Die Episiotomie

Episiotomy is the most commonly performed surgical procedure in obstetrics. There are many purported benefits such as prevention of trauma to the pelvic floor, prevention of severe perineal tears and third-degree and fourth-degree lacerations, shortening of the second stage of labour, reduced compression to the foetal head and enlargement of the vaginal outlet. This belief resulted in various indications for episiotomy: perineal or vaginal tears presumed to be imminent, prolonged second stage of labour in the case of foetal distress, breech delivery and other foetal malpresentations (i.e. occiput malpresentation), assisted delivery (vacuum and forceps extraction), and propyhlactic use of episiotomy (routine episiotomy). However, there is little scientific evidence to support the ascribed benefits. There are only few indications for an episiotomy with proved benefit for mother or child. Liberal use of episiotomy does not decrease trauma to the pelvic floor and its sequelae such as urinary incontinence, anal incontinence or pelvic floor relaxation. Compared to spontaneous tears, episiotomy is not associated with improved wound healing. Routine use of episiotomy, therefore, should be avoided; the indication for an episiotomy should be determined individually on a case-by-case basis.     

Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States

OBJECTIVE: The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy. STUDY DESIGN: From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome. RESULTS: Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P<.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P<.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage. CONCLUSION: Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.     

Vaginale Geburt

Postpartal stress incontinence occurs in 0.7–35% of cases. Approximately 10% of women have persistent symptoms of anorectal incontinence. A third-degree perineal tear leads to incontinence problems in 20–50% of cases. Individual constitution of the connective tissue, further vaginal deliveries and age of the patient determine the risk of deterioration. An episiotomy does not reduce the occurrence of either incontinence or genital prolapse. Greater perineal damage occurs more often after episiotomy than with no episiotomy. We should therefore consider a very strict policy regarding episiotomy in the future. Patients with symptoms of pelvic floor weakness or insufficiency should be thoroughly examined and informed before any further pregnancies or deliveries are undertaken. Forty percent of women with occult anal sphincter lesions will develop an anal weakness after delivery of a second child. Forceps delivery is the most traumatic mode of delivery for the mother. The significance of an epidural anaesthetic has not yet been clarified. In the literature, the trend is toward recommending antenatal consultation regarding elective cesarian section in cases of pelvic floor insufficiency.     

Minimizing genital tract trauma and related pain following spontaneous vaginal birth

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.     

The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery

OBJECTIVE: To evaluate the effect of mediolateral episiotomy on puerperal pelvic floor strength and dysfunction (urinary and anal incontinence, genital prolapse). METHODS: Five hundred nineteen primiparous women were enrolled 3 months after vaginal delivery. Puerperae were divided in 2 groups: group A (254 women) comprised the women who received mediolateral episiotomy and group B (265 women) the women with intact perineum and first- and second-degree spontaneous perineal lacerations. Each woman was questioned about urogynecological symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. Data were subjected to Student t test and Fisher exact test to assess, respectively, the difference between the mean values and the proportions within the subpopulations. Using a simple logistic regression model to test an estimate of relative risk, we expressed the odds ratios of the variables considered with respect to the control population (group B). RESULTS: No significant difference was found with regard to the incidence of urinary and anal incontinence and genital prolapse, whereas dyspareunia and perineal pain were significantly higher in the episiotomy group (7.9% versus 3.4%, P =.026; 6.7% versus 2.3%, P =.014, respectively). Episiotomy was associated with significantly lower values, both in digital test (2.2 versus 2.6; P <.001) and in vaginal manometry (12.2 versus 13.8 cm water; P <.001), but not in uroflowmetric stop test. CONCLUSION: Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain. LEVEL OF EVIDENCE: II-2     

Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types

OBJECTIVE: To determine the risk factors for third-degree perineal tears during vaginal delivery and to investigate the relation between different types of episiotomy and the occurrence of such tears. STUDY DESIGN: This retrospective multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and Semmelweis Frauenklinic Wien between February and July 1999. The study was restricted to a sample that included all women with uncomplicated pregnancy as well as uncomplicated first and second stages of labor, gestational age > 37 weeks and a pregnancy with cephalic presentation. Women with multiple gestations, noncephalic presentation, cesarean deliveries, shoulder dystocia and gestational age < or = 37 weeks were excluded from the study. RESULTS: Among the 1,118 births, 37 women (3.3%) experienced third-degree perineal tears. The use of episiotomy per se and the type of episiotomy (midline) as well as forceps delivery, primiparity, large infant head diameter, prolonged second stage of labor and use of oxytocin were identified as risk factors for third-degree perineal tears during vaginal delivery. When analyzing different types of episiotomy, there was approximately a sixfold-higher risk of third-degree perineal tears in women undergoing midline episiotomy as compared to mediolateral episiotomy. A stepwise logistic regression analysis revealed that episiotomy, prolonged second stage of labor and large infant head diameter remained independent risk factors for third-degree perineal tears. CONCLUSION: We found several risk factors for third-degree perineal tears. The use of midline episiotomy was associated especially with an increased risk of severe anal sphincter tears. To prevent women from long-term sequelae due to third-degree perineal tears, avoidable risk factors should be minimized whenever possible.     

Effectiveness of local anaesthetics with and without vasoconstrictors for perineal repair during spontaneous delivery: double-blind randomised controlled trial

Objective

to investigate the use of local anaesthetics, in the presence or absence of vasoconstrictors, for perineal repair during spontaneous delivery.

Design

double-blind, randomised-controlled trial.

Setting

a birth centre, in the city of Sao Paulo, Brazil.

Participants

from June to December 2004, a total of 96 women were allocated into three groups (first-degree perineal lacerations, second-degree perineal lacerations or episiotomy), and treated with local anaesthesia (1% lidocaine or 1% lidocaine with epinephrine) (n=16 per treatment per group).

Interventions

an initial local infiltration of the anaesthetic solution was given so that episiotomy could be carried out (5 ml) and to suture spontaneous lacerations (1 ml), followed by repeated doses (1 ml) until pain was completely inhibited.

Measurements and findings

the main outcome measurement was the volume of anaesthetic used during episiotomy and perineal suture. Our data suggest that the concomitant use of the vasoconstrictor resulted in a significantly lower average volume used in the treatment of first-degree (1 ml, 95% confidence interval (CI) 0.4–1.6) and second-degree (3.7 ml, 95% CI 1.6–5.8) lacerations (p=0.002 and 0.001, respectively). A 0.3 ml (95% CI 1.5–2.1) average decrease in anaesthetic volume was observed with episiotomy (p=0.724). The maximum volume of anaesthetic used with and without vasoconstrictor was 1–2 ml in 95% and 3–4 ml in 50% of first-degree lacerations, respectively, and 1–6 ml in 88% and 7–15 ml in 81% of second-degree lacerations, respectively. For episiotomy, the maximum dose was 15 ml, regardless of anaesthetic solution used.

Key conclusions

our data confirm the hypothesis that the use of anaesthetics in conjunction with vasoconstrictors is more effective than anaesthetics alone in the repair of perineal lacerations, but not for episiotomy.     

Severe perineal lacerations in nulliparous women and episiotomy type

OBJECTIVE: To determine the patient-related factors associated with severe perineal lacerations in nulliparous women and to evaluate the effect of episiotomy type on the risk of severe perineal tears. STUDY DESIGN: In all, 400 nulliparous women admitted in labor between June and December 2001 were prospectively enrolled. Maternal height, perineal length, fetal birth weight, fetal head circumference, and severe perineal lacerations (third and fourth degrees) were recorded. RESULTS: The rate of severe perineal lacerations was 2% (8/400); 3% with midline, 1% with mediolateral groups. In patients with severe lacerations, perineal length was significantly (p < 0.001) shorter and the head circumference of their babies in the midline significantly (p < 0.05) greater than normal, and birth weights were also significantly (p < 0.05) greater in the mediolateral group. A cut-off value for perineal length of 3.05 cm was found for severe lacerations in the midline group. CONCLUSION: If episiotomy is to be performed, it must be borne in mind that patients with a perineal length of < or = 3 cm have an elevated risk of severe perineal lacerations, and if clinical or ultrasound examination suggests that the fetal head is large, mediolateral episiotomy may be preferred. Otherwise, midline episiotomy must be considered.     

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial

Backgroundperineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida.Aimthe aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma.Designa single-blind quasi-randomized controlled trial with two groups: standard care and intervention.Settinga tertiary, metropolitan hospital in Seville, Spain.Participantswomen (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives.Resultsoutcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001).Conclusionsa training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma.Key conclusionthe pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only.Implications for practicethe programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.     

Restricted use of episiotomy

Objective

To compare the outcome of restricted versus routine use of episiotomy in a tertiary care center.

Method

A prospective observational study was conducted for singleton normal vaginal term deliveries. Deliveries managed with routine use of episiotomy formed the ‘Control Group’, while those managed with restricted use of episiotomy formed the ‘Study Group’. Data so obtained was analyzed.

Results

Total number of deliveries analyzed was 458 (‘Control Group’: n=210, ‘Study Group’: n=248). Restricted use of episiotomy led to 64% (n=159) women delivering without any perineal laceration, in ‘Study Group’. This translated into 41% (n=38) reduction in the number of perineal lacerations in primipara, and 23% (n=36) in multipara, compared to the ‘Control Group’. Only 2% of primipara in ‘Study Group’ had severe third degree perineal tears.

Conclusion

Restricted use of episiotomy resulted in considerable reduction in maternal morbidity due to perineal lacerations.     

PRESUMPTIVE MATERNAL BENEFITS OF ROUTINE EPISIOTOMY

The use of episiotomy has been widespread in the United States since the 1920s. Obstetric textbooks cite several justifications for its use; the presumed maternal benefits are maintenance of pelvic floor integrity and prevention of lacerations. Despite its frequent use, surprisingly few studies of episiotomy have been undertaken to evaluate its actual effectiveness. Most of these studies were done before the era of active participation in birth by the laboring woman which, along with methodologic problems, severely restricts their value to practitioners today. Additional well-designed studies are sorely needed, not only of episiotomy itself but of other techniques such as antenatal perineal massage, which are recommended as alternatives but remain untested.     

Does the angle of episiotomy affect the incidence of anal sphincter injury?

OBJECTIVE: Mediolateral episiotomy is associated with lower rates of significant perineal tears than midline episiotomy. However, the relationship between precise angle of episiotomy from the perineal midline and risk of third-degree tear has not been established. This study quantifies this relationship. DESIGN: Case-control study. SETTING: National Maternity Hospital, Dublin, Ireland. SAMPLE: One hundred primiparous women who had undergone right mediolateral episiotomy 3 months previously. METHODS: Two groups of primiparous women were compared. Cases had sustained clinically apparent anal sphincter injury during delivery, while controls had not. The angle of episiotomy measured from the midline was marked on a superimposed sheet of transparent plastic film and measured using a protractor. Data were analysed using Student's t test, chi-square test and logistic regression analysis. MAIN OUTCOME MEASURES: Angle of mediolateral episiotomy from the perineal midline. RESULTS: Fifty-four cases and 46 controls were assessed. Cases were more likely to have undergone assisted delivery and consequently to have been delivered by an obstetrician than by a midwife. The mean angle of episiotomy measured significantly smaller in cases (30 degrees, 95% CI 28-32 degrees) than in controls (38 degrees, 95% CI 35-41 degrees; P<0.001). Analysis showed a 50% relative reduction in risk of sustaining third-degree tear for every 6 degrees away from the perineal midline that an episiotomy was cut. CONCLUSIONS: These results show that a larger angle of episiotomy is associated with a lower risk of third-degree tear and mediolateral episiotomy incisions should be made at as large an angle as possible to minimise the risk of sphincter disruption.     

Third degree perineal tears in a university medical center where midline episiotomies are not performed

Objective Midline episiotomy is a known major risk factor for severe perineal lacerations. The study was aimed to define obstetric risk factors for third-degree perineal tears in a university medical center where midline episiotomies are not performed.Study design A comparison between vaginal deliveries complicated with third-degree perineal tears and deliveries without third-degree perineal tears was performed. Deliveries occurred between the years 1988–1999 in a tertiary medical center. Multiple gestations, preterm deliveries (<37 weeks gestation), cesarean deliveries and cases of shoulder dystocia were excluded from the analysis. A multiple logistic regression model was constructed in order to find independent risk factors for third-degree perineal tears. Odds ratios (OR) and their 95% confidence interval (CI) were calculated from the regression coefficient.Results During the study period, 79 (0.1%) consecutive cases of third degree perineal tears were identified. Significant risk factors from the univariate analysis were fetal macrosomia (OR 2.7, 95%CI 1.2–5.5), nulliparity (OR 2.9, 95%CI 1.8–4.6), labor induction (OR 1.9, 95%CI 1.0–3.5), failure of labor to progress during the second stage (OR 10.8, 95%CI 5.4–21.1), non-reassuring fetal heart rate patterns (OR 11.7, 95%CI 6.1–21.5), mediolateral episiotomy (OR 2.8, 95%CI 1.8–4.5), vacuum extraction (OR 10.6, 95%CI 6.1–18.3), and forceps delivery (OR 29.2, 95%CI 7.3–97.2). However, using a multivariable analysis, only fetal macrosomia (OR 2.5, 95%CI 1.2–4.9), vacuum extraction (OR 8.2, 95%CI 4.7–14.5), and forceps delivery (OR 26.7, 95%CI 8.0–88.5) remained as independent risk factors. The combined risk for instrumental deliveries of macrosomic newborns was 8.6 (95% CI 1.2–62.5; p=0.010).Conclusions After adjustment for possible confounding variables, mediolateral episiotomy per se was not an independent risk factor for third-degree perineal tears. Instrumental vaginal deliveries of macrosomic fetuses should be avoided whenever possible to decrease the occurrence of third-degree perineal tears.Presented in part at the Society for Gynecologic Investigation 50th Annual Scientific Meeting, Washington, DC, 27–30 March 2003     

Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife,Brazil: a cohort study

Objectives: The objective of this study is to determine factors associated with spontaneous perineal laceration in low-risk pregnant women who delivered vaginally without episiotomy in a university maternity hospital in Recife, Pernambuco, Brazil.

Methods: A prospective cohort study was conducted with 222 low-risk, full-term pregnant women admitted in labor with a single fetus in cephalic presentation. Women with malformed fetuses were excluded from the study. The variables analyzed were: the frequency and severity of lacerations, the women’s biological, sociodemographic, clinical and obstetrical characteristics, neonatal characteristics, and data on their deliveries and procedures. For the data analysis, risk ratios and their 95% confidence intervals were calculated. A significance level of 5% was adopted and multiple regression analysis was performed.

Results: Spontaneous first-degree perineal tears were registered in 47% of the women, second-degree tears in 31%, and third degree tears in only 1.8%. There were no cases of fourth-degree tears. Having experienced normal childbirth previously constituted a protective factor against vaginal tearing (OR?= 0.46; 95%CI: 0.23–0.91; p?=?.027).

Conclusion: The principal protective factor against spontaneous lacerations was having experienced normal childbirth previously. Intrapartum strategies aimed at protecting the perineum and pelvic floor muscle training during prenatal care should be encouraged in these women.     

Episiotomy and perineal tears presumed to be imminent: the influence on the urethral pressure profile, analmanometric and other pelvic floor findings--follow-up study of a randomized controlled trial

BACKGROUND: The influence of the restrictive use of episiotomy at perineal tears judged to be imminent on the urethral pressure profile, analmanometric, and other pelvic floor findings is unknown. METHODS: Follow-up study of a randomized controlled trial with two perineal management policies includes the use of episiotomy: (a) only for fetal indications and (b) in addition at a tear presumed to be imminent. Participants were 146 primiparous women with an uncomplicated singleton pregnancy >34 weeks of gestation. For the intention-to-treat analysis, 68 women after vaginal delivery were included who delivered a live full-term baby between January 1999 and September 2000. OUTCOME MEASURES: Maximum urethral closure pressure (MUCP, cmH2O), functional urethral length (mm), maximum anal pressure (MAP, mmHg), functional anal sphincter length (ASL, mmHg) at rest and during contraction, and pelvic floor muscle strength (5-grade Oxford score) are the outcome measures. The rate of dyspareunia, urinary incontinence, and anorectal incontinence was documented. RESULTS: At a mean follow up of 7.3 months, there were no statistically significant differences between the two groups (a versus b): mean MUCP at rest (98 versus 101 cmH2O), during contraction (95 versus 103 cmH2O), mean MAP at rest (113 versus 121 mmHg), during contraction (143 versus 166 mmHg), mean ASL at rest (50 versus 50 mmHg), during contraction (42 versus 45 mmHg), mean pelvic floor muscle strength (2.2 versus 2.6), no pain during sexual intercourse (79 versus 67%), prevalence of urinary incontinence (48 versus 27%), and anorectal incontinence (19 versus 24%). CONCLUSIONS: Episiotomy at a perineal tear presumed to be imminent does not have any advantage with regard to pelvic floor function and should be avoided.     

Risk of recurrence of anal sphincter lacerations

OBJECTIVE: To estimate the rate of recurrence of anal sphincter lacerations in subsequent pregnancies and analyze the risk factors associated with recurrent lacerations METHODS: Data were obtained from the Pennsylvania Health Care Cost Containment Council, Division of In-Patient Statistics, regarding all cases of third- and fourth-degree perineal lacerations that occurred during a 2-year period (from January 1990 through December 1991). All subsequent pregnancies in this group of women over the next 10 years were identified, and the rate of recurrence of sphincter tears and risk factors for recurrence were analyzed. RESULTS: The rate of anal sphincter lacerations was 7.31% (n = 18,888) during the first 2 years of study (1990-1991). In the next 10 years, these patients with prior lacerations were delivered of 16,152 pregnancies. Of these, 1,162 were by cesarean. Among the 14,990 subsequent vaginal deliveries, 864 (5.76%) had a recurrence of a third- or fourth-degree laceration. Women with prior fourth-degree lacerations had a much higher rate of recurrence than those with prior third-degree laceration (7.73% versus 4.69%). The rate for recurrent lacerations was significantly lower than the rate for initial lacerations (odds ratio 1.29, 95% confidence interval [CI] 1.2-1.4). Forceps delivery with episiotomy had the highest risk for recurrent laceration (17.7%, odds ratio 3.6, 95% CI 2.6-5.1), whereas vacuum use without episiotomy had the lowest risk (5.88%, odds ratio 1.0, 95% CI 0.6-1.7). CONCLUSION: Prior anal sphincter laceration does not appear to be a significant risk factor for recurrence of laceration. Operative vaginal delivery, particularly with episiotomy, increases the risk of recurrent laceration as it does for initial laceration. LEVEL OF EVIDENCE: III.     

Hospital Variation in Episiotomy Use and the Risk of Perineal Trauma During Childbirth

Background: Episiotomies are the most frequently performed surgical procedure among United States women, but there are no published epidemiological studies of the extent of variation in episiotomy use among different obstetrical providers, or the outcomes associated with different levels of use. The objective of this study was to assess the extent of hospital variation in the use of episiotomy and the relationship between hospital episiotomy use and the incidence and risk of perineal trauma among women residing in a large urban area in the United States. Methods: Linked birth certificate and hospital discharge data pertaining to births to nulliparous women without prolonged labor or obstructed deliveries, and with infants weighing between 2500 and 4000 g, were analyzed for 18 major maternity hospitals. The relationship between episiotomy use and perineal trauma at the hospital level was examined using regression analysis. Results: Hospital episiotomy rates ranged from approximately 20 to 73 percent. The rate of third or fourth degree perineal lacerations varied from a low of 4 percent to a high of more than 13 percent among hospitals. Rates of episiotomy were significantly correlated with rates of a third or fourth degree perineal laceration (r = 0.70; p < 0.01), and with the hospital‐specific, adjusted odds ratios for such lacerations (r = 0.65; p < 0.01). Conclusions: Findings from the analysis of epidemiological data for this study population were consistent with those from clinical studies, indicating that liberal as opposed to restrictive use of episiotomy is unwarranted, and probably even harmful. Hospital episiotomy rates exceeded 20 percent in all cases, but such rates appear difficult to justify in face of the evidence. (BIRTH 29:2 June 2002)     

Episiotomy and third-degree tears

Summary. The relation of episiotomy to third-degree perineal tears was investigated in 21 273 singleton deliveries. The incidence of episiotomy was 28.4% ( n =6041). Third-degree tears occurred in 14% (85) of the deliveries with episiotomy and in 0.9% (132) of the deliveries without episiotomy ( P <0.01). To avoid the effect of confounding factors, we analysed a sub-sample that included only vertex presentations with spontaneous occipitoanterior vaginal deliveries. After stratification for birthweight and parity, no relation between episiotomy and third-degree tear was found.     

ROUTINE USE OF EPISIOTOMY IN MODERN OBSTETRICS: Should It Be Performed?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. It has been associated with a more difficult and lengthy repair as measured by the need for suture material and operating room time. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. The value of episiotomy use on a routine basis bears scientific examination in prospective, randomized, controlled trials. These types of trials are certainly achievable, ethically correct, and much needed. Until these trials are completed and published, obstetricians should not routinely perform the procedure but rather determine the need for episiotomy on a case-by-case basis.