Evaluation of third-degree and fourth-degree laceration rates as quality indicators.
OBJECTIVE
To examine the patterns and predictors of third-degree and fourth-degree laceration in women undergoing vaginal delivery.


METHODS
We identified a population-based cohort of women in the United States who underwent a vaginal delivery between 1998 and 2010 using the Nationwide Inpatient Sample. Multivariable log-linear regression models were developed to account for patient, obstetric, and hospital factors related to lacerations. Between-hospital variability of laceration rates was calculated using generalized log-linear mixed models.


RESULTS
Among 7,096,056 women who underwent vaginal delivery in 3,070 hospitals, 3.3% (n=232,762) had a third-degree laceration and 1.1% (n=76,347) had a fourth-degree laceration. In an adjusted model for fourth-degree lacerations, important risk factors included shoulder dystocia and forceps and vacuum deliveries with and without episiotomy. Other demographic, obstetric, medical, and hospital variables, although statistically significant, were not major determinants of lacerations. Risk factors in a multivariable model for third-degree lacerations were similar to those in the fourth-degree model. Regression analysis of hospital rates (n=3,070) of lacerations demonstrated limited between-hospital variation.


CONCLUSIONS
Risk of third-degree and fourth-degree laceration was most strongly related to operative delivery and shoulder dystocia. Between-hospital variation was limited. Given these findings and that the most modifiable practice related to lacerations would be reduction in operative vaginal deliveries (and a possible increase in cesarean delivery), third-degree and fourth-degree laceration rates may be a quality metric of limited utility.
Divisions of Maternal-Fetal Medicine and Gynecologic Oncology, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and the Department of Epidemiology, Mailman School of Public Health, Columbia University, and New York Presbyterian Hospital, New York, New York.
Alexander M
AM
Friedman
Cande V
CV
Ananth
Eri
E
Prendergast
Mary E
ME
D'Alton
Jason D
JD
Wright
D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D001003:Anal Canal / Q000293:injuries*; D004420:Dystocia / Q000453:epidemiology; D004461:Eclampsia / Q000453:epidemiology; D004841:Episiotomy / Q000706:statistics & numerical data; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D022125:Lacerations / Q000453:epidemiology* / Q000209:etiology*; D010502:Perineum / Q000293:injuries*; D011225:Pre-Eclampsia / Q000453:epidemiology; D011247:Pregnancy; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D015599:Trauma Severity Indices; D014481:United States / Q000453:epidemiology; D014620:Vacuum Extraction, Obstetrical / Q000706:statistics & numerical data; D055815:Young Adult