Women's Health

A combination of maternal, baby, and episiotomy factors contribute to high rates of maternal birth trauma in Iowa

Compared with national rates, the State of Iowa has lower rates of cesarean delivery, but higher rates of maternal trauma during birth, concludes a new study. Significant risk factors at Iowa hospitals for one type of maternal trauma—third/fourth-degree lacerations—included episiotomy (surgical incision through the perineum to enlarge the vagina to assist childbirth), artificial rupture of the amniotic membranes, obstructed labor, and late pregnancies (over 40 weeks gestation).

Disproportionately large babies were also a risk factor. Third- and fourth-degree lacerations are perineal tears that damage the anal sphincter muscles. This damage can lead to fecal incontinence, even if repaired, in some cases. The higher rates of maternal birth trauma at predominantly rural hospitals may in part be due to lack of infrastructure to perform cesareans for difficult deliveries.

Faced with borderline decisions, physicians may opt to use vacuum extraction, forceps, and episiotomy procedures, explain the University of Iowa researchers. They analyzed patient safety indicators (PSIs) from Iowa's State Inpatient Datasets for the years 2002-2004, and national data from the 2003 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. They used PSI software to identify obstetric trauma with third/fourth-degree lacerations with and without instrument assistance (PSIs #27 and #28) and to quantify cesarean delivery rates for each hospital in the Iowa and national data. They also used the PSI software to flag 29 conditions (for example, diabetes) that are potential risk factors for maternal birth trauma. In addition, they examined birth-related diagnostic codes (for example, gestational diabetes), instrument/episiotomy procedure use, and birth-related complexities (such as late pregnancy more than 40 weeks gestation) as potential risk factors.

The study was supported in part by the Agency for Healthcare Research and Quality (HS15009).

See "Factors contributing to maternal birth-related trauma," by Lance L. Roberts, M.S., John W. Ely, M.D., and Marcia M. Ward, Ph.D., in the September 2007 American Journal of Medical Quality 22(5), pp. 334-343.

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