What actually predicts a second-degree tear breaking down

Design

Secondary analysis of a single-centre randomised controlled trial, analysed as one cohort

Population

442 women with second-degree perineal tear or episiotomy, Denmark, March-December 2023

Primary outcome

Clinically relevant perineal wound complication at initial consultation

Effect

55/433 (12.7%) affected; prolonged active second stage aOR 2.25 (95% CI 1.11-4.46), deep tear aOR 2.11 (1.10-4.24), prophylactic amoxicillin-clavulanic acid aOR 0.34 (0.18-0.65)

Perineal wound complications have mostly been studied after obstetric anal sphincter injury. This secondary analysis of the Danish REPAIR trial looked at the far commoner group: 442 women with a second-degree tear or episiotomy at a university hospital in the Capital Region of Denmark, randomised to prophylactic antibiotics or placebo and here analysed as one cohort.

Of the 433 who attended the initial consultation, 55 — 12.7% — had a clinically relevant wound complication. On multivariable analysis, prolonged active second stage of labour (adjusted odds ratio 2.25, 95% CI 1.11 to 4.46) and deep tear (aOR 2.11, 95% CI 1.10 to 4.24) were associated with complication. Prophylactic amoxicillin-clavulanic acid was protective (aOR 0.34, 95% CI 0.18 to 0.65). Doctor involvement in suturing was also associated (aOR 2.47, 95% CI 1.20 to 4.96), which the authors themselves read as probable residual confounding by tear complexity — the doctor gets called to the harder repair.

Episiotomy did not reach independent significance (aOR 2.01, 95% CI 0.92 to 4.21) and was kept in the model on prior evidence rather than on this result.

The practical yield is triage of follow-up. A one in eight complication rate in a group usually discharged without a plan is the argument for looking harder at the women who had a long second stage and a deep tear.

• Record duration of active second stage in the notes as a follow-up flag, not just as a labour outcome
• A deep second-degree tear deserves the same follow-up thought as a third-degree one
• Offer a defined review to women with a long second stage plus a deep tear rather than open-access advice
• Do not read 'doctor sutured' as a quality signal — the harder repairs get referred up
• 12.7% is the number to quote when a woman asks how often these break down

Why it matters

A one-in-eight complication rate sits in a group most units discharge without any perineal follow-up at all.

Don't overread it

This was a secondary, exploratory analysis of a single-centre trial; the risk factors are associations, not a validated prediction rule.

The statistics, in plain English

These are adjusted odds ratios from an exploratory model, and the confidence intervals are wide — 1.11 to 4.46 for prolonged second stage means the true effect could be a fifth the size of the point estimate. The episiotomy interval crosses 1.0 (0.92 to 4.21), so this cohort cannot say episiotomy independently raises the risk. The antibiotic result comes from the randomised comparison inside the parent trial and is the most reliable number here.

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