Subclassification of second-degree tears at delivery: creation and reported outcomes

Subclassification of second-degree tears at delivery: creation and reported outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Subclassification of second-degree tears at delivery: creation and reported outcomes EVA UUSTAL, Malin Edqvist, Anna Bonnevier, Ann Olsson, Marianne Nilsson, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5338780/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 15 You are reading this latest preprint version Abstract Background : Perineal tears at delivery are common. The current WHO classification system compacts all the varying extents of second-degree tears into one code. Some tears lead to long-term injuries. The correct identification and classification of disease is necessary for correct clinical management as well as for research. Regulatory standards govern care practices. This article describes the process of creating and testing new subclassifications for second-degree tears at delivery. Methods : The development and implementation of new subclassifications of second-degree perineal tears after delivery in Sweden are described. The new classification was tested for incidence and relevance via the national perineal laceration register (PLR) in 11203 women with prospectively recorded second degree tears. Results : Second-degree tears after delivery are subdivided into four subgroups according to the anovaginal distance and the extent in length and depth of the largest perineal/vaginal tear, which can be combined with uni-or bilateral levator ani avulsion. Women with larger second-degree tears were more likely than women with smaller tears to report complications after eight weeks (OR 1.41 CI 1.21–1.64, p < 0.001) and one year (OR 1.27, CI 1.1–1.46, p < 0.001). Conclusion : Detailed subclassifications of perineal and vaginal tears are implemented in the Swedish ICD-10 coding system and Swedish national registers. The outcomes after second-degree tears differ according to their extent, which corroborates the classification rationale. These subclassifications can be used in studies of preventive measures, treatment and patient-reported outcomes and experiences taking into account the extent of second-degree perineal tears at delivery. Trial registration Data regarding women were prospectively collected from the National perineal laceration register (PLR) from January 1, 2021, to December 31, 2022. International Classification of Diseases ICD-10-SWE Obstetric Labor Complications perineum pelvic floor Figures Figure 1 Figure 2 Figure 3 Figure 4 Highlights • Subclassification of second- degree tears at delivery has been established • Women with larger tears have larger suturing times and worse patient-reported outcomes than women with smaller tears do. Background Second-degree tears are common and can cause substantial morbidity[ 1 ]. More women experience perineal pain after a second-degree tear or an episiotomy than after an intact perineum or first‐degree tear[ 2 ]. The extent, and possible consequences, of second-degree tears vary from smeal tears in the fibrous perineum to large muscle avulsions. Perineal and vaginal tears that involve muscle attachments contribute to sexual dysfunction and are associated with an increased risk of symptomatic pelvic organ prolapse later in life, particularly rectocele[ 3 ]. Injuries affecting the anal sphincter are sometimes wrongly classified as second‐degree tears and are therefore not diagnosed and sutured correctly[ 4 , 5 ]. A perineal tear that is not found will not be repaired. The diagnostic process is influenced by systems, cognitive, teamwork, and social factors that may either enhance or reduce diagnostic accuracy[ 6 ]. If an ailment or injury is sought after by official agencies, the importance of a thorough diagnostic procedure can be highlighted. This article describes the process of creating subclassifications of second-degree tears at delivery. The second-degree subclassification was subsequently tested for differences in outcome via the perineal laceration register (PLR). The text has been written according to the SQUIRE guidelines for quality improvement studies [ 7 ]. Methods This is a descriptive account of how a subclassification of second-degree perineal delivery tears was created and tested. A comprehensive national audit about prevention, diagnostic procedures, suturing, and follow-up routines after perineal tears was performed from 2013–2014 in Sweden. This multiprofessional national audit revealed a need for training among doctors and midwives regarding both the anatomy and classification of perineal tears, corroborating international data [ 8 ]. A multidisciplinary collaboration, the Pelvic Floor Education Group (PEG), was established by the SFOG (Swedish Society of Obstetricians and Gynecologists) and the Swedish Association of Midwives. Two obstetricians, two urogynecologists and three midwives, were appointed as experts and authors. The PEG collected excellent practice and care routines from the national audit, and a systematic literature review was performed [ 9 ]. A pelvic floor educational web program with tutorials about prevention, diagnostic procedures and treatment of perineal tears was created and finally published on July 1, 2017. The program is updated yearly. The process is further described on the program website [ 10 ]. As we created the educational framework for perineal tears, the members of the PEG identified the disturbing lack of precision in the classification of second-degree tears. There is a difference between small second-degree tears involving only the fibrous tissue in the perineum and large second-degree tears involving deep paravaginal muscles and fasciae, in terms of treatment and outcome for women. This was not reflected in the earlier classification system. The PEG developed a new subclassification based on clinical experience over several meetings. We did not want an overly ambitious complex classification system detailing every anatomic structure in uni- and/or bilateral tears. Our pragmatic approach was that the longer and deeper the tear is, the more pelvic floor structures are likely to be involved. This concept was used in a previous study [ 11 ]. A three subtype-model according to the length and depth of the longest tear was discussed by the group as part of a first draft in 2018. The model was used in a clinical study, which revealed that measuring tears in centimeters was feasible for teaching and repeating [ 2 ]. We also wanted to implement mandatory bidigital anorectovaginal examination of all delivered women, and the classification was expanded to a four-subtype model to include the palpated anovaginal distance to quantify the thinnest part of the perineal body[ 12 , 13 ]. The four-subtype model was published as a preliminary classification on the program website in 2018. It was introduced by the PEG group in national lectures and meetings and revised according to suggestions from stakeholders, obstetricians and midwives. It was found important to allow classification of levator ani avulsions or deep tears, unilateral or bilateral, and these classifications were added to the subclassification in late 2018 (Table 1 ). Table 1 Second-degree perineal and vaginal tears at delivery, Swedish subclassification established 2020. Label ICD Code Description in the 2020 Swedish classification, clarification in italics Proportions grade II perineal tears in the PLR Classification code/label according to the WHO-classification ICD-11 Second degree tear O70.1 Tear of perineal muscles/ muscle insertions but not anal sphincters. Includes extension of a perineotomy. Excludes isolated vaginal tear (O71.4) The shape of the vagina is affected. N = Total 11203 JB09.1 Second degree perineal laceration involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter Small second-degree tear O70.1a Perineal tear affecting less than half the perineal body. The anovaginal distance¤ is more than one cm¤. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and can include a vaginal tear less than two cm deep. 50% (5620) No Intermediate second-degree tear O70.1b Perineal tear affecting more than half the perineal body. The anovaginal distance¤ is less than one cm. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points. Can include a vaginal tear less than two cm deep. 1% (112) No Large second degree-tear with a low vaginal tear O70.1c Perineal tear affecting the perineal body and a vaginal tear up to or four cm long, more than two cm deep. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and the rectovaginal fascia. 26% (2899) No Large second degree-tear with a high deep vaginal tear O70.1d Perineal tear affecting the perineal body and a vaginal tear more than 4 cm long, more than 2 cm deep. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and the rectovaginal fascia. 1% (135) No Unspecified second-degree tear O70.1X Other unspecified second-degree tear 22% (2437) JB09.Z Perineal laceration during delivery, unspecified Unilateral levator ani tear O70.1e Unilateral avulsion or tear of the levator ani muscles. Unilateral tear of the levator ani muscle complex ventral to the perineal plane. The muscle is avulsed from the symphysis pubis or fragmented. No data No Bilateral levator ani tear O70.1f Bilateral avulsion or tear of the levator ani muscles. Bilateral tear of the levator ani muscle complex ventral to the perineal plane. The muscle is avulsed from the symphysis pubis or fragmented. No data No Distribution regarding extent of tears from the Perineal laceration register (PLR) in 2021 and 2022, and current WHO ICD-codes • Tear-depth is measured at a right angle from the vaginal wall. • Tear-length is measured in the mucosal plane. • Only the largest tear is classified but levator ani injury codes can be added separately • Explanatory text in italics. ¤ The anovaginal distance is the bidigitally palpated shortest distance between the anal canal and the distal vaginal wall In late 2018, the classification was presented to the National Board of Health and Welfare, which in turn appointed a separate reference group of midwives, obstetricians, and generic classification experts to analyze and ratify the new subclassifications. All Swedish delivery units use the perineal laceration register (PLR) for follow-up of complications and patient-reported outcomes after obstetric anal sphincter rupture [ 14 ] and increasingly for follow-up after perineotomy and second-degree tears. The PLR was described in detail earlier [ 15 , 16 ]. Registered medical record data for 2021 and 2022 were converted into new subclasses in PLR via an algorithm for subclassification. The new subclassifications after second-degree tears were then compared to each other according to the duration of repair, patient-reported complications at eight weeks and one year, and overall patient assessment of the results. All 11203 women from hospitals using the PLR for systematic follow-up of all women after second-degree tears in 2021 and 2021 were included. Statistics: Descriptive data are presented as the means and standard deviations for continuous variables and as quantities and proportions for categorical variables. For comparisons between 2 groups, the Welch two-sample t test was used for continuous variables; for categorical variables, Fisher’s test was used to assess proportions. Risk estimates are presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs). All the statistical tests were 2-sided and had a p value < .05. The statistical analyses were conducted via the R statistical package (R version 4.3.0, 2023; R Foundation for Statistical Computing; Vienna, Austria). Results On January 1, 2020, the new subclassification sets were published by the National Board of Health and Welfare classification department. The subclassification sets with added explanatory texts were published on the Pelvic floor education website and in the national diagnosis code manual published by the SFOG in 2020.[ 10 , 17 ] The subclassification is now implemented nationally. Among the systematically registered second-degree tears, 78% could be subclassified via data from the current medical record system (Table 1 ). The questionnaire response rate for the PLR at the one-year follow-up was 69%, and it did not differ according to the extent of the tears. The subclassified tears were tested for relevance via data from the PLR. The twenty-two percent of women with tears that could not be classified due to lack of data regarding bidigital palpation (O70.1X) had durations of suturing and complication rates similar to those of women with smaller tears (O70.1A and B). (Figs. 1 – 3 ). The second-degree tears were dichotomized into larger (O70.1C and D) and smaller tears (O70. X, A and B) to allow calculation of the odds ratio. Women with larger tears were more likely than women with smaller tears to report complications after eight weeks (OR 1.49 CI 1.29–1.72, p < 0.001) and one year (OR 1.27, CI 1.1–1.46, p < 0.001). (Figs. 2 , 3 ). Overall satisfaction with the outcome one year after perineal tear was lower among women with larger tears (OR 0.87 CI 0.76–0.99 p = 0.029) (Fig. 4 ). The duration of suturing was longer for women with larger tears than for women with smaller tears (Fig. 1 ). Discussion The understanding of which specific structures are involved in obstetric tears has expanded over the last few decades. The classical concept of externally visible superficial perineal tears has evolved, and new diagnostic measures and codes now also target injuries of deeper pelvic floor structures. Our study shows that the implementation of mandatory bidigital anorectovaginal examination in Sweden has been successful. The examination as instructed in the pelvic floor education web program was documented in 78% of all delivered women. This examination is crucial for establishing the extent of deeper injuries as well as anal sphincter rupture. However, the World Health Organization (WHO) coding system, the International Classification of Diseases (ICD), has not yet been revised accordingly and does not reflect current knowledge. This was also noted by Macedo et al., who recently also established good interrater reliability of a similar classification for second-degree tears [ 18 ]. In contrast to our findings, Macedo’s group have found no significant difference in patient reported symptoms between their classification groups.[ 19 ] The reason for this may be that their classification is limited to describing the superficial perineal body, and does not take into account the deeper structures of the pelvic floor. Also, their data concerns a smaller population, 803 women compared with our dataset of 11203 women. The more extensive tears are rare, and a larger study population may be more appropriate in regard to study power. Most second-degree tears studied (73%) were small, 070.1X, A and B. Only 2% of the tears were reported to have an anovaginal distance < 1 centimeter (070.1B). This corroborates the findings that an AVD of less than one centimeter is associated with anal sphincter injury and should be uncommon in second-degree tears. [ 13 ] The outcome for rare O70.1B cases was similar to, or even better than that for O70.1A cases, indicating correct classification and suturing. Perineal tears reportedly heal well once they are found and sutured correctly. Our data show that women with larger second degree- tears have worse outcomes than those with smaller tears despite being registered in labor wards with a special interest in the follow-up. For follow-up, larger tears (070.1C and D) seem more important to monitor because of the more common complications. The codes for levator ani injury have not yet been incorporated into the current obstetric medical record systems. Levator ani injuries could be the cause of the higher rate of complications among the larger second-degree tears that require longer suturing times. A strength of the study is that it is the first large register study that describes patient-reported outcomes according to the extent of second-degree tears. It also reflects current clinical practice among Swedish midwives and doctors. Limitations of the study include the retrospective account of our endeavor to create new subclassifications, the need for which originated from a clinical perspective. Our efforts were put into creating and anchoring the concept. Designing a state-of-the-art consensus study may have improved the generalizability for other counties. Areas for future research include multivariate analyses of subclassified register data of second-degree tears in relation to prevention, treatment and patient-reported outcomes. This could provide valuable insights into the long-term effects of perineal tears. Conclusion The implementation of detailed subclassifications for second-degree tears of the pelvic floor at delivery, as well as for persisting injuries after delivery in Sweden, is a significant advancement. This underscores the importance of collaboration between obstetricians, gynecologists, midwives, and regulatory agencies in making the implementation of new classification systems possible. The subclassification for second-degree tears shows worse outcomes after larger tears and appears to be clinically relevant for both individual follow-up and future research. This not only enhances our understanding but also potentially improves care and treatment strategies for affected individuals. Abbreviations CI-confidence interval ICD - International Classification of Disease ICD-10-SWE – the Swedish Edition of the ICD-10 OR: odds ratio PEG -Pelvic Floor Education Group PLR - Perineal Laceration Register SFOG- Swedish Society of Obstetrics and Gynecology Declarations Ethics statement: The Regional Ethical Review Board in Linköping approved the study regarding PLS data retrieval on April 20th, 2016; Dnr 2016/144-31. Consent for publication: n/a Availability of data: All PLR datasets are available for research after request and ethical permit from https://www.gynop.se/home/. The data analyzed are available from the corresponding author on reasonable request. Competing interests: n/a Funding:Financial support for the author EU was received from the County Council of Östergötland and Linköping University, Sweden (ALF grants, Region Östergötland). The Pelvic Floor Education Group (PEG) collaboration and website, a part of the national project for safe delivery care, has been financed by the National Swedish Patient Insurance Company (Lof). Author contributions Eva Uustal wrote the manuscript and analyzed the register data. Malin Edqvist edited the manuscript. Both authors read and approved the final manuscript. Acknowledgments: The Pelvic floor education group, including Anna Bonnevier, Malin Edqvist, Ann Olsson, Monica Orrskog, Marianne Nilsson, Gunilla Tegerstedt, Eva Uustal and Marie Vikström Bolin, have contributed to the framework of subclassification and have anchored the delivery-code concepts in the Swedish obstetric community. Clara Nygren from the Swedish National Quality Register of Gynecological Surgery (PLR) provided PLR data. Their contributions have been invaluable in this endeavour. References Rotstein E, Åhlund S, Lindgren H, Lindén Hirschberg A, Rådestad I, Tegerstedt G. 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Edqvist M, Hildingsson I, Mollberg M, Lundgren I, Lindgren H. Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study. Birth. 2017;44(1):86–94. 10.1111/birt.12267 . Hjertberg L, Uustal E, Pihl S, Blomberg M. Maternal Body Mass Index and Anovaginal Distance in Active Phase of Term Labor. Biomed Res Int. 2018;2018:1532949. 10.1155/2018/1532949 . Pihl S, Uustal E, Blomberg M. Anovaginal distance and obstetric anal sphincter injury: a prospective observational study. Int Urogynecol J. 2019;30(6):939–44. 10.1007/s00192-018-3838-5 . Pihl S, Blomberg M, Uustal E. Internal anal sphincter injury in the immediate postpartum period; Prevalence, risk factors and diagnostic methods in the Swedish perineal laceration registry. Eur J Obstet Gynecol Reprod Biol. 2020;245:1–6. 10.1016/j.ejogrb.2019.11.030 . Otterheim M, Hjertberg L, Pihl S, Uustal E, Blomberg M. Complications 8 weeks after an obstetric second-degree perineal laceration in relation to body mass index. Int Urogynecol J. 2023. 10.1007/s00192-023-05609-y . Lindberg IPM, Nilsson M, Uustal E, Lindqvist M. Taken by surprise - Women's experiences of the first eight weeks after a second degree perineal tear at childbirth. Midwifery. 2020. https://doi.org/10.1016/j.midw.2020.1027 . Pihl K. Diagnoshandbok för Kvinnosjukvården. Sixth edition ed. Stockholm: SFOG; 2020. Macedo MD, Ellström Engh M, Siafarikas F. Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study. Acta Obstet Gynecol Scand. 2022;101(8):880–8. 10.1111/aogs.14369 . Macedo MD, Risløkken J, Rotstein E, Benth J, Ellström Engh M, Siafarikas F. Pelvic floor symptoms according to the severity of second-degree perineal tears within 12 months post-partum: A longitudinal prospective cohort study. Acta Obstet Gynecol Scand. 2024;103(7):1366–76. 10.1111/aogs.14854 . Additional Declarations No competing interests reported. Supplementary Files Supportinginformationquestionnaires.docx Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 02 Dec, 2024 Reviews received at journal 01 Dec, 2024 Reviews received at journal 26 Nov, 2024 Reviews received at journal 25 Nov, 2024 Reviewers agreed at journal 17 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 13 Nov, 2024 Reviews received at journal 13 Nov, 2024 Reviewers agreed at journal 13 Nov, 2024 Reviewers agreed at journal 12 Nov, 2024 Reviewers invited by journal 11 Nov, 2024 Editor invited by journal 28 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 28 Oct, 2024 First submitted to journal 26 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Medians and 10th and 90th percentiles.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/cbd7a6bffc129928e0dae81c.png"},{"id":69354023,"identity":"e22da2cb-7e43-447a-a48d-c377e9f2499a","added_by":"auto","created_at":"2024-11-19 13:33:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32840,"visible":true,"origin":"","legend":"\u003cp\u003ePatient-reported complications eight weeks after second-degree tears according to subclassification.\u003c/p\u003e\n\u003cp\u003eLegend: Perineal laceration register data from 2021 and 2022. Medians and 10th and 90th percentiles.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/1bc6f1c4f41f2f769310871f.png"},{"id":69354022,"identity":"43c47421-e321-40f7-9154-8358519f4c69","added_by":"auto","created_at":"2024-11-19 13:33:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":43982,"visible":true,"origin":"","legend":"\u003cp\u003ePatient-reported complications one year after second-degree tears according to subclassification.\u003c/p\u003e\n\u003cp\u003eLegend: Perineal laceration register data from 2021 and 2022. Medians and 10th and 90th percentiles.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/f64c02f81c01b33a6d70fcec.png"},{"id":69354024,"identity":"2a0f4e9c-a340-484d-bdef-96b381c7b94a","added_by":"auto","created_at":"2024-11-19 13:33:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":37698,"visible":true,"origin":"","legend":"\u003cp\u003ePatient overall assessment of the results of second-degree perineal repair according to subclassification.\u003c/p\u003e\n\u003cp\u003eLegend: The black line denotes the proportion of women reporting good or very good assessments one year postpartum. Perineal laceration register data from 2021 and 2022.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/2c931d01be06e120539bd173.png"},{"id":78688992,"identity":"c6ace709-e31b-4e7d-bc6b-e7fd9b05140a","added_by":"auto","created_at":"2025-03-17 16:09:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725106,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/2ad462ac-7330-4380-8a6b-e1b3d4f1e58c.pdf"},{"id":69354025,"identity":"fa900e16-221c-4188-ad5e-5284e37d0ffe","added_by":"auto","created_at":"2024-11-19 13:33:18","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":12456,"visible":true,"origin":"","legend":"","description":"","filename":"Supportinginformationquestionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-5338780/v1/0192cb7ce7b39965fa724422.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Subclassification of second-degree tears at delivery: creation and reported outcomes","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; Subclassification of second- degree tears at delivery has been established\u003c/p\u003e\u003cp\u003e\u0026bull; Women with larger tears have larger suturing times and worse patient-reported outcomes than women with smaller tears do.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eSecond-degree tears are common and can cause substantial morbidity[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. More women experience perineal pain after a second-degree tear or an episiotomy than after an intact perineum or first‐degree tear[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The extent, and possible consequences, of second-degree tears vary from smeal tears in the fibrous perineum to large muscle avulsions. Perineal and vaginal tears that involve muscle attachments contribute to sexual dysfunction and are associated with an increased risk of symptomatic pelvic organ prolapse later in life, particularly rectocele[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Injuries affecting the anal sphincter are sometimes wrongly classified as second‐degree tears and are therefore not diagnosed and sutured correctly[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A perineal tear that is not found will not be repaired. The diagnostic process is influenced by systems, cognitive, teamwork, and social factors that may either enhance or reduce diagnostic accuracy[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. If an ailment or injury is sought after by official agencies, the importance of a thorough diagnostic procedure can be highlighted.\u003c/p\u003e \u003cp\u003eThis article describes the process of creating subclassifications of second-degree tears at delivery. The second-degree subclassification was subsequently tested for differences in outcome via the perineal laceration register (PLR).\u003c/p\u003e \u003cp\u003eThe text has been written according to the SQUIRE guidelines for quality improvement studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThis is a descriptive account of how a subclassification of second-degree perineal delivery tears was created and tested. A comprehensive national audit about prevention, diagnostic procedures, suturing, and follow-up routines after perineal tears was performed from 2013\u0026ndash;2014 in Sweden. This multiprofessional national audit revealed a need for training among doctors and midwives regarding both the anatomy and classification of perineal tears, corroborating international data [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A multidisciplinary collaboration, the Pelvic Floor Education Group (PEG), was established by the SFOG (Swedish Society of Obstetricians and Gynecologists) and the Swedish Association of Midwives. Two obstetricians, two urogynecologists and three midwives, were appointed as experts and authors. The PEG collected excellent practice and care routines from the national audit, and a systematic literature review was performed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A pelvic floor educational web program with tutorials about prevention, diagnostic procedures and treatment of perineal tears was created and finally published on July 1, 2017. The program is updated yearly. The process is further described on the program website [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs we created the educational framework for perineal tears, the members of the PEG identified the disturbing lack of precision in the classification of second-degree tears. There is a difference between small second-degree tears involving only the fibrous tissue in the perineum and large second-degree tears involving deep paravaginal muscles and fasciae, in terms of treatment and outcome for women. This was not reflected in the earlier classification system.\u003c/p\u003e \u003cp\u003eThe PEG developed a new subclassification based on clinical experience over several meetings. We did not want an overly ambitious complex classification system detailing every anatomic structure in uni- and/or bilateral tears. Our pragmatic approach was that the longer and deeper the tear is, the more pelvic floor structures are likely to be involved. This concept was used in a previous study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A three subtype-model according to the length and depth of the longest tear was discussed by the group as part of a first draft in 2018. The model was used in a clinical study, which revealed that measuring tears in centimeters was feasible for teaching and repeating [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. We also wanted to implement mandatory bidigital anorectovaginal examination of all delivered women, and the classification was expanded to a four-subtype model to include the palpated anovaginal distance to quantify the thinnest part of the perineal body[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe four-subtype model was published as a preliminary classification on the program website in 2018. It was introduced by the PEG group in national lectures and meetings and revised according to suggestions from stakeholders, obstetricians and midwives. It was found important to allow classification of levator ani avulsions or deep tears, unilateral or bilateral, and these classifications were added to the subclassification in late 2018 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSecond-degree perineal and vaginal tears at delivery, Swedish subclassification established 2020.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICD Code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription in the 2020 Swedish classification, clarification in italics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProportions grade II perineal tears in the PLR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClassification code/label according to the WHO-classification ICD-11\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSecond degree tear\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eO70.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTear of perineal muscles/ muscle insertions but not anal sphincters.\u003c/p\u003e \u003cp\u003e\u003cem\u003eIncludes extension of a perineotomy. Excludes isolated vaginal tear (O71.4) The shape of the vagina is affected.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;Total 11203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJB09.1 Second degree perineal laceration involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall second-degree tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerineal tear affecting less than half the perineal body. \u003cem\u003eThe anovaginal distance\u0026curren; is more than one cm\u0026curren;. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and can include a vaginal tear less than two cm deep.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50% (5620)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate second-degree tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerineal tear affecting more than half the perineal body. \u003cem\u003eThe anovaginal distance\u0026curren; is less than one cm. The tear affects the bulbocavernosus, transverse perineal muscles or their insertion points. Can include a vaginal tear less than two cm deep.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1% (112)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge second degree-tear\u003c/p\u003e \u003cp\u003ewith a low vaginal tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerineal tear affecting the perineal body and a vaginal tear up to or four cm long, more than two cm deep. \u003cem\u003eThe tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and the rectovaginal fascia.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26% (2899)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge second degree-tear with a high deep vaginal tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerineal tear affecting the perineal body and a vaginal tear more than 4 cm long, more than 2 cm deep. \u003cem\u003eThe tear affects the bulbocavernosus, transverse perineal muscles or their insertion points and the rectovaginal fascia.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1% (135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnspecified second-degree tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1X\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther unspecified second-degree tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22% (2437)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJB09.Z Perineal laceration during delivery, unspecified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral levator ani tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnilateral avulsion or tear of the levator ani muscles. \u003cem\u003eUnilateral tear of the levator ani muscle complex ventral to the perineal plane. The muscle is avulsed from the symphysis pubis or fragmented.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral levator ani tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO70.1f\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBilateral avulsion or tear of the levator ani muscles. \u003cem\u003eBilateral tear of the levator ani muscle complex ventral to the perineal plane. The muscle is avulsed from the symphysis pubis or fragmented.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eDistribution regarding extent of tears from the Perineal laceration register (PLR) in 2021 and 2022, and current WHO ICD-codes\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Tear-depth is measured at a right angle from the vaginal wall.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Tear-length is measured in the mucosal plane.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Only the largest tear is classified but levator ani injury codes can be added separately\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Explanatory text in italics.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u0026curren;\u003c/sup\u003eThe anovaginal distance is the bidigitally palpated shortest distance between the anal canal and the distal vaginal wall\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn late 2018, the classification was presented to the National Board of Health and Welfare, which in turn appointed a separate reference group of midwives, obstetricians, and generic classification experts to analyze and ratify the new subclassifications.\u003c/p\u003e \u003cp\u003eAll Swedish delivery units use the perineal laceration register (PLR) for follow-up of complications and patient-reported outcomes after obstetric anal sphincter rupture [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and increasingly for follow-up after perineotomy and second-degree tears. The PLR was described in detail earlier [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Registered medical record data for 2021 and 2022 were converted into new subclasses in PLR via an algorithm for subclassification. The new subclassifications after second-degree tears were then compared to each other according to the duration of repair, patient-reported complications at eight weeks and one year, and overall patient assessment of the results. All 11203 women from hospitals using the PLR for systematic follow-up of all women after second-degree tears in 2021 and 2021 were included.\u003c/p\u003e \u003cp\u003eStatistics:\u003c/p\u003e \u003cp\u003eDescriptive data are presented as the means and standard deviations for continuous variables and as quantities and proportions for categorical variables. For comparisons between 2 groups, the Welch two-sample t test was used for continuous variables; for categorical variables, Fisher\u0026rsquo;s test was used to assess proportions. Risk estimates are presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs). All the statistical tests were 2-sided and had a p value\u0026thinsp;\u0026lt;\u0026thinsp;.05. The statistical analyses were conducted via the R statistical package (R version 4.3.0, 2023; R Foundation for Statistical Computing; Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOn January 1, 2020, the new subclassification sets were published by the National Board of Health and Welfare classification department. The subclassification sets with added explanatory texts were published on the Pelvic floor education website and in the national diagnosis code manual published by the SFOG in 2020.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] The subclassification is now implemented nationally.\u003c/p\u003e \u003cp\u003eAmong the systematically registered second-degree tears, 78% could be subclassified via data from the current medical record system (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The questionnaire response rate for the PLR at the one-year follow-up was 69%, and it did not differ according to the extent of the tears.\u003c/p\u003e \u003cp\u003eThe subclassified tears were tested for relevance via data from the PLR. The twenty-two percent of women with tears that could not be classified due to lack of data regarding bidigital palpation (O70.1X) had durations of suturing and complication rates similar to those of women with smaller tears (O70.1A and B). (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The second-degree tears were dichotomized into larger (O70.1C and D) and smaller tears (O70. X, A and B) to allow calculation of the odds ratio. Women with larger tears were more likely than women with smaller tears to report complications after eight weeks (OR 1.49 CI 1.29\u0026ndash;1.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and one year (OR 1.27, CI 1.1\u0026ndash;1.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Overall satisfaction with the outcome one year after perineal tear was lower among women with larger tears (OR 0.87 CI 0.76\u0026ndash;0.99 p\u0026thinsp;=\u0026thinsp;0.029) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The duration of suturing was longer for women with larger tears than for women with smaller tears (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe understanding of which specific structures are involved in obstetric tears has expanded over the last few decades. The classical concept of externally visible superficial perineal tears has evolved, and new diagnostic measures and codes now also target injuries of deeper pelvic floor structures. Our study shows that the implementation of mandatory bidigital anorectovaginal examination in Sweden has been successful. The examination as instructed in the pelvic floor education web program was documented in 78% of all delivered women. This examination is crucial for establishing the extent of deeper injuries as well as anal sphincter rupture. However, the World Health Organization (WHO) coding system, the International Classification of Diseases (ICD), has not yet been revised accordingly and does not reflect current knowledge. This was also noted by Macedo et al., who recently also established good interrater reliability of a similar classification for second-degree tears [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In contrast to our findings, Macedo\u0026rsquo;s group have found no significant difference in patient reported symptoms between their classification groups.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] The reason for this may be that their classification is limited to describing the superficial perineal body, and does not take into account the deeper structures of the pelvic floor. Also, their data concerns a smaller population, 803 women compared with our dataset of 11203 women. The more extensive tears are rare, and a larger study population may be more appropriate in regard to study power.\u003c/p\u003e \u003cp\u003eMost second-degree tears studied (73%) were small, 070.1X, A and B. Only 2% of the tears were reported to have an anovaginal distance\u0026thinsp;\u0026lt;\u0026thinsp;1 centimeter (070.1B). This corroborates the findings that an AVD of less than one centimeter is associated with anal sphincter injury and should be uncommon in second-degree tears. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The outcome for rare O70.1B cases was similar to, or even better than that for O70.1A cases, indicating correct classification and suturing.\u003c/p\u003e \u003cp\u003ePerineal tears reportedly heal well once they are found and sutured correctly. Our data show that women with larger second degree- tears have worse outcomes than those with smaller tears despite being registered in labor wards with a special interest in the follow-up. For follow-up, larger tears (070.1C and D) seem more important to monitor because of the more common complications. The codes for levator ani injury have not yet been incorporated into the current obstetric medical record systems. Levator ani injuries could be the cause of the higher rate of complications among the larger second-degree tears that require longer suturing times.\u003c/p\u003e \u003cp\u003eA strength of the study is that it is the first large register study that describes patient-reported outcomes according to the extent of second-degree tears. It also reflects current clinical practice among Swedish midwives and doctors. Limitations of the study include the retrospective account of our endeavor to create new subclassifications, the need for which originated from a clinical perspective. Our efforts were put into creating and anchoring the concept. Designing a state-of-the-art consensus study may have improved the generalizability for other counties.\u003c/p\u003e \u003cp\u003eAreas for future research include multivariate analyses of subclassified register data of second-degree tears in relation to prevention, treatment and patient-reported outcomes. This could provide valuable insights into the long-term effects of perineal tears.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe implementation of detailed subclassifications for second-degree tears of the pelvic floor at delivery, as well as for persisting injuries after delivery in Sweden, is a significant advancement. This underscores the importance of collaboration between obstetricians, gynecologists, midwives, and regulatory agencies in making the implementation of new classification systems possible. The subclassification for second-degree tears shows worse outcomes after larger tears and appears to be clinically relevant for both individual follow-up and future research. This not only enhances our understanding but also potentially improves care and treatment strategies for affected individuals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI-confidence interval\u003c/p\u003e\n\u003cp\u003eICD - International Classification of Disease\u003c/p\u003e\n\u003cp\u003eICD-10-SWE \u0026ndash; the Swedish Edition of the ICD-10\u003c/p\u003e\n\u003cp\u003eOR: odds ratio\u003c/p\u003e\n\u003cp\u003ePEG -Pelvic Floor Education Group\u003c/p\u003e\n\u003cp\u003ePLR - Perineal Laceration Register\u003c/p\u003e\n\u003cp\u003eSFOG- Swedish Society of Obstetrics and Gynecology\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics statement: The Regional Ethical Review Board in Linköping approved the study regarding PLS data retrieval on April 20th, 2016; Dnr 2016/144-31.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: n/a\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data: All PLR datasets are available for research after request and ethical permit from https://www.gynop.se/home/. The data analyzed are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: n/a\u003c/p\u003e\n\u003cp\u003eFunding:Financial support for the author EU was received from the County Council of Östergötland and Linköping University, Sweden (ALF grants, Region Östergötland). The Pelvic Floor Education Group (PEG) collaboration and website, a part of the national project for safe delivery care, has been financed by the National Swedish Patient Insurance Company (Lof).\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eEva Uustal wrote the manuscript and analyzed the register data. Malin Edqvist edited the manuscript.\u0026nbsp;Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments:\u003c/p\u003e\n\u003cp\u003eThe Pelvic floor education group, including Anna Bonnevier, Malin Edqvist, Ann Olsson, Monica Orrskog, Marianne Nilsson, Gunilla Tegerstedt, Eva Uustal and Marie Vikström Bolin, have contributed to the framework of subclassification and have anchored the delivery-code concepts in the Swedish obstetric community. Clara Nygren from the Swedish National Quality Register of Gynecological Surgery (PLR) provided PLR data. Their contributions have been invaluable in this endeavour.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRotstein E, \u0026Aring;hlund S, Lindgren H, Lind\u0026eacute;n Hirschberg A, R\u0026aring;destad I, Tegerstedt G. Posterior compartment symptoms in primiparous women 1 year after non-assisted vaginal deliveries: a Swedish cohort study. 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Acta Obstet Gynecol Scand. 2024;103(7):1366\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/aogs.14854\u003c/span\u003e\u003cspan address=\"10.1111/aogs.14854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"International Classification of Diseases, ICD-10-SWE, Obstetric Labor Complications, perineum, pelvic floor","lastPublishedDoi":"10.21203/rs.3.rs-5338780/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5338780/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003ePerineal tears at delivery are common. The current WHO classification system compacts all the varying extents of second-degree tears into one code. Some tears lead to long-term injuries. The correct identification and classification of disease is necessary for correct clinical management as well as for research. Regulatory standards govern care practices. This article describes the process of creating and testing new subclassifications for second-degree tears at delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe development and implementation of new subclassifications of second-degree perineal tears after delivery in Sweden are described. The new classification was tested for incidence and relevance via the national perineal laceration register (PLR) in 11203 women with prospectively recorded second degree tears.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eSecond-degree tears after delivery are subdivided into four subgroups according to the anovaginal distance and the extent in length and depth of the largest perineal/vaginal tear, which can be combined with uni-or bilateral levator ani avulsion. Women with larger second-degree tears were more likely than women with smaller tears to report complications after eight weeks (OR 1.41 CI 1.21–1.64, p \u0026lt; 0.001) and one year (OR 1.27, CI 1.1–1.46, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eDetailed subclassifications of perineal and vaginal tears are implemented in the Swedish ICD-10 coding system and Swedish national registers. The outcomes after second-degree tears differ according to their extent, which corroborates the classification rationale. These subclassifications can be used in studies of preventive measures, treatment and patient-reported outcomes and experiences taking into account the extent of second-degree perineal tears at delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData regarding women were prospectively collected from the National perineal laceration register (PLR) from January 1, 2021, to December 31, 2022.\u003c/p\u003e","manuscriptTitle":"Subclassification of second-degree tears at delivery: creation and reported outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 13:33:01","doi":"10.21203/rs.3.rs-5338780/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-02T18:02:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-01T11:58:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-26T19:18:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-26T01:11:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70063308316707081577464249114258487842","date":"2024-11-17T14:50:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283525324706473793293148666059895224610","date":"2024-11-14T08:42:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21501927028792820773893136768465688416","date":"2024-11-13T21:07:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-13T09:48:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84903354926762164950809995204252352837","date":"2024-11-13T09:21:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20441312026819440943164971654089242304","date":"2024-11-12T07:46:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-11T15:42:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-28T16:08:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T05:28:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-28T05:28:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-10-26T18:25:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e704242-ed13-473f-b61c-318fadc7c0d9","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:02:28+00:00","versionOfRecord":{"articleIdentity":"rs-5338780","link":"https://doi.org/10.1186/s12884-025-07371-z","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-03-11 15:57:48","publishedOnDateReadable":"March 11th, 2025"},"versionCreatedAt":"2024-11-19 13:33:01","video":"","vorDoi":"10.1186/s12884-025-07371-z","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07371-z","workflowStages":[]},"version":"v1","identity":"rs-5338780","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5338780","identity":"rs-5338780","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}