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The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non\u2010instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third\u2010 or fourth\u2010degree perineal tears was associated with a maternal age above 25\u00a0years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio\u2010economic status, higher birthweight, and shoulder dystocia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Changes in major risk factors are unlikely explanations for the observed increase in the rate of third\u2010 or fourth\u2010degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1471-0528.12363","type":"journal-article","created":{"date-parts":[[2013,7,3]],"date-time":"2013-07-03T04:22:51Z","timestamp":1372825371000},"page":"1516-1525","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":354,"title":["Third\u2010 and fourth\u2010degree perineal tears among primiparous women in\n                    <scp>E<\/scp>\n                    ngland between 2000 and 2012: time trends and risk factors"],"prefix":"10.1111","volume":"120","author":[{"given":"I","family":"Gurol\u2010Urganci","sequence":"first","affiliation":[{"name":"Department of Health Services Research and Policy London School of Hygiene and Tropical Medicine London UK"},{"name":"Office for Research and Clinical Audit Lindsay Stewart R&amp;D Centre Royal College of Obstetricians and Gynaecologists (RCOG) London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"DA","family":"Cromwell","sequence":"additional","affiliation":[{"name":"Department of Health Services Research and Policy London School of Hygiene and Tropical Medicine London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"LC","family":"Edozien","sequence":"additional","affiliation":[{"name":"Maternal and Fetal Health Research Manchester Academic Health Sciences Centre University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"TA","family":"Mahmood","sequence":"additional","affiliation":[{"name":"Office for Research and Clinical Audit Lindsay Stewart R&amp;D Centre Royal College of Obstetricians and Gynaecologists (RCOG) London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"EJ","family":"Adams","sequence":"additional","affiliation":[{"name":"Department of Urogynaecology Liverpool Women's NHS Foundation Trust Liverpool UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"DH","family":"Richmond","sequence":"additional","affiliation":[{"name":"Office for Research and Clinical Audit Lindsay Stewart R&amp;D Centre Royal College of Obstetricians and Gynaecologists (RCOG) London UK"},{"name":"Department of Urogynaecology Liverpool Women's NHS Foundation Trust Liverpool UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A","family":"Templeton","sequence":"additional","affiliation":[{"name":"Office for Research and Clinical Audit Lindsay Stewart R&amp;D Centre Royal College of Obstetricians and Gynaecologists (RCOG) London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"JH","family":"van der Meulen","sequence":"additional","affiliation":[{"name":"Department of Health Services Research and Policy London School of Hygiene and Tropical Medicine London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2013,7,3]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e3181e2f50b"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1080\/00016340802030629"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2009.04.033"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1701-2163(16)31018-0"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ypmed.2009.10.005"},{"key":"e_1_2_7_7_1","unstructured":"TyagiV PereraM GuerreroK.Trends in obstetric anal sphincter injuries over 10 years\u2010incidence and risk factors. 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