title: Anal sphincter lacerations and upright delivery postures--a risk analysis from a randomized controlled trial.
abstract: OBJECTIVE
  To evaluate obstetric sphincter lacerations after a kneeling or sitting position at second stage of labor in a multivariate risk analysis model.
  
  
  METHODS
  Two hundred and seventy-one primiparous women with normal pregnancies and spontaneous labor were randomized, 138 to a kneeling position and 133 to a sitting position. Medical data were retrieved from delivery charts and partograms. Risk factors were tested in a multivariate logistic regression model in a stepwise manner.
  
  
  RESULTS
  The trial was completed by 106 subjects in the kneeling group and 112 subjects in the sitting group. There were no significant differences with regard to duration of second stage of labor or pre-trial maternal characteristics between the two groups. Obstetrical sphincter tears did not differ significantly between the two groups but an intact perineum was more common in the kneeling group (p<0.03) and episiotomy (mediolateral) was more common in the sitting group (p<0.05). Three grade IV sphincter lacerations occurred in the sitting group compared to none in the kneeling group (NS). Multivariate risk analysis indicated that prolonged duration of second stage of labor and episiotomy were associated with an increased risk of third- or fourth-degree sphincter tears (p<0.01 and p<0.05, respectively). Delivery posture, maternal age, fetal weight, use of oxytocin, and use of epidural analgesia did not increase the risk of obstetrical anal sphincter lacerations in the two upright postures.
  
  
  CONCLUSIONS
  Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.
authors.affiliation: Pelvic Floor Center, Department of Obstetrics and Gynecology, Karolinska Institute Danderyd Hospital, Stockholm, Sweden. daniel.altman@ds.se
authors.forename: Daniel
authors.initials: D
authors.lastname: Altman
authors.forename: Inga
authors.initials: I
authors.lastname: Ragnar
authors.forename: Asa
authors.initials: A
authors.lastname: Ekström
authors.forename: Tanja
authors.initials: T
authors.lastname: Tydén
authors.forename: Sven-Eric
authors.initials: SE
authors.lastname: Olsson
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000293:injuries*; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods*; D004841:Episiotomy / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D022125:Lacerations / Q000453:epidemiology / Q000209:etiology*; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010502:Perineum / Q000293:injuries; D011187:Posture; D011247:Pregnancy