The recently published article by Muraca and colleagues (1) highlights some key aspects of discussion and counselling around assisted vaginal birth. However, we have concerns regarding the study methodology and conclusions, which do not align with the reality and complexities of clinical intrapartum care.
Validation of the data set used by Muraca and colleagues includes only small-scale, noncontemporaneous, province-specific studies. The individual components included within the composite maternal trauma outcome are missing published, objective indicators of maternal trauma, including postpartum hemorrhage, requirement for blood transfusion and intensive care admission, which reflect true maternal morbidity. (2) The conclusions drawn by the authors stem from their findings of increased rates of third-degree perineal lacerations. However, we reject the notion that the most common type of laceration, a 3A tear (which involves disruption of the superficial fibres of the external anal sphincter), should be aggregated with the less common, but potentially disabling, disruption of both the external and internal anal sphincters (3C tear) or of the entire anal sphincter complex (fourth-degree tear), which have significantly different short- and long-term outcomes. (3) Defining terms and using appropriate...