Perineum: a better reporting of severe tears and assessment of very restrictive policy of episiotomies

The rates of severe perineal tears and episiotomies have been proposed as indicators of obstetrical quality of care and as indicators of implementation of evidence-based medicine. However there are wide variations in the rates of both indicators in European countries and a negative correlation is observed between these rates. Our results suggest that we need better, more standardised assessment and reporting of severe tears in Europe before these rates can be compared with confidence across countries; we also need an evaluation of very restrictive use of episiotomies by a randomized control trial.



The use of rates of severe perineal tears and episiotomies as indicators of obstetrical quality of care may be limited because of the difficulties in ascertainment of tears and the uncertainties regarding the optimal rate of episiotomies. Our objective was to investigate geographical differences in rates of severe perineal tears and episiotomies in European countries and to analyse the association between these two indicators.


We used aggregate data from national routine statistics available in the Euro-Peristat project. We compared rates of severe (third- and fourth-degree) tears and episiotomies in 2010 by mode of vaginal delivery (N=20 countries), and investigated time trends between 2004 and 2010 (N=9 countries). Ecological associations were assessed with Spearman’s ranked correlations (rho)


In 2010 in all vaginal deliveries, rates of severe tears ranged from 0.1% in Romania to 4.9% in Iceland, and rates of episiotomies from 3.7% in Denmark to 75.0% in Cyprus. A negative correlation between the rates of episiotomies and severe tears was observed in all deliveries (rho=-0.66; p=0.001), instrumental deliveries (rho=-0.67; p=0.002) and non-instrumental deliveries (rho=-0.72; p<0.001). However there was no relation between time trends of these two indicators (rho=0.43; p=0.28).


The large variation in severe tears and the negative association with episiotomies in 2010 show the importance of improving data on tears and evaluating the impact of low episiotomy rates on the perineum. A European protocol for diagnosis and reporting of tears would improve surveillance of maternal morbidity and assessment of the quality of obstetric care.

To learn more

Blondel B, Alexander S, Bjarnadóttir RI, Gissler M, Langhoff Roos J, Novak-Antolič Ž, Prunet C, Zhang WH, Hindori-Mohangoo AD, Zeitlin J. Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand (in press)