title: Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women.
abstract: OBJECTIVE
  To identify risk factors for the development of severe perineal lacerations and to give recommendations for their prevention in nulliparous women.
  
  
  METHODS
  A retrospective case-control analysis of deliveries at our University Hospital was performed. Multiparae, Caesarean sections, twin pregnancies, fetal breech position and preterm deliveries were excluded. Univariate and multivariate step forward regression analyses were performed; correlations between contributors were further analyzed by Spearman Rank Correlation. Differences between the degree of lacerations and maternal age were further analyzed with Friedman ANOVA followed by Dunn's Multiple Comparison Test.
  
  
  RESULTS
  A total of 2,967 deliveries fitted our inclusion criteria, 50 (1.7%) mothers had higher-grade lacerations. Mediolateral and median episiotomy, advanced maternal age, vaginal operative delivery, higher fetal birth weight and abnormal cephalic presentation were associated with severe lacerations.
  
  
  CONCLUSIONS
  Advanced maternal age plays an important role in the development of anal sphincter tears in nulliparous women. Episiotomy and operative vaginal deliveries should be restrictively performed when possible. To identify further preventive approaches in patients with accumulated risk factors prospective randomized studies are needed.
authors.affiliation: Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, Luebeck, Germany.
authors.forename: Amadeus
authors.initials: A
authors.lastname: Hornemann
authors.forename: Axel
authors.initials: A
authors.lastname: Kamischke
authors.forename: Doerte W
authors.initials: DW
authors.lastname: Luedders
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Beyer
authors.forename: Klaus
authors.initials: K
authors.lastname: Diedrich
authors.forename: Michael K
authors.initials: MK
authors.lastname: Bohlmann