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

Abstract

There is convincing evidence that routine episiotomy is inappropriate. The Cochrane Collaborations' systematic review and several randomized trials have shown that the restricted use of episiotomy, compared with routine use, causes significantly less damage to the posterior perineum and fewer complications of healing. The present investigators compared these 2 strategies in a prospective follow-up study of a randomized, controlled trial. Restrictive episiotomy was done only on fetal indications or when a tear was thought to be imminent. The participants in this 18-month study were 146 primiparous women with uncomplicated singleton pregnancies past 34 weeks gestation. Sixty-eight women who delivered live infants at term during the study interval were added for an intention-to-treat analysis. Maximum urethral closure pressure (MUCP), functional urethral length, maximum anal pressure (MAP), and functional anal sphincter length (ASL) were estimated at rest and during contraction. Pelvic floor muscle strength also was graded. Women were asked about dyspareunia, urinary incontinence, and anorectal incontinence. After a mean follow up of 7.3 months, there were no statistically significant differences between the ordinary and restrictive approaches to episiotomy with respect to mean MUCP, mean MAP, or mean ASL at rest or during contraction. In addition, no significant differences were found in mean pelvic floor muscle strength, the frequency of pain on intercourse, or the prevalence of either urinary or anorectal incontinence. These findings suggest that there is no advantage in performing mediolateral episiotomy when a tear is considered imminent when considering the urodynamic and analmanometric results and pelvic floor function. Because mediolateral episiotomy under this condition causes significant perineal pain without any apparent benefit to the mother or infant, the investigators believe that an imminent tear is not an indication for mediolateral episiotomy.