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PubMed1995

Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.

OBJECTIVE: To evaluate whether physicians' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth. DESIGN: Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy. SETTING: Two tertiary care hospitals and one community hospital in Montreal. PARTICIPANTS: Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded. MAIN OUTCOME MEASURES PATIENTS: intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. RESULTS: Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably. CONCLUSIONS: Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.

Adult↗
PubMed2005

Outcomes of routine episiotomy: a systematic review.

CONTEXT: Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use. OBJECTIVE: To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. EVIDENCE ACQUISITION: We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality. EVIDENCE SYNTHESIS: Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function--pain with intercourse was more common among women with episiotomy. CONCLUSIONS: Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.

Episiotomy↗
PubMed1994

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.

OBJECTIVE: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. CONCLUSION: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

Adolescent↗
PubMed2003

Effects of episiotomy on bonding and mothers' health.

BACKGROUND: Historically, episiotomy has been carried out during labour to facilitate delivery, shorten the duration of the second stage and prevent spontaneous lacerations. However, recent studies of episiotomy have recommended that it be carried out only when necessary. In Turkey, midwives are authorized to perform episiotomy. AIM: To analyse the effects of episiotomy on mothers' health and mother-infant bonding. DESIGN: A cohort study of 100 women who gave birth by normal vaginal delivery in a Turkish hospital between 15 March 1999 and 6 April 2000. METHODS: Participants were divided into episiotomy (n = 50) and control (n = 50) groups. Data on biographical characteristics and the process of labour were collected in hospital, and follow-up was conducted at home 1, 3 and 12 weeks after labour. RESULTS: Mean duration of the second stage was longer in the episiotomy group than the control group, but the difference was not significant. The number of spontaneous lacerations was significantly lower in the episiotomy group. Mean time from delivery to maternal rest and time taken to bond with the infant were significantly longer in the episiotomy group. There were significantly higher scores for overall incidence and severity of pain on the first day, and pain incidence and severity at 1 week in the episiotomy group. Significantly fewer women in the episiotomy group were able to do chores and to sit/stand up comfortably in the first postpartum week CONCLUSION: Episiotomy should not be used unless indicated. Measures should be taken to avoid perineal trauma during labour, establish bonding between mother and infant as soon as possible, and minimize perineal discomfort after delivery.

Adult↗
PubMed1989

Episiotomy and perineal trauma during childbirth.

A study was conducted to assess the frequency of episiotomy and spontaneous tears in 807 primiparas during singleton births. The incidence of episiotomy was 50%, spontaneous tears 22% and intact perineum 28%. A significantly lower frequency of episiotomy (P less than 0.001) as well as epidural anaesthesia (P less than 0.001) was found among immigrant women. There were no indications registered for 58% of the episiotomies. The non-episiotomy group experienced more clitoris/labia tears (P less than 0.01). On the other hand there was a tendency towards an increased risk for second and third degree tears, 4.2% in the episiotomy group compared to 1.7% in the non-episiotomy group (P = 0.06). Haemorrhage (greater than 600 ml) was more frequent in the episiotomy group than in the non-episiotomy group (P less than 0.001). We conclude that there is little support for the claim that episiotomy prevents tears in normal deliveries, and that the rationale for the practice of episiotomy is in need of reappraisal.

Cohort Studies↗
PubMed1994

Methods and consequences of changes in use of episiotomy.

OBJECTIVES: To evaluate the use of feedback by graphical profiles of rates of episiotomy and the impact on clinical practice and perineal state after spontaneous vaginal deliveries assisted by midwives with different attitudes towards episiotomy. DESIGN: Observation period in labour ward followed by feedback to midwives about their own and other midwives' use of episiotomies. The periods before and after the intervention were compared. SUBJECTS: All women (n = 3919) delivering during the two periods who had been assisted by one of 30 midwives; each midwife supervised at least 20 deliveries during each period. MAIN OUTCOME MEASURES: Overall rates of episiotomies and indications, incidence of intact perineums, perineal lacerations, and tears of anal sphincter. RESULTS: The overall rate of episiotomy during the observation period was 37.1% (615). During the second period the rate was 6.6% lower (95% confidence interval 3.6% to 9.6%), corresponding to a relative decrease of 17.8% (10.1% to 24.7%). Higher rates of episiotomy during the observation period were associated with larger reductions in the second period. The decrease could be explained by less use of episiotomy in deliveries with rigid perineum or impending perineal tear. Compared with the observation period, in the second period 3.2% more women (0.3% to 6.3%) had an intact perineum after delivery and 3.4% (0.4% to 6.2%) experienced perineal tears. The overall incidence of tears of the anal sphincter remained unchanged. Women had a slightly reduced incidence of tears of the anal sphincter, however, if they were delivered by midwives who reduced a medium or high initial rate of episiotomy and a tendency towards an increased incidence of tears if they were assisted by midwives who reduced low initial rates (around 20%) of episiotomy. CONCLUSIONS: Changes in the use of episiotomy induced by awareness of clinical practice among midwives seem to increase the incidence of parturients with intact perineum without a concomitant rise in tears of the anal sphincter. To avoid the increase of such tears these changes should probably be restricted to midwives with rates of episiotomies above 30%.

Adult↗
PubMed2006

The practice of episiotomy in public hospitals in Hong Kong.

OBJECTIVE: To review the use of episiotomy during vaginal delivery in Hong Kong public hospitals. DESIGN: Prospective observational survey. SETTING: Public hospitals, Hong Kong. PARTICIPANTS: Women who underwent normal vaginal delivery of a singleton foetus with cephalic presentation. MAIN OUTCOME MEASURES: Number of women having an episiotomy, severe-degree (third- or fourth-degree) tear, other types of tear, blood loss at delivery, postpartum haemorrhage, need for blood transfusion, puerperal pyrexia, wound infection, gaping wound that required suture removal, and drainage or resuturing of a perineal wound. RESULTS: Between 1 January and 31 March 2003, there were 6222 singleton spontaneous normal vaginal deliveries in the public hospitals of Hong Kong. Of the 6167 women in whom the status of the perineum was known, episiotomy was performed in 5274 (85.5%). Primiparous women were more likely to undergo episiotomy at delivery than multiparous women (97.9% vs 71.4%). Women with episiotomy had significantly less perineal tearing of any kind than those without. The occurrence of any type of perineal tear and severe-degree (third- or fourth-degree) tear was significantly lower in primiparous women who had an episiotomy than those without (P<0.05). Women with episiotomy had increased mean blood loss at delivery but other complications were not significantly increased. CONCLUSIONS: In Hong Kong, episiotomy is routinely performed during normal vaginal delivery. It is associated with a significantly lower overall rate of perineal tearing. This study was observational, nonetheless the occurrence of other complications was likely to increase when episiotomy was performed. Firm evidence from several randomised controlled studies shows that routine episiotomy is unjustified and possibly harmful. Routine episiotomy should not be promoted in Hong Kong without further randomised controlled study.

Adolescent↗
PubMed2005

Decreased anal sphincter lacerations associated with restrictive episiotomy use.

OBJECTIVE: To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN: This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS: The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION: With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.

Adult↗
PubMed2006

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.

Adolescent↗
PubMed2003

Puerperal complications of episiotomies at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

OBJECTIVES: To establish the epidemiological variables associated with episiotomies and their puerperal complications at Ahmadu Bello University Teaching Hospital Zaria, in order to institute appropriate management including preventive measures. DESIGN: A prospective cohort study. SETTING: Ahmadu cello University Teaching Hospital, Zaria, Nigeria. METHODS: A cohort of all consecutive patients that underwent vaginal deliveries during a 12-week period were followed up for six weeks in order to determine the distribution and determinants of episiotomy and its complications. RESULTS: The episiotomy rate was 35.6% of all vaginal deliveries. Episiotomies were significantly associated with primigravidity being performed in 88.5% of all primigravidae. The mean delivery-repair interval was 60.5 minutes. The most common puerperal complication of episiotomies was perineal pain that lasted an average of 5.5 days. Other complications included asymmetry (32.9%), infection (23.7%), partial dehiscence (14.5%), skin tags (7.9%), haemorrhage (5.3%) and extension of the incision (1.3%). The complications were not significantly associated with any potential risk factor. CONCLUSION: In view of the very high episiotomy rate among primigravidae, it is recommended that the episiotomy rate among primigravidae be reduced by re-acquainting accoucheurs with the indications for episiotomy. Attention needs to be given to adequate pain relief for all women who have had an episiotomy and the delivery-repair interval in this unit should be reduced by provision of materials for episiotomy repair in the delivery suite.

Adult↗
PubMed2002

A two years retrospective review of episiotomy at Jimma Teaching Hospital, southwestern Ethiopia.

Episiotomy is one of the most commonly performed obstetric interventions. The practice has been on the rise since hospital confinement became the tradition of childbirth. Unlike the rising cesarean section rate the rise in episiotomy rate has not been challenged. There is evidence that episiotomy rate of over 30% is not acceptable and it should be done on selective basis than routinely. A retrospective review of all deliveries that took place at Jimma teaching Hospital from Sept 23, 1998 to Sept 23, 2001 was done to determine the episiotomy rate and factors influencing the practice. The overall incidence of episiotomy among 2861 vaginal deliveries was 25%. The incidence of episiotomy by specific procedure was: 6 out of 21 forceps deliveries (29%), 30 out of 101(30%) vacuum deliveries and 8 out of 71(11%) destructive deliveries. 47% of nulliparas and 5% of multiparas needed episiotomy. The mean ages of patruents delivering by episiotomy and spontaneous vertex delivery were 22 +/- 4 and 26 +/- 6 years respectively. The difference was significant (p < 0.0001). There was not statistically significant difference in mean birth weight, head circumference and gestational age between the two groups. The incidence of episiotomy in this study was low compared to the findings of other studies from both developing and developed countries. Similar studies are warranted in other hospitals of the country to address the practice pattern. Prospective studies should be done to establish indications and outcomes of episiotomy.

Adult↗
PubMed1990

Midline episiotomies: more harm than good?

The association between episiotomy and severe (third- and fourth-degree) perineal lacerations was studied in 24,114 women. The overall rates of severe lacerations were 8.3 and 1.5% for primiparous and multiparous women, respectively. Women who had midline episiotomies were nearly 50 times more likely and women who had mediolateral episiotomies were over eight times more likely to suffer a severe laceration than were women who did not undergo an episiotomy. Severe lacerations were also more common after use of forceps, in occiput transverse and posterior presentations, among women with smaller pelvic outlet measurements or lower prepregnant weight, and with larger fetuses. The same factors that caused a woman to have an increased risk of laceration also made performance of an episiotomy more likely. After statistical adjustment for these risk factors, mediolateral episiotomy was associated with a 2.5-fold reduction in the risk of severe lacerations among primiparous women, and a statistically nonsignificant 2.4-fold increase among multiparous women, compared with no episiotomy. Midline episiotomy was associated with statistically significant 4.2- and 12.8-fold increases in the risk of lacerations among primiparous and multiparous women, respectively. We conclude that the risks and benefits of midline episiotomy should be evaluated in a randomized clinical trial that compares policies of "usual" versus conservative use of episiotomy.

Delivery, Obstetric↗
PubMed1995

Reducing the frequency of episiotomies through a continuous quality improvement program.

OBJECTIVE: To determine the effectiveness of a continuous quality improvement (CQI) program in reducing episiotomy rates. DESIGN: Before-and-after study; CQI methods were used to examine the process of care during labour and birth. INTERVENTIONS: Identification of care factors that would increase the probability of episiotomy. Implementation of initiatives that would change the process of care to minimize the probability of episiotomy. Educational strategies included promotion of better understanding of what constitutes an appropriate episiotomy rate and ways to reduce maternal exhaustion and true fetal distress as well as manoeuvres to protect the perineum during birth. SETTING: Low-risk family practice obstetrics service in a tertiary care hospital in southwestern Ontario. PARTICIPANTS: All 102 family physicians at the study hospital who provided intrapartum care in the year before and the year during which the CQI program was implemented and the women for whom the care was provided (approximately 1,400 per year). OUTCOME MEASURES: Episiotomy rates (overall, among primiparous and multiparous women, and among individual family physicians) and rates of perineal tear, perineal infection and postpartum readmission. RESULTS: Although the planned reduction in the episiotomy rate was not achieved during the study period, the overall rate decreased significantly from 44.5% to 33.3% (p < 0.001). Among the primiparous women the rate decreased from 57.6% to 46.2% (p < 0.001) and among the multiparous women from 34.3% to 23.6% (p < 0.001). The reduced episiotomy rate among the primiparous women was associated with a significant decrease in the rate of third- and fourth-degree perineal tears and a significant increase in the number of women giving birth with an intact perineum or a minor (first-degree) tear. These benefits were not seen among the multiparous women, whose decreased episiotomy rate was associated with a significant increase in the number of women experiencing a second-degree perineal tear. During the intervention period, there was no increase in the rates of vaginal trauma or postpartum bleeding, infection or readmission because of complications related to perineal trauma. The episiotomy rates for most physicians decreased significantly during the intervention period. CONCLUSIONS: The CQI model may be useful in modifying clinical practices such as episiotomy because it focuses on understanding the process of care and the environment in which care is provided, both of which may have a major impact on physician behaviour. Further study is needed to ascertain the sustainability of the effects of this approach and which components of the model had the greatest effect.

Algorithms↗
PubMed2000

Episiotomy in Nigeria.

OBJECTIVE: To review the incidence and complications associated with episiotomy and perineal tears at the University of Benin Teaching Hospital, Benin City, Nigeria. METHOD: A retrospective review of all vaginal births conducted in the hospital between January 1997 and December 1998 was undertaken. Vaginal births (1345) were reviewed. RESULT: The prevalence of episiotomy in the hospital during the period was 46.6%. Over 90% of primigravid parturients had episiotomy. The incidence of episiotomy decreased with increasing parity, while the incidence of spontaneous vaginal tears increased with parity. As compared with perineal tears, episiotomy was associated with a statistically significant increased risk of wound breakdowns requiring secondary resuturing. When controlled for parity, breech births, forceps and vacuum delivery were more likely to lead to episiotomy, compared to spontaneous vertex delivery occurring at term. CONCLUSION: A policy of systematic reduction in the incidence of episiotomy can be pursued in this hospital. Greater attention needs to be paid to selection of women to undergo episiotomy, the prevention of spontaneous perineal tears and the care of episiotomy wounds in this institution.

Episiotomy↗
PubMedDate not supplied

Clinician-specific episiotomy rates: impact on perineal outcomes.

Recent, large, randomized, controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum. Yet episiotomy remains the most common surgical procedure women undergo. This article examines if clinician experience, rather than scientific evidence, forms the basis for continuing this practice. Perineal outcome data are analyzed for 865 low-risk women who were attended at birth by the staff nurse-midwives or faculty obstetricians at a university-based, tertiary-care hospital. Data were collected under routine, nonexperimental conditions such that the circumstances of the labor and the clinician's preferences were allowed to determine management decisions regarding the use of episiotomy or other techniques of perineal management. Multivariate findings indicate that in the absence of episiotomy, rates of perineal integrity were highest among clinicians who usually had the lowest rate of episiotomy use. When an episiotomy was done, rates of third- and fourth-degree extensions were highest among clinicians who used episiotomy most frequently. This finding challenges the idea that clinicians who were very experienced with the use of episiotomy would avoid complications such as extensions. Future research should explore the use of nonsurgical techniques such as those employed by midwives to promote perineal integrity. Then interdisciplinary research and evidence-based education regarding these techniques can occur to improve perineal outcomes for all women.

Episiotomy↗
PubMed2002

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.

Adolescent↗
PubMed2004

Episiotomy use among residents and faculty compared with private practitioners.

OBJECTIVE: To describe trends in episiotomy use among residents, faculty, and private practitioners at an academic institution. METHODS: We reviewed data from the Magee Obstetric Medical and Infant database, containing details of every delivery at Magee-Womens Hospital since 1995. The study population was women who had spontaneous or operative vaginal delivery of a singleton, liveborn, vertex-presenting infant, at 37 weeks or more, from 1995 to 2000 (completed data set years). The first delivery recorded for a patient in the database was analyzed. Residents and faculty were described as "academic" practitioners. Data were analyzed with the Fisher exact test, chi2 test for linear trend, and logistic regression models. RESULTS: There were 27702 women with 15190 episiotomies, for an episiotomy rate of 54.8%. The rate of episiotomies decreased from 59.7% to 45.0% during the study period (P <.001). Independent risk factors for episiotomy included age 30 years or more, white race, higher educational status, married, nulliparity, and history of cesarean delivery. The strongest predictor of episiotomy use was practitioner type, with women attending private physicians having an adjusted 7-fold increased risk of episiotomy (odds ratio 7.1; 95% confidence interval 6.5, 7.7). Patient characteristics related to practitioner type included age, race, educational status, marital status, nulliparity, and mode of delivery (P <.001). CONCLUSION: High rates of episiotomy use were found among private practitioners, despite current evidence-based literature that supports restricted use of episiotomy.

Adult↗
PubMed1992

Episiotomy and perineal lesions in spontaneous vaginal deliveries.

OBJECTIVE: To evaluate the influence of mediolateral episiotomy on the perineal state after spontaneous, singleton vaginal deliveries with fetus in the occiput anterior position. DESIGN: The study was a population based, observational study. Two approaches were used in the analyses. Initially, we considered the parturients as quasi-randomised to one of three equally sized groups of midwives with different attitudes towards episiotomy. Secondly, we studied the effect of episiotomy on the state of the anal sphincter, controlling for birthweight, parity, and duration of second stage of labour. SUBJECTS: 2188 pregnant women delivering consecutively. MAIN OUTCOME MEASURES: Perineal lacerations and tear of the anal sphincter. RESULTS: Women allocated to the group of midwives with the lowest rate of episiotomy were more likely to have intact perineum after delivery (OR = 1.8 (1.4-2.2)), had a slight tendency towards more perineal lacerations (OR = 1.3 (1.0-1.5)), but no increase risk of having tear of the anal sphincter, compared with the women allocated to the two groups of midwives with higher frequencies of episiotomy. The second approach showed that episiotomy was related to an increased risk of tear of the anal sphincter (OR = 2.3 (1.2-4.6)). However, this relation was not found among the group of parturients delivered by the midwives with the lowest rate of episiotomy (22%). CONCLUSIONS: Our results encourage a conservative approach to the use of mediolateral episiotomy, and in the light of previous findings, it seems reasonable to suggest that episiotomy should ideally be used in about one in five spontaneous vaginal deliveries.

Adult↗