Need for and consequences of episiotomy in vaginal birth: a critical approach

Abstract

Objective to describe and explain the short-term effects of lateral episiotomy, and determine the factors associated with more/less common use of episiotomy. Design prospective cross-sectional survey using a postal questionnaire. Setting the study was conducted at two university hospitals and one regional hospital in Finland between October and December 2006. The hospitals were chosen using cluster sampling. The sample consisted of 1000 vaginal births, and data were collected using questionnaires which were completed by midwives or student midwives. The overall response rate was 88%. Participants midwives or student midwives who took care of the women in labour provided information about childbearing women ( n=879), obstetric factors and details of staff experience. Findings episiotomies were more common among primiparous than multiparous women (55% vs 12%, p⩽0.001). More common use of episiotomy was also associated with induced births compared with spontaneous births in primiparous women (66% vs 53%, p=0.036), assisted vaginal births in all women (89% vs 25%, p⩽0.001), and a prolonged active second stage of labour and epidural analgesia (17% vs 10%, p=0.036) in multiparous women. Correspondingly, episiotomies were less common among primiparous (44% vs 57%, p=0.041) and multiparous (7% vs 16%, p=0.003) women using spontaneous pushing compared with coached pushing. In the active second stage of labour, alternative birth positions (lateral, squatting, all fours, sitting) were associated with less common use of episiotomy than half-sitting or lithotomy positions among primiparous women (22% vs 48% vs 85%, p⩽0.001). There were no differences between primiparous women with and without episiotomy in low Apgar score at 1 minute (10.6% vs 6.4%, p=0.131) or 5 minutes (1.8% vs 1.1%, p=0.557), or between multiparous women with and without episiotomy in low Apgar score at 1 minute (1.9% vs 2.2%, p=0.855) or 5 minutes (0% vs 0.5%, p=0.603). There were more first- and second-degree perineal injuries as well as injuries to the vagina, labia minora and urethra in births performed without episiotomies among primiparous women ( p⩽0.001). Correspondingly, third-degree perineal injuries were more common if episiotomy was performed in both primiparous (2.2% vs 1.6%) and multiparous women (3.7% vs 0%). The maternity hospital was the most significant determinant of the episiotomy rate (odds ratio 1 vs 1.9 vs 2.6, p=0.049). Key conclusions episiotomy rates can be reduced without causing harm to women or newborn babies. Episiotomies can be avoided if induction and vacuum assistance are used sparingly, and if spontaneous pushing techniques and alternative birth positions (lateral, sitting, squatting, all fours) are used more often during labour.