General obstetrics

DOI: 10.1111/j.1471-0528.2011.03150.x
www.bjog.org

Risk of recurrence and subsequent delivery after

obstetric anal sphincter injuries
E Baghestan,a,b,c LM Irgens,c,d PE Brdahl,a,b S Rasmussena,b,c
a
Institute of Clinical Medicine, University of Bergen, Bergen, Norway b Department of Obstetrics and Gynaecology, Haukeland University
Hospital, Bergen, Norway c Medical Birth Registry of Norway, Norwegian Institute of Public Health, Bergen, Norway d Locus for Registry
Based Epidemiology, Department of Public Health and Primary Health Care, University of Bergen, Norway
Correspondence: Dr E Baghestan, Department of Obstetrics and Gynaecology, Haukeland University Hospital, N-5021, Bergen, Norway.
Email elham.baghestan@kk.uib.no

Accepted 11 August 2011. Published Online 10 October 2011.

Objective To investigate the recurrence risk, the likelihood of

having further deliveries and mode of delivery after third to

fourth degree obstetric anal sphincter injuries (OASIS).
Design Population-based cohort study.
Setting The Medical Birth Registry of Norway.
Population A cohort of 828 864 mothers with singleton, vertex-

presenting infants, weighing 500 g or more, during the period

19672004.
Methods Comparison of women with and without a history of

OASIS with respect to the occurrence of OASIS, subsequent

delivery rate and planned caesarean rate.
Main outcome measures OASIS in second and third deliveries,

forceps deliveries, birthweights of 3500 g or more and large

maternity units were associated with a recurrence of OASIS.
Instrumental delivery did not further increase the excess
recurrence risk associated with high birthweight. A man who
fathered a child whose delivery was complicated by OASIS was
more likely to father another child whose delivery was
complicated by OASIS in another woman who gave birth in the
same maternity unit (adjusted OR 2.1; 95% CI 1.23.7; 5.6%).
However, if the deliveries took place in different maternity units,
the recurrence risk was not significantly increased (OR 1.3; 95%
CI 0.82.1; 4.4%). The subsequent delivery rate was not different
in women with and without previous OASIS, whereas women
with a previous OASIS were more often scheduled to caesarean
delivery.
Conclusion Recurrence risks in second and third deliveries were

subsequent delivery rate and mode of delivery.

Results Adjusted odds ratios of the recurrence of OASIS in

women with a history of OASIS in the first, and in both the

first and second deliveries, were 4.2 (95% CI 3.94.5; 5.6%) and
10.6 (95% CI 6.218.1; 9.5%), respectively, relative to women
without a history of OASIS. Instrumental deliveries, in particular

high. A history of OASIS had little or no impact on the rates of

subsequent deliveries. Women with previous OASIS were
delivered more frequently by planned caesarean delivery.
Keywords Caesarean, fertility, recurrence, sphincter injuries,

subsequent delivery.

Please cite this paper as: Baghestan E, Irgens L, Brdahl P, Rasmussen S. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries.
BJOG 2012;119:6269.

Introduction
Obstetric anal sphincter injuries (OASIS) occur in 110%
of vaginal deliveries,13 and can result in complications
such as perineal pain, dyspareunia, as well as urinary and
fecal incontinence.46 Cross-sectional studies have identified
strong risk factors such as primiparity, high birthweight
and instrumental delivery,3,7 whereas longitudinal studies
have reported that OASIS tends to recur in subsequent
births,811 but not consistently.12,13
An assessment of the reproductive history in women
who have sustained OASIS, focusing on recurrence as well

62

as the likelihood of having a subsequent pregnancy, would

be of particular value in counselling women who have had
OASIS.
Hospital-based studies on the recurrence of OASIS may
be affected by selection bias and small sample size. Additionally, the choice of reference group may have caused
some of the inconsistency in reported relative risks of
recurrence.12,13 In a big population-based study, Spydslaug
et al.9 reported a 4.3-fold increased recurrence risk of
OASIS in the second delivery. They also reported an
increasing absolute risk of the recurrence of OASIS according to the birthweight of the offspring (23.3% recurrence

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Obstetric career after sphincter injuries

rate for a birthweight >5000 g). However, little is known

about other possible risk factors for recurrence, such as
instrumental delivery, interdelivery interval and maternal
age. Furthermore, paternal influence, represented in the
fetus by characteristics such as birthweight,14 has to our
knowledge never been analysed. Additionally, little is
known about the recurrence of OASIS beyond the second
birth.
One may expect that a severe delivery complication such
as OASIS would deter a woman from having a subsequent
pregnancy. Previous studies have focused on the quality of
life after OASIS,5,15,16 but subsequent delivery rate and the
mode of subsequent deliveries has not been properly
addressed.11
The aim of the present study was to assess the recurrence
risk of OASIS in second and third deliveries, and to study
the effect of instrumental delivery, interdelivery interval,
maternal age and size of maternity unit on the recurrence
of OASIS. We also wanted to estimate the proportion of
OASIS cases attributable to a history of OASIS, and to
assess the paternal contribution to the recurrence of OASIS.
Finally, we wanted to assess the likelihood of having a
further delivery and mode of delivery after OASIS.

Methods
In this registry-based cohort study, we used data from the
Medical Birth Registry of Norway, which, based on compulsory notification of all live births and stillbirths in the
country after 16 weeks of gestation, comprises records of
more than 2 000 000 births from 1967 to 2004. A notification form including data on maternal health before and
during pregnancy, interventions and complications during
delivery and health of the newborn is completed by the
midwives and attending physicians. The notification form
remained almost unchanged until 1999, when a revised version was introduced.17
All births of a mother were linked by the national identification number, providing sibship files with the mother as
the unit of analysis. The analysis was based on mothers
with singleton, vertex-presenting infants, weighing 500 g or
more, who had their first delivery after 1967: 828 864
mothers in total. In order to compare subsequent rates of
OASIS after vaginal births with and without OASIS, women
with caesarean in previous deliveries were excluded. Only
current vaginal deliveries were followed with respect to the
recurrence of OASIS. When subsequent delivery rates from
first to second and second to third births were calculated,
mothers with caesarean deliveries in previous births (first
and first or second, respectively) were excluded, because
caesarean delivery may influence further delivery rates.18,19
The main outcome, OASIS, was classified according to
the international classification of diseases and included

third-degree injury (ICD-10: O70.2), involving sphincter

muscle, and fourth-degree injury (ICD-10: O70.3), involving sphincter muscle and rectal mucosa. From 1967 to
1998, OASIS was reported to the Medical Birth Registry as
plain text, whereas from 1999 onwards it was reported by
checking a box in the form. The registration of OASIS in
the Medical Birth Registry of Norway has been validated
with a satisfactory result.20,21
The recurrence rate of OASIS was estimated in the
mothers second and third delivery. The odds ratio (OR) of
recurrence was defined as the odds of OASIS among
women having already had OASIS relative to the odds of
OASIS in those without previous OASIS. Adjusted ORs
were obtained from logistic regression with adjustment for
year of delivery (19671974, 19751982, 19831990, 1991
1998 and 19992004), instrumental delivery (yes or no),
maternal age (<20, 2029, 3034, 3539 and 40 years or
older), birthweight (<3000, 30003499, 35003999, 4000
4499, 45004999 and 5000 g or more) and size of maternity unit (<50, 50499, 500999, 10001999, 20002999
and 3000 deliveries per year or more) in the subsequent
delivery. The associations of recurrence of OASIS in the
subsequent delivery with maternal age, instrumental delivery, birthweight, size of maternity unit and interdelivery
interval (<5, 59 and 10 years or more) were assessed by
logistic regression, restricting these analyses to women with
a history of OASIS. To assess whether the effects of birthweight on OASIS in instrumental and non-instrumental
delivery were significantly different, an interaction term
between birthweight and instrumental delivery was added
to the regression model.
In order to increase sample size in analyses of paternal
contribution to the recurrence of OASIS, 48 392 pairs of
first to second, second to third, third to fourth and fourth
to fifth singleton, vertex-presenting vaginal deliveries, with
birthweights of 500 g or more, with the same father and
different mothers were identified. Among these pairs of
births, 18 579 (from 11 372 fathers) and 29 813 (from
17 986 fathers) took place in the same and different maternity units, respectively. To avoid underestimated standard
errors caused by the nested structure of the data (one or
more pairs of births in the same father), we used multilevel
logistic regression analysis.22
To estimate the proportions of all cases of OASIS in the
second and third delivery attributable to a history of
OASIS, population-attributable risk percentages were estimated as 100 (incidence in the populationincidence in
the non-exposed group)/incidence in the population, on
the assumption of a causal relationship between an initial
and a subsequent OASIS. Exposed third deliveries were
those with either OASIS in the first or second delivery.
The subsequent delivery rate was defined as the percentage of all women who had a delivery (second or third)

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63

Baghestan et al.

subsequent to the first or second delivery. The proportion

of planned caesareans among all subsequent deliveries was
calculated, irrespective of how the delivery was performed
(planned or emergency caesarean or vaginal delivery). The
classification of caesarean deliveries into emergency and
planned caesareans in the Medical Birth Registry was introduced in 1988. Consequently, analyses of planned caesarean
deliveries were restricted to the period 19882004. In the
calculation of the subsequent total delivery rate after the
first and second delivery, each woman was observed until
the end of the observation period (31 December 2004).
Adjustments were made in a Cox proportional hazards
regression of time from OASIS to a subsequent delivery for
possible confounding factors in the previous delivery:
infant death within 1 year (yes or no); year of delivery
(19671974, 19751982, 19831990, 19911998 and 1999
2004); instrumental delivery (yes or no); maternal age
(<20, 2029, 3034, 3539 and 40 years or older); maternal
marital status (married, cohabiting, unmarried or single,
other, unknown); and maternal level of education (<8, 8
10, 1112, 1317, 18 or more years, unknown). Because the
Medical Birth Registry covers all births in Norway, lost to
follow-up were women who emigrated or died. By logistic
regression adjusted for year of delivery we found no significant differences in emigration (0.31.6%), nor in maternal
death (0.51.7%), between groups of women with OASIS
or not in first and second deliveries. Data on women who
did not have a subsequent delivery were treated as censored
observations, with censored time equal to the last date of
registration (31 December 2004), the date of emigration or
maternal death.
The statistical analyses were carried out in spss (SPSS
Inc., Chicago, IL, USA) and mlwin (Centre for Multilevel
Modelling, University of Bristol, UK). The regional committee for medical research ethics approved the study protocol (REK Vest no. 247.09).

Results
Figure 1 shows the study population according to the
mode of delivery and occurrence of OASIS in first, second
and third deliveries. OASIS occurred in 2.8, 1.1 and 0.7%
of first, second and third vaginal deliveries, respectively.
The data from all 828 864 women, without exclusions, is
included in Figure 1.

Recurrence of OASIS in second and

third deliveries
The occurrence of OASIS in second deliveries subsequent
to deliveries with OASIS was 5.6% (750/13 305) and without OASIS was 0.8% (4546/545 469) [OR 4.2; 95% CI 3.9
4.5; relative to women without a history of OASIS,
adjusted for year of delivery (19671974, 19751982,

64

First delivery
828 864 mothers

Vaginal delivery
755 921 (91.2%)

OASIS
21 692 (2.8%)

Caesarean delivery
72 943 (8.8%)

Second delivery
624 939 (75.0%)
mothers continued to
second delivery
Vaginal delivery
580 155 (92.8%)

OASIS
6503 (1.1%)

Caesarean delivery
44 784 (7.2%)

Third delivery
242 179 (29.2%)
mothers continued to
third delivery
Vaginal delivery
222 690 (92.0%)

OASIS
1506 (0.7%)

Caesarean delivery
19 489 (8.0%)

Figure 1. Study population according to mode of delivery and history

of obstetric anal sphincter injuries (OASIS) in the first, second and third
delivery.

19831990, 19911998 and 19992004), birthweight

(<3000, 30003499, 35003999, 40004499, 45004499 and
5000 g or more), instrumental delivery (yes or no) and
size of maternity unit (<50, 50499, 500999, 10001999,
20002999 and 3000 deliveries per year or more) in the
second delivery]. Additionally, forceps deliveries, birthweights >3500 g and maternity units with over 3000 deliveries per year were associated with the recurrence of
OASIS in the second delivery (Table 1). Vacuum deliveries
only marginally increased the risk of recurrence (OR 1.5;
95% CI 1.02.3; Table 1). Maternal age of <40 years and
interdelivery interval were not associated with an excess
recurrence risk of OASIS (Table 1). Instrumental delivery
did not increase birthweight-specific recurrence risks
(Table 2). An interaction term between birthweight and
instrumental delivery added to the model was not significant (P = 0.6).
A history of OASIS in the first or second delivery
increased the occurrence in the third delivery (Table 3).
The ORs relative to women without OASIS in the first and
second delivery were highest in women with no OASIS in
the first delivery but with OASIS in the second delivery,

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Obstetric career after sphincter injuries

Table 1. Risk factors for recurrence of obstetric anal sphincter

injuries (OASIS) in the second vaginal delivery in 13 305 women
with OASIS in the first delivery, Norway, 19672004
Characteristics

Total number
of deliveries

Birthweight (g)
<3000
841
30003499
3167
35003999
5247
40004499
3117
45004999
812
5000 or more
121
Instrumental delivery
Non instrumental
12 921
Vacuum
268
Forceps
116
Maternal age (years)
<20
65
2029
7698
3034
4387
3539
1039
40 or older
116
Interdelivery interval (years)*
<5
11 259
59.9
1818
10 or more
228
Maternity unit (deliveries/year)
<50
46
50499
1172
500999
1376
10001999
3220
20002999
1959
3000 or more
5102
Outside
430
maternity unit

Numbers of
OASIS
N (%)

18
102
252
249
104
25

(2.1)
(3.2)
(4.8)
(8.0)
(12.8)
(20.7)

Adjusted
OR (95% CI)

0.6 (0.41.1)
Reference
1.5 (1.21.9)
2.5 (1.93.1)
4.2 (3.15.6)
7.1 (4.311.6)

702 (5.4)
30 (11.2)
18 (15.5)

Reference
1.5 (1.02.3)
3.2 (1.95.4)

1
383
288
66
12

0.5 (0.13.6)
Reference
1.0 (0.91.2)
1.0 (0.71.3)
1.8 (1.03.4)

(1.5)
(5.0)
(6.6)
(6.4)
(10.3)

623 (5.5)
116 (6.4)
11 (4.8)

Reference
1.1 (0.91.4)
0.7 (0.41.4)

0
46
41
161
113
357
32

0.8 (0.61.2)
0.6 (0.40.9)
Reference
1.2 (0.91.5)
1.4 (1.21.8)
1.1 (0.71.6)

(3.9)
(3.0)
(5.0)
(5.8)
(7.0)
(7.4)

Adjusted for year of delivery (19671974, 19751982, 19831990,

19911998 and 19992004), birthweight (<3000, 30003499,
35003999, 40004499, 45004499 and 5000 g or more), instrumental delivery (yes or no) and size of maternity unit (<50, 50499,
500999, 10001999, 20002999 and 3000 deliveries per year or
more) in the second delivery.
*Adjusted for year of delivery and maternal age in the second delivery.

and women with OASIS in both first and second deliveries

(adjusted ORs 9.3 and 10.6, respectively; 95% CIs 7.311.8
and 6.218.1, respectively).
The population-attributable risk percentage of OASIS in
second and third deliveries as a result of previous OASIS
was 10 and 15%, respectively.
No time trends of ORs of recurrence in second or third
deliveries were found, as assessed by adding an interaction
term between year of the current delivery and a history of
OASIS to the model or stratifying for year of birth (not
presented).

A man who fathered a birth resulting in OASIS was

more likely to father a subsequent birth resulting in OASIS
in another woman who gave birth in the same maternity
unit (adjusted OR 2.1, relative to men with no history of
OASIS, for year of delivery, maternal age and maternal
birth order in the current delivery; 95% CI 1.23.7; 5.6%,
compared with 2.3%). Adjusting for birthweight had a negligible effect. However, if the deliveries took place in different maternity units, the recurrence risk was not
significantly increased (OR 1.3; 95% CI 0.82.1; 4.4% compared with 2.9%).

Subsequent delivery after OASIS

After OASIS in the first delivery, 66.7% of women had a
second delivery compared with 76.9% of women with no
OASIS in the first delivery (Table 4). However, adjusted
hazard ratios revealed no significant differences. Consistently, after stratifying analyses by year of first delivery, no
significant differences were observed in second delivery
rates between women with and without OASIS in the first
delivery (not presented). Cumulative proportions by time
from deliveries with and without OASIS were almost the
same (not presented). Women with OASIS in the first
delivery more frequently had a planned caesarean in the
second delivery than women without OASIS in the first
delivery (6.0 and 1.5%, respectively; Table 4). The difference persisted after adjustment for possible confounding
factors (OR 3.0; 95% CI 2.83.3).
Women with OASIS in the first or second delivery had a
lower subsequent delivery rate (from the second to the
third delivery) than women without a history of OASIS
(Table 5). However, adjusted hazard ratios revealed small
or insignificant differences. Consistently, after stratifying
analyses by year of first delivery, no significant differences
were observed in third delivery rates between women with
and without OASIS in first or second delivery (not presented). Women with a history of OASIS in the first or second delivery were delivered significantly more frequently
by planned caesarean in the third delivery (Table 5).
Cumulative proportions by time from deliveries with and
without OASIS were almost the same (not presented).
In women with OASIS in both first and second deliveries,
the rate of planned caesarean delivery was 13 times higher
than in women with no previous OASIS (adjusted
OR 13.4; 95% CI 9.119.7) (Table 5).

Discussion
Women with a history of OASIS in the first and the twofirst deliveries had four- and ten-fold increased risks of
OASIS in the subsequent delivery, respectively. The recurrence of OASIS was strongly associated with forceps delivery and birthweights of 3500 g or more in the second

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Baghestan et al.

Table 2. Recurrence of obstetric anal sphincter injuries (OASIS) in the second vaginal delivery by birthweight and instrumental delivery, Norway,
19672004
Instrumental delivery
in the second delivery

Birthweight (g)
in second delivery

No instrumental delivery

<3000
30003499
35003999
40004499
45004999
5000 or more
<3000
30003499
35003999
40004499
45004999
5000 or more

Instrumental delivery Forceps/vacuum

Total numbers of
second deliveries

OASIS in second
delivery
no. (%)

814
3108
5129
2991
761
107
27
59
118
126
51
14

17
96
240
230
96
22
1
6
12
19
8
3

Adjusted
OR
(95% CI)

(2.1)
(3.1)
(4.7)
(7.7)
(12.6)
(20.6)
(3.7)
(10.2)
(10.2)
(15.1)
(15.7)
(21.4)

0.7 (0.41.1)
Reference
1.5 (1.21.9)
2.5 (2.03.2)
4.4 (3.36.0)
7.9 (4.713.3)
1.3 (0.29.8)
3.3 (1.48.1)
3.3 (1.76.2)
5.1 (3.08.7)
5.2 (2.311.5)
8.0 (2.130.0)

Adjusted for year of delivery (19671974, 19751982, 19831990, 19911998 and 19992004), maternal age (<20, 2029, 3034, 3539 and
40 years or older) and size of maternity unit (<50, 50499, 500999, 10001999, 20002999 and 3000 deliveries per year or more) in the second
delivery.

Table 3. Recurrence of obstetric anal sphincter injuries (OASIS) in third vaginal deliveries, Norway, 19672004
OASIS in first
delivery

OASIS in second
delivery

No OASIS
No OASIS
OASIS
OASIS

No OASIS
OASIS
No OASIS
OASIS

Total number of
third deliveries
207 299
1179
3986
169

OASIS in third
deliveries no. (%)
1106
82
124
16

(0.5)
(7.0)
(3.1)
(9.5)

Adjusted OR
(95% CI)
Reference
9.3 (7.311.8)
4.0 (3.34.9)
10.6 (6.218.1)

Adjusted for year of delivery (19671974, 19751982, 19831990, 19911998 and 19992004), maternal age (<20, 2029, 3034, 3539 and
40 years or older), instrumental delivery (yes or no), birthweight (<3000, 30003499, 35003999, 40004499 and 5000 g or more) and size of
maternity unit (<50, 50499, 500999, 10001999, 20002999 and 3000 deliveries per year or more) in the third delivery.

Table 4. Subsequent pregnancy after first vaginal delivery with or without obstetric anal sphincter injuries (OASIS), total and planned caesarean
in second delivery, Norway, 19672004
First delivery

No OASIS
OASIS

Second delivery

Total number of
women with first vaginal
deliveries no. (%)

Total number of second

deliveries no. (%) Adjusted
hazard ratio (95% CI)

Numbers of planned
caesarean in second delivery no. (%)*
Adjusted OR (95% CI)

734 245 (100)

564 826 (76.9)

Reference
14 461 (66.7)
1.02 (1.001.04)

4050 (1.5)
Reference
658 (6.0)
3.0 (2.83.3)

21 676 (100)

Women delivered by caesarean in the first delivery were excluded.

Hazard ratios and odds ratios are adjusted for infant death within 1 year (yes or no), year of delivery (19671974, 19751982, 19831990,
19911998, and 19992004), instrumental delivery (yes or no), maternal age (<20, 2029, 3034, 3539 and 40 years or older), maternal marital
status (married, cohabiting, unmarried or single, other, unknown) and maternal level of education (<8, 810, 1112, 1317, 18 or more years,
unknown) in the first delivery.
*Numbers of second deliveries after 1988 without and with OASIS (denominators) were 271 512 and 11 065, respectively.

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Obstetric career after sphincter injuries

Table 5. Subsequent pregnancy after two vaginal deliveries with or without obstetric anal sphincter injuries (OASIS), total and planned caesarean
third deliveries, Norway, 19672004
First delivery

Second delivery

No OASIS

No OASIS

No OASIS

OASIS

OASIS

No OASIS

OASIS

OASIS

Third delivery
Total number of women with
two vaginal deliveries
N (%)

Total numbers of deliveries N (%)

Adjusted hazard ratio
(95% CI)

Numbers of planned
caesarean N (%)*
Adjusted
OR (95% CI)

540 923 (100)

215 823 (39.9)

Reference
1331 (29.3)
0.90 (0.850.95)
4181 (33.3)
1.01 (0.981.04)
213 (28.4)
1.08 (0.941.23)

1552 (1.3)
Reference
92 (8.4)
6.2 (4.97.7)
74 (2.2)
1.7 (1.32.1)
34 (16.9)
13.4 (9.119.7)

4546 (100)
12 555 (100)
750 (100)

Women delivered by caesarean in the first and second delivery were excluded.
Hazard ratios and odds ratios are adjusted for infant death within 1 year (yes or no), year of delivery (19671974, 19751982, 19831990,
19911998 and 19992004), instrumental delivery (yes or no), maternal age (<20, 2029, 3034, 3539 and 40 years or older), maternal marital
status (married, cohabiting, unmarried or single, other, unknown) and maternal level of education (<8, 810, 1112, 1317, 18 or more years,
unknown) in the second delivery.
*Numbers of third deliveries after 1988; denominators in the same order according to OASIS in the first two deliveries were 120 907, 1099, 3348
and 201, respectively.

delivery. However, instrumental delivery did not further

increase the excess recurrence risk observed in heavy newborns. The recurrence risk of OASIS increased with size of
maternity unit, but was not influenced by maternal age
under 40 years or by the interdelivery interval. A man who
fathered a birth that resulted in OASIS was more likely to
father a subsequent birth that resulted in OASIS in another
woman. However, if the deliveries took place in different
maternity units, the recurrence risk was not significantly
increased. The subsequent delivery rate was not different in
women with and without previous OASIS, whereas women
with previous OASIS were more often scheduled for caesarean delivery.
Strengths of our study include the population-based
design and the prospective collection of data, reducing the
risk of selection and recall bias. The national identification
number allowed the linkage of births to both parents. The
long follow-up period allowed us to study recurrence risk
and subsequent delivery rates beyond the second delivery.
Our nationwide registry allowed for the collection of data
in subsequent deliveries, regardless of any change in maternity unit. The OASIS variable has a high validity.20,21 However, increased awareness in the current pregnancy may
have caused a higher sensitivity or case ascertainment in a
delivery after previous OASIS. Furthermore, data on several
possible confounding factors were available.
In this study, women who had OASIS in the first delivery had a roughly four-fold excess risk of OASIS in the

second delivery. Although the risk of the occurrence of

OASIS tends to decrease with vaginal birth order,3 we generally noted an increased recurrence risk in birth order 3.
Women who had OASIS in the second delivery, but not
in the first, were nine times more likely to have OASIS in
the third delivery, and also had high absolute risks (7%).
The risk in women who had OASIS in the two-first deliveries was particularly high (absolute risk 9.5%, adjusted
OR 10.6). Also, women who had OASIS in the first, but
not the second, delivery were at increased risk in the third
delivery, although with a modest absolute risk (3.1%).
This could not result from the exclusion of women with
caesarean delivery in the second delivery, because in a supplementary analysis, inclusion of caesarean delivery had little effect on ORs. The high absolute risk in the third
delivery in women with OASIS in the second delivery was
not expected, and justifies attention to the recurrence of
OASIS beyond the second delivery. It cannot be ruled out
that women with a history of OASIS and subsequent caesarean delivery more often had fourth-degree OASIS and
therefore higher recurrence risks if they were delivered
vaginally.
To our knowledge, nine studies have previously reported
on the recurrence risk of OASIS,813,2325 with conflicting
results. Seven of these studies have reported increased
recurrence risk of OASIS in a second delivery,811,2325 and
another two studies found no increased risk of OASIS in
women with prior OASIS.12,13 The last two studies

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67

Baghestan et al.

included women with OASIS in birth order 1 in the reference group, and thus probably underestimated the relative
risks arising from the higher risk of OASIS in the first
deliveries, concluding that prior OASIS does not increase
recurrence, and that the increased recurrence found in previous studies could be caused by bias.
Although most women sustaining OASIS in second and
third deliveries did not have previous OASIS, as many as
10% of all cases of OASIS in the second delivery, and 15%
of cases of OASIS in the third delivery, were attributable to
a history of OASIS.
Consistent with another study based on the Medical
Birth Registry of Norway,9 birthweights of 3500 g or more
were strongly associated with a recurrence of OASIS. This
indicates that for women with a history of OASIS and high
estimated fetal weight, caesarean delivery must be considered.9
As in previous studies,12,13 in the present study instrumental deliveries, and particularly forceps deliveries, were
strongly associated with a recurrence risk of OASIS. Vacuum deliveries only marginally increased the recurrence
risk of OASIS. Therefore, vacuum delivery is probably a
better choice than forceps when women with prior OASIS
are delivered instrumentally, unless the clinician is skilled
in forceps delivery.
Although instrumental delivery was strongly associated
with the recurrence of OASIS, it did not further increase
the excess recurrence risk in heavy newborns. This may be
useful information for the clinical decision of whether an
instrumental delivery of a large infant should be performed
in a woman with a history of OASIS.
We have previously reported that maternal age is associated with the occurrence of OASIS.3 However, our results
indicate no association of either maternal age under
40 years or interdelivery interval with the recurrence of
OASIS. Our results provide reassurance that recurrence risk
in older women is not substantially different from that in
younger women, and that the time to the next pregnancy
does not seem to influence recurrence. The recurrence risk
of OASIS was higher in the maternity units with more than
3000 deliveries per year. After adjusting for instrumental
delivery, which is more common in referral hospitals, the
higher risk persisted. However, it cannot be ruled out that
the excess risk was the result of better registration, diagnostic skills or referral of complicated pregnancies to larger
maternity units.
Most risk factors for OASIS relate to the mother, and little is known about a potential paternal influence on OASIS.
A change of female partner after a birth with OASIS should
remove the previous mothers genetic contribution to the
recurrence risk. The excess paternal recurrence rate was not
present if both deliveries took place in different maternity
units, which contradicts a biological paternal effect. How-

68

ever, a man who fathered a birth with OASIS was more

likely to father a subsequent birth with OASIS in another
woman if the delivery took place in the same delivery unit.
Only including births that took place in the same delivery
unit would hold effects such as practices of perineal protection more constant. This potential genetic paternal effect
warrants further study.
Some studies on the quality of life after OASIS have
reported conflicting results,5,15,16 but subsequent fertility
and mode of subsequent deliveries have not been emphasised. Consistent with the present study, one study has
reported a reduced unadjusted likelihood of having a further delivery after OASIS.11 After stratification by year of
first delivery in the present study, no differences from
expected values were generally observed in subsequent
delivery rates (data not shown). A recent small casecontrol study showed that women who had OASIS wished to
postpone or avoid a further delivery, but consistent with
the present study a history of OASIS did not influence
further delivery rates.26 However, the excess rate of
planned caesarean delivery in the present study, which has
been reported to be associated with increased risk of
severe maternal and neonatal morbidity and mortality,27
persisted.

Conclusion
The absolute and relative recurrence rates after OASIS in
the first and second deliveries were high. Therefore,
emphasis should be placed on counselling women after an
initial OASIS, and attention should be paid to prevent
OASIS in the first delivery. A history of OASIS had little or
no impact on the subsequent delivery rate. However,
women with previous OASIS more frequently had planned
caesarean delivery. The potential risk factors related to the
father should be further studied.

Disclosure of interests
All authors declare that they have no relevant interests to
declare.

Contribution to authorship
EB contributed by writing the article, performing the statistical analyses, in the conception and design of the study,
and in the interpretation of data. LMI contributed by
supervising, drafting the article and revising it for important intellectual content. PEB contributed by supervising
and drafting the article, and by revising it for important
intellectual content. The main supervisor, SR contributed
by revising the article, by the conception and design of the
study, by the interpretation of data and by supervising the
statistical analyses. All authors approved the final version
of the article.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

Obstetric career after sphincter injuries

Details of ethics approval

The regional committee for medical research ethics
approved the study protocol (REK Vest no. 247.09).

Funding
The study was funded by the Norwegian Foundation for
Health and Rehabilitation and the Norwegian Womens
Public Health association.

Acknowledgements
The authors want to thank the Norwegian Foundation for
Health and Rehabilitation and the Norwegian Womens
Public Health association for funding the study. j

References
1 Groom KM, Paterson-Brown S. Can we improve on the diagnosis of
third degree tears? Eur J Obstet Gynecol Reprod Biol 2002;101:19
21.
2 Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter
tears in four Nordic countries through the last decades. Eur J Obstet
Gynecol Reprod Biol 2009;146:715.
3 Baghestan E, Irgens LM, Bordahl PE, Rasmussen S. Trends in risk factors for obstetric anal sphincter injuries in norway. Obstet Gynecol
2010;116:2534.
4 Scheer I, Andrews V, Thakar R, Sultan AH. Urinary incontinence
after obstetric anal sphincter injuries (OASIS) is there a relationship? Int Urogynecol J Pelvic Floor Dysfunct 2008;19:17983.
5 Samarasekera DN, Bekhit MT, Wright Y, Lowndes RH, Stanley KP,
Preston JP, et al. Long-term anal continence and quality of life following postpartum anal sphincter injury. Colorectal Dis 2008;10:
7939.
6 Haadem K, Ohrlander S, Lingman G. Long-term ailments due to anal
sphincter rupture caused by delivery a hidden problem. Eur J
Obstet Gynecol Reprod Biol 1988;27:2732.
7 Samarasekera DN, Bekhit MT, Preston JP, Speakman CT. Risk factors
for anal sphincter disruption during child birth. Langenbecks Arch
Surg 2009;394:5358.
8 Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of
cohorts by parity and prior mode of delivery. Am J Obstet Gynecol
2007;196:344 e341345.
9 Spydslaug A, Trogstad LI, Skrondal A, Eskild A. Recurrent risk of anal
sphincter laceration among women with vaginal deliveries. Obstet
Gynecol 2005;105:30713.
10 DiPiazza D, Richter HE, Chapman V, Cliver SP, Neely C, Chen CC,
et al. Risk factors for anal sphincter tear in multiparas. Obstet Gynecol 2006;107:12337.
11 Elfaghi I, Johansson-Ernste B, Rydhstroem H. Rupture of the sphincter ani: the recurrence rate in second delivery. BJOG 2004;111:
13614.

12 Edwards H, Grotegut C, Harmanli OH, Rapkin D, Dandolu V. Is

severe perineal damage increased in women with prior anal sphincter injury? J Matern Fetal Neonatal Med 2006;19:7237.
13 Dandolu V, Gaughan JP, Chatwani AJ, Harmanli O, Mabine B, Hernandez E Risk of recurrence of anal sphincter lacerations. Obstet
Gynecol 2005;105:8315.
14 Lunde A, Melve KK, Gjessing HK, Skjaerven R, Irgens LM. Genetic
and environmental influences on birth weight, birth length, head
circumference, and gestational age by use of population-based
parent-offspring data. Am J Epidemiol 2007;165:73441.
15 Rothbarth J, Bemelman WA, Meijerink WJ, Stiggelbout AM, Zwinderman AH, Buyze-Westerweel ME, et al. What is the impact of
fecal incontinence on quality of life? Dis Colon Rectum 2001;44:67
71.
16 Scheer I, Thakar R, Sultan AH. Mode of delivery after previous
obstetric anal sphincter injuries (OASIS) a reappraisal? Int Urogynecol J Pelvic Floor Dysfunct 2009;20:1095101.
17 Irgens LM. The Medical Birth Registry of Norway. Epidemiological
research and surveillance throughout 30 years. Acta Obstet Gynecol
Scand 2000;79:4359.
18 Albrechtsen S, Rasmussen S, Dalaker K, Irgens LM. Reproductive
career after breech presentation: subsequent pregnancy rates, interpregnancy interval, and recurrence. Obstet Gynecol 1998;92:345
50.
19 Tollanes MC, Melve KK, Irgens LM, Skjaerven R. Reduced fertility
after cesarean delivery: a maternal choice. Obstet Gynecol 2007;110:
125663.
20 Baghestan E, Bordahl PE, Rasmussen S, Sande AK, Lyslo I, Solvang I
A validation of the diagnosis of obstetric sphincter tears in two Norwegian databases, the Medical Birth Registry and the Patient Administration System. Acta Obstet Gynecol Scand 2007;86:2059.
21 Droyvold WB, Rydning A, Baghestan E, Gjessing L, Kristoffersen M,
Norderval S, et al. Validation of the diagnose of anal sphincter tear
in Medical birth registry of Norway and pasient administrative system. SINTEF Helse 2008; Report No., A6301.
22 Goldstein H, Browne W, Rasbash J. Multilevel modelling of medical
data. Stat Med 2002;21:3291315.
23 Harkin R, Fitzpatrick M, OConnell PR, OHerlihy C. Anal sphincter
disruption at vaginal delivery: is recurrence predictable? Eur J Obstet
Gynecol Reprod Biol 2003;109:14952.
24 Payne TN, Carey JC, Rayburn WF. Prior third- or fourth-degree perineal tears and recurrence risks. Int J Gynaecol Obstet 1999;64:557.
25 Peleg D, Kennedy CM, Merrill D, Zlatnik FJ. Risk of repetition of a
severe perineal laceration. Obstet Gynecol 1999;93:10214.
26 Wegnelius G, Hammarstrom M. Complete rupture of anal sphincter
in primiparas: long-term effects and subsequent delivery. Acta
Obstet Gynecol Scand 2011;90:25863.
27 Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al.
Maternal and neonatal individual risks and benefits associated with
caesarean delivery: multicentre prospective study. BMJ 2007;335:
1025.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

69