
Parity Nil .024 3.973 1.202 13.130
Parity 1-4 .448 1.583 .484 5.180
Had previous vaginal delivery .016 1.262 1.045 1.525
Had antenatal booking .002 .457 .279 .749
APGAR scores > 7 after 5 minutes of delivery.078 1.397 .963 2.026
Constant .000 .007

Table 4: Logistic regression output for OASI

95% C.I. for OR

Variables Sig. Odds ratio (OR) Lower Upper
Birth weight .000
Birth weight < 3 Kgs .000 .14 .011 .142
Birth weight 3-3.99 Kgs .000 .55 .133 .223
Gestational age < 37 weeks .066 .115 .011 1.157
Constant .997 .000

Primipara women and women with gestational age multipara Pregnant women at term pregnancy (>37
at term (> 37 weeks) were 3.9 (p<0.05) and 2 times weeks) were 6 times (OR=6.22, p< 001) more likely
(p< 0.05) more likely to have perineal injuries than to have episiotomy than those had preterm
their counterparts. Primipara women were almost 4 childbirths. Similarly, women who had a previous
times (OR=3.97, p<0.05) more likely to have vaginal delivery were 1.2 (OR= 1.2, p<0.05) times
undergone episiotomy (Table 3) compared to more likely to have an episiotomy than those that

African Journal of Reproductive Health August 2021; 25 (4):57

Hoque et al. Trends, incidence and risk factors of perineal injuries
did not have previous vaginal deliveries. On the (lithotomy, standing, sitting, left lateral, etc.),
other hand, pregnant women who attended antenatal perineal support, bearing down of babies all
care were 55% less likely to have undergone contributed to the reduction of episiotomy and
episiotomy (OR=.457, p<0.05) than those who did overall perineal injuries.
not. Lower birth weights of the babies were found Five years summary data showed that more
to be a protective factor for OASI. Result (Table 4) than one fifth (21.1%) of these women had
showed that the birth weights of the babies < 3.0 Kg spontaneous and 11.3% had induced (episiotomy)
and between 3.0-3.99 Kg were 86% (OR=0.14, perineal injuries. The incidence of spontaneous
p<0.05) and 45% (OR=0.55, p <0.05) less likely perineal injuries among the low-risk pregnant
respectively to have OASI compared to birth weight women appeared higher than other reports from
of > 4kgs. No demographic, obstetrics variables, similar resource-constrained settings11,28,32. The rate
and episiotomy were associated with OASI. was higher than the rate found from a hospital
delivery in Durban (16.2%), SA28. This could be due
Discussion to the support that midwives received from doctors
in the hospital. The incidence of perineal injuries
This study collected data from a large number of was also found to be higher among black South
vaginal deliveries from low-risk pregnant women African pregnant women than the other races in SA
between 2013 and 2017 and estimated the and elsewhere28,33. The rates of the second degree
incidences and risk factors for different degrees of and OASI were minimum in our setting compared
perineal injuries. Firstly, we found trends of all to other studies in hospital settings in SA and
injuries over 5 years period (spontaneous, abroad14,27-28. Regional hospitals in SA conduct
episiotomy, and total) and secondly incidence of deliveries of complicated pregnancies referred from
total injuries of different degrees and their risk MOUs and district hospitals thus a higher rate of
factors. We found a decreasing trend of episiotomy OASI is likely. The incidences of perineal injuries
from a higher rate of 17.6% in 2013 to a lower rate were found to markedly vary between different
of 7.6% in 2017, a reduction of 57%. The study settings with higher rates in hospitals
episiotomy rate in 2017 had reached the rate compared to lower in community settings and those
recommended by WHO and is similar to other were found from Sweden and Nicaragua11,34. The
findings from Africa16,30,31. However, this trend first degree perineal injury is considered minor and
must be seen with the increasing trend of it was 18% in our study. We found a low incidence
spontaneous perineal injuries over the same period. of the second degree and OASI (3.3% and 0.2%
There was an increase in spontaneous injury respectively). The spontaneous second-degree
(21.3%) in 2017 compared to the rate of 15.7% in perineal injuries were much lower than the reported
2013 (Figure 1). It can be argued that it was due to rate from a meta-analysis (23%)8. However, the rate
the reduction of episiotomy, there was an increase of second-degree perineal injury in our study is
of spontaneous perineal injuries. However, there comparable with other findings from Nicaragua
was a significant reduction (13%) of all perineal (2.7%), Pakistan (3.2%), and Bangladesh
injuries from 2013 to 2017. These decreasing trends (1.1%)34-36. The second degree perineal injury
of total perineal injuries including episiotomy though considered a minor injury still needed
indicated that there were constant efforts to avoid special attention as it affects the perineal muscles.
unnecessary use of surgical intervention Though muscular injury is classified as a second-
(episiotomy) and to prevent any spontaneous degree injury it is equal to and often becomes worse
injuries for a physiological process of vaginal than a routine episiotomy. However, if the injury
delivery. The reduction rates should be seen involves the levator ani muscle it leads to pelvic
positively as midwives are constantly striving floor disorders in later life10.
towards better services for pregnant women and Risk factors for spontaneous perineal
minimizing preventable perineal injuries at this injuries were well documented in previous reports.
MOU. However, good practices of perineal care Teenagers (age < 20 years) and ages between 20-29
during childbirth such as the position of women years), nulliparous (parity nil) pregnant women

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Hoque et al. Trends, incidence and risk factors of perineal injuries
showed strong risk factors for spontaneous perineal gestational age > 37 weeks, primipara, and previous
injuries in our study which were well recognized in vaginal deliveries which are similar to other reports
earlier reports24,37. In our study, term pregnancy had from Africa and elsewhere38,39,43. Pregnant women
twice the chance of having spontaneous injuries. who had antenatal care during pregnancy were
Not many studies looked at gestational age as a risk found to be protective (55%) against episiotomy.
factor for perineal injury. The case-control study There is no report which highlighted that antenatal
from Cape Town tertiary hospital (SA) looked into care during the antenatal period could reduce
it and reported that gestational age was not a risk perineal injuries, especially episiotomy. However, it
factor27. As the gestational age increases, the foetus was reported that antenatal education prepares
grows bigger and gains weight. These two factors pregnant women for delivery and found to impact
(higher gestational age and baby weight) are positively on wound-healing and compliance with
interrelated. We found both factors were indeed risk wound care44.
factors for perineal injuries like other study26. The OASI in our study was low of 0.2%.
The episiotomy rate in our study was lower This is lower than the rates found in Brazil (0.75%
compared to other reports from Ethiopia where they for low-risk pregnancies) and Mexico (0.8% for all
found a rate of 35%, France (national average of vaginal deliveries)14,32. The reason for the low rate
14.1% for all non-operative vaginal deliveries), and of OASI in our study could well be due to low-risk
Vietnam (15.1%)38-40. However, the incidence of pregnant women who delivered in our facility. The
episiotomy is similar to the rate (10%) misdiagnosis and underreporting of major perineal
recommended by WHO when it is undertaken for injuries cannot be ruled out as suggested by others32.
selected cases16. However, the episiotomy rate in However, underreporting is less likely as all OASI
our study is higher than the rates reported from cases were needed to be referred to a hospital for
Brazil (8%) for low-risk pregnancies delivered at a surgical intervention like suturing of an anal
hospital referred from PHC clinics and in Nigeria sphincter. Several studies suggested that the heavier
(9.3%)14,30. The possible reason for this low birth weight of babies at delivery was associated
incidence of episiotomy in our study was because with severe perineal injuries. Our study found a
episiotomy was undertaken when it was indicated, similar trend of lower birth weight (<4Kg) was
and also to the fact that the low-risk pregnant protective for OASI11,32,33. The earlier studies from
women delivered at this MOU29. Routine Brazil and Mexico reported that women with
episiotomy in reducing severe or major perineal younger age (teenage women) had 1.3 and 2.9 times
injury (third or fourth degrees) became a respectively more likely to have OASI14,32. This was
controversial issue in modern obstetric practice. not the case in our study. In an earlier report, it was
There was a systematic review report that supported found that the negative impact of OASI in
that standard episiotomy (at mediolateral position) subsequent pregnancies was five-fold to have severe
was found to reduce severe forms of perineal injury perineal injuries thus strategies should be
(third- and fourth-degree injuries)31. Similarly, considered essential to prevent OASI49.
episiotomy was found with an association of
reducing perineal injuries in hospital deliveries from Strengths and limitations
Durban, SA28. On the contrary, other reports from
Cape Town and the Cochrane study found that there The strength of this study was its fairly large
was no association to protect major perineal injuries homogenous type of sample. The limitations of this
using routine episiotomy27,41. We also did not find study were its retrospective nature and review of
any association between episiotomy and OASI. A records limited the study variables and made us
report from Australia indicated that episiotomy was reliant on the quality of data recorded. Finally, more
associated with minimising major injuries when prospective studies are necessary, in order to assess
assisted vaginal delivery was conducted using more risk factors associated with mild and severe
forceps42. In our set up there was no forceps assisted perineal injuries. It is important to identify women
deliveries undertaken. The factors found associated who are at risk of OASI during childbirth, in order
with undertaking episiotomy in our study were to minimize the risks of perineal injury during this

African Journal of Reproductive Health August 2021; 25 (4):59

Hoque et al. Trends, incidence and risk factors of perineal injuries
period. Midwives from PHC facilities need to have collation and analysis, preparation, and finalization
advanced knowledge of pelvic and perineal of the manuscript.
anatomy, so as to prevent injuries during childbirth. MEH– Conceptualisation, data analysis, editing,
and finalization of the manuscript
Conclusion GVH – Conceptualisation, editing, and finalization
of the manuscript. All authors have read and
This large sample of women from a MOU had approved the manuscript.
shown declining trends of perineal injuries. Risk
factors identified for these injuries are similar to References
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