Abstract
Episiotomy should be cut at certain internationally set criteria to minimize risk of obstetric anal sphincter injuries (OASIS) and anal incontinence. The aim of this study was to assess the accuracy of cutting right mediolateral episiotomy (RMLE). An institution-based prospective cohort study was undertaken in a Palestinian maternity unit from February 1, to December 31, 2016. Women having vaginal birth at gestational weeks ≥24 or birthweight ≥1000 g and with intended RMLE were eligible (n=240). Transparent plastic films were used to trace sutured episiotomy in relation to the midline within 24-hour postpartum. These were used to measure incisions' distance from midline, and suture angles were used to classify the incisions into RMLE, lateral, and midline episiotomy groups. Clinical characteristics and association with OASIS were compared between episiotomy groups. A subanalysis by profession (midwife or trainee doctor) was done. Less than 30% were RMLE of which 59% had a suture angle of <40° (equivalent to an incision angle of <60°). There was a trend of higher OASIS rate, but not statistically significant, in the midline (16%, OR: 1.7, CI: 0.61–4.5) and unclassified groups (16.5%, OR: 1.8, CI: 0.8–4.3) than RMLE and lateral groups (10%). No significant differences were observed between episiotomies cut by doctors and midwives. Most of the assessed episiotomies lacked the agreed criteria for RMLE and had less than optimal incision angle which increases risk of severe complications. A well-structured training program on how to cut episiotomy is recommended.
Highlights
Episiotomy is a surgical incision of the perineum used to facilitate childbirth [1]
Based on Kalis et al.’s [10] classification criteria, measurements of distance from midline and the suture angle were used to classify the episiotomy incisions into four groups: right mediolateral episiotomy (RMLE), lateral, midline, and unclassified episiotomy. e suture angle categorization was based on Kalis et al.’s [22] demonstration that the suture angle is 15°–20° less than the incision angle
An episiotomy incision angle of 40°–60° was considered equivalent to a suture angle of 25°–40°, respectively
Summary
Episiotomy is a surgical incision of the perineum used to facilitate childbirth [1]. Episiotomy may cause bleeding, infection, dyspareunia, and postpartum pain [1] and should not be used routinely but only when indicated [2]. e use of episiotomy has declined markedly from 60% in 1979 to 9.4%in 2011 in the United States [3, 4] and from 20% in 1975 to 7% in 2010 in some Scandinavian countries [5, 6]. e rate in low-income countries remains relatively high. E main aim of this study was to evaluate the accuracy and characteristics of RMLE cut by doctors and midwives in relation to the international recommendations. Based on Kalis et al.’s [10] classification criteria, measurements of distance from midline and the suture angle were used to classify the episiotomy incisions into four groups: RMLE, lateral, midline, and unclassified episiotomy.
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