Episiotomy Angle Research Articles

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

BackgroundA mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle.MethodsWorkshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement.ResultsOne hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (− 0.01 to 0.36) with a SEM of ± 12.2°ConclusionsKnowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

Predictive factors for obstetric anal sphincter injury in primiparous women: systematic review and meta-analysis.

The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective. We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool. A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2 = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2 = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias. Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of Episiotomy Characteristics of EPISCISSORS-60 Scissors Compared with Mayo Scissors: A Single-Blind Randomized Clinical Trial.

It seems that angled scissors may be able to minimize the occurrence of obstetric anal sphincter injuries (OASIS) during vaginal delivery by correcting the angle of the episiotomy incision.For this purpose, this study aimed to evaluate the episiotomy characteristics of EPISCISSORS-60 scissors compared with Mayo scissors. In this single-blind clinical trial study, 64 pregnant women candidates for natural childbirth were included; 32 women underwent episiotomy with Mayo scissors and 32 underwent episiotomy with the EPISCISSORS-60 instrument. Then, post-suturing angle, incision length, episiotomy, postpartum pain, bleeding volume, and the incidence of OASIS and dyspareunia were assessed. The collected data were analyzed by independent sample t test, chi-square test, and the Fisher exact test. Episiotomy incision length in the EPISCISSORS-60 group with a mean of 4.75 ± 0.72 cm was significantly longer than the Mayo group with a mean of 3.91 ± 0.52cm (P < 0.001). In addition, the incidence of dyspareunia was not significantly different between the 2 groups (6.3% vs 15.6%; P = 0.426). Sphincter damage did not occur at all in the EPISCISSORS-60 group and only 2 cases of grade 3 sphincter rupture occurred in the Mayo group (P = 0.238). The mean of post suturing angle in the EPISCISSORS-60 group (59.09° ± 3.47°) was significantly higher than the Mayo group, with a mean of 31.06° ± 7.21° (P < 0.001). According to the results of the present study, the use of EPISCISSORS-60 can be associated with a higher post-suture episiotomy angle compared with Mayo scissors. As a result, both the incidence of OASIS and its long-term side effects, like dyspareunia, were decreased. However, in our study, the incidence of these complications was very rare and not different between the 2 groups.

Detection of Occult Anal Sphincter Injuries in Primipara by 2D Transperineal Ultrasound and its Clinical Association: A Cohort Study

Introduction: Endoanal Ultrasound (EAUS), the gold standard for the detection of occult Obstetric Anal Sphincter Injuries (OASI) has limited clinical application due to its intrusiveness and need for specialised equipment and personnel. A 2D Transperineal Ultrasound (TPU) is simple, non invasive and shows a high degree of agreement with EAUS. Few studies have evaluated the use of 2D TPU in determining the incidence and clinical outcomes of occult OASI in primigravida. Aim: To study the incidence, risk factors, and clinical outcome of occult obstetric anal sphincter injury using 2D TPU in primigravida. Materials and Methods: The present cohort study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Radiology at Guru Teg Bahadur Hospital, Delhi, India, from November 2018 to April 2020. A total of 200 low risk primigravida ≥36 weeks period of gestation underwent baseline TPU of the anal sphincter complex antenatally and on day 2 postpartum. On the basis of difference between pre and postdelivery measurements, they were divided into group I (n=91): women with occult OASI (diagnosed as thinning of the internal and External Anal Sphincter (EAS), interruption in the anal sphincter, alteration in mucosa and half-moon sign) and group II (n=109): no OASI. Group I was followed at two and six weeks postpartum with TPU and clinical tests were applied at 6 weeks to assess clinical outcomes of sphincter injury. Data was analysed using Chi-square test/Fisher’s-exact test for qualitative parameters, Analysis of Variance (ANOVA) for comparison of predelivery and postpartum measurements; and multiple logistic regression for determining sphincter injury determinants. Results: Incidence of occult OASI was 91/200 (45.5%). Significant risk factors for OASI were lower baseline thickness of anal sphincter, position of baby (p=0.028), longer duration of second stage of labour (p&lt;0.001), greater length and angle of episiotomy (p&lt;0.001) and greater baby weight (p=0.042). Group I had significantly lower pelvic floor muscle strength testing score (p&lt;0.001), Digital Rectal Examination Scoring System (DRESS) resting (p=0.013) and squeeze scores (p=0.008), weaker muscle contraction (p&lt;0.001), reduced anal sphincter tone, and was more clinically symptomatic at six weeks postpartum. Conclusion: The technique of 2D TPU is simple and feasible to detect OASI. Women, who sustain OASI, can be followed up in perineal clinic more meticulously, using TPU for pelvic floor rehabilitation.

Episcissors-60 for Mediolateral Episiotomy: Evaluation of Clinical and Economic Evidence to Inform NICE Medical Technologies Guidance.

Obstetric anal sphincter injury (OASI) occurs in 2.9% of all vaginal births in the UK and can result in faecal incontinence. Where there is a clinical need for episiotomy, OASI can be minimised by accurate selection of the optimum angle of mediolateral episiotomy. Episcissors-60 are adapted surgical scissors incorporating a guide-limb to help achieve an accurate angle of mediolateral episiotomy. The ability of Episcissors-60 to reduce OASI by preventing inaccurate visual estimates of episiotomy angles was considered by the National Institute of Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme (MTEP). NICE concluded that Episcissors-60 shows promise for mediolateral episiotomy both in terms of clinical effectiveness and potential cost savings, but that there was not enough evidence to support routine adoption into the NHS at this time. NICE MTG47 recommends that key gaps in the evidence including patient-reported outcomes and the addition of Episcissors-60 to care bundles be addressed through research with specific focus on potential equality considerations.

Is mediolateral episiotomy angle associated with postpartum perineal pain in primiparous women?

OBJECTIVE:Our aim is to elucidate the relationship between mediolateral episiotomy (MLE) angle and postpartum perineal pain.METHODS:This study was designed prospectively. Primiparous women with MLE in the postpartum period were included in the study and divided into three groups according to episiotomy angle ranges (Group 1: <40°, Group 2: 40°–60°, and Group 3: >60°). Postpartum perineal pain was quantified with the short-form McGill Pain questionnaire (SF-MPQ) consisting of the following three parts: Sensory-affective-verbal descriptions, visual pain scale (VPS), and present pain intensity scale (PPI). Postpartum perineal pain scores on days 1 and 7 were compared among the angle group.RESULTS:Overall, 86 eligible women were enrolled in this study. Seventy-three women (85%) scored the perineal pain between 0 and 3 on the VPS and 13 women (15%) rated the pain from 4 to 6 on the 1st postpartum day. No significant differences were noted among the three groups regarding the total pain scores on SF-MPQ and on the each part of form at the 1st postpartum day. At 7 days postpartum, total pain score was found significantly high in Group 1 [Med; IQR (min-max)=0; 4 (0–5)] compared with Group 2 [Med; IQR (min-max)=0; 0(0–5)]. The pain scores obtained from the sensory, affective, VPS, and PPI parts of the questionnaire were [Med; IQR (min-max)=0; 1 (0–2)], [Med; IQR (min-max)=0; 1 (0–1)], [Med; IQR (min-max)=0; 2 (0–2)], and [Med; IQR (min-max)=0; 0.25 (0–1)], respectively, in Group 1. For Group 2, pain scores obtained from the sensory, affective, and PPI were [Med; IQR (min-max)=0; 0(0-1)]; and VPS was [Med; IQR (min-max)=0; 0(0-2)]. No significant differences were observed between Groups 1 and 2 for each part of the questionnaire on day 7. Percentage of need for analgesics on day 7 was found significantly higher in Group 1 (42.9%) than Group 2 (31.2%)CONCLUSION:MLE at an angle <40° to the midline is associated with a higher score of perineal pain and an increase need for analgesics during the early postpartum days.

Incidence of obstetric anal sphincter injuries after implementing the Triepi-45 tool to improve episiotomy angle in instrumental deliveries.

To assess the impact of Triepi-45-a tool that enables an episiotomy angle of 45° to be marked on the perineum at rest-on the incidence of obstetric anal sphincter injuries (OASIS) during operative vaginal delivery (OVD). A retrospective-prospective cohort study was performed among successive women who underwent OVD at Complejo Asistencial Universitario de de León, Spain, between 2011 and 2013 (preintervention cohort, n=986) and between 2014 and 2016 (intervention cohort, n=986) after implementation of an interventional programme in 2013 to improve the episiotomy angle, including use of Triepi-45, in OVD. The intervention cohort had a lower incidence of OASIS than the preintervention cohort (70/986 [7.1%] vs 93/986 [9.4%]), but the difference was not significant, owing to the low use of Triepi-45 in the intervention cohort (n=375). However, the OASIS incidence was significantly lower in the Triepi-45 cohort than in the preintervention cohort (18/375 [4.8%] vs 93/986 [9.4%]; odds ratio, 0.47; 95% confidence interval, 0.26-0.86). Use of Triepi-45 had a positive impact on reducing OASIS in OVD. It remains essential to raise obstetricians' awareness of the importance of the episiotomy angle and to implement the systematic use of tools to reduce the incidence of OASIS.

Evaluation of the ease of use and acceptability of an innovative device – the ‘Episiometer’, in ensuring an accurate mediolateral episiotomy: a pilot study

The present study was undertaken at the Port Moresby General Hospital, Papua New Guinea, to evaluate the ease of use and acceptability of a perineal measuring device (Episiometer) for giving a correct length and angle of a mediolateral episiotomy. An Episiometer was placed on the perineum to guide the angle and length immediately before giving an episiotomy. A feedback survey was collected and the angle and length of the episiotomy were measured at the time of delivery and at 6 weeks postpartum. The length and angle of episiotomy were found to be accurate in 86% of the cases. Forty-two of the fifty (86%) clinicians felt that the Episiometer was easy or very easy to use. They also found this device to be beneficial (92%). The Episiometer seems to be an easy-to-use and feasible device that is well accepted by clinicians and patients and may aid in standardising the length and angle of an episiotomy.Impact statementWhat is already known on this subject? Episiotomy is the commonest obstetric procedure performed worldwide. However, the angle and length of an episiotomy vary greatly amongst operators. It is also recognised that birth trauma and an inaccurate episiotomy result in debilitating anal sphincter injury. Therefore, a pilot study was conducted to evaluate the ease of use and acceptability of a new, inexpensive, low- tech device “Episiometer” to guide clinicians and midwives to perform an appropriate episiotomy.What do the results of this study add? This pilot study to evaluate the usability of the new innovation amongst clinician and patients revealed high acceptance of the device amongst clinicians and positive attitude of the patients towards the device. The clinicians also felt the device to be an effective teaching tool. Usage if the device results in a more accurate length and angle of an episiotomy.What are the implications of these findings for clinical practice and/or further research? Further research and multicentre randomised control trials are needed to establish the effectiveness of the device in reducing the complications of episiotomy and risk of OASIS. The present study has shown the Episiometer as an acceptable and easy to use device amongst clinicians and can benefit the young clinicians as a teaching tool in directing a correct angle and length of episiotomy.

Which characteristics of the episiotomy and perineum are associated with a lower risk of obstetric anal sphincter injury in instrumental deliveries

ObjetiveOperative vaginal delivery (OVD) is the most important risk fact for obstetric anal sphincter injury (OASI). Knowledge of possible risk factors for their occurrence may therefore reduce the likelihood of faecal incontinence. The aim is to analyse the effect of mediolateral episitomy and perineum characteristics on the occurrence of OASI in OVD. Study DesignCase-control study, which included 958 OVD that were reviewed in Pelvic Floor and Puerperium Clinic. The episiotomy and perineum characteristics of those women who experienced OASIs (n = 150) were compared with those who had no evidence of anal sphincter injury (n = 788). ResultsIn multivariate logistic regression analysis the factors which were independently associated were nulliparity, persistent occipitoposterior position, birthweight >3500 g, an angle of episiotomy <30°, a distance episiotomy-fourchette <5 mm and a distance of perineal body <30 mm. The analysis of subgroups show that only the multiparous women does not benefit from any feature of the episiotomy, and an angle greater than 30° and a distance episiotomy-fourchette >5 mm are associated with a risk reduction of OASI in nulliparous, perineal bodies ≤30 mm and occipitoanterior position. ConclusionsTwo modifiable risk factors at the time of performing the episiotomy, the angle and distance episiotomy-fourchette, have been identified as the risk modification of OASI. It is necessary to achieve an adequate angle to reduce the probability of OASIs in OVD, and in nulliparous women with an anterior position and a distance of perineal body ≤30 mm could benefit from increasing the episiotomy-fourchette distance.

The optimal angle of the mediolateral episiotomy at crowning of the head during labor

The aim of the mediolateral episiotomy incision is to increase the diameter of the soft tissue of the vaginal outlet to facilitate birth and to prevent vaginal tears. Episiotomy angles that are too narrow and close to the midline increase the risk of obstetric anal sphincter injuries. In order to determine the optimal angle of the episiotomy, we assessed the changes in the angles of episiotomy lines marked during the first stage of labor and measured at the time of crowning of the head. Incision lines for mediolateral episiotomy were marked on the perineal skin at angles of 30°, 45°, and 60° from the midline during the first stage of labor in women with a singleton pregnancy. The angles of the marked lines were measured at crowning of the head. Mediolateral episiotomy was performed only for obstetric indications. The study included 102 women with a singleton pregnancy. Of these women, 50 were primiparous and 52 were multiparous. All angles marked during the first stage of labor increased significantly (by more than 30°) at crowning of the head. Similar changes were observed in primiparous and multiparous women. The angle of the mediolateral episiotomy line was significantly greater at crowning of the head than when marked during the first stage of labor. To achieve the desired episiotomy angle, it is important to take into consideration the changes in mediolateral episiotomy angles that occur during labor.

Episiotomy: What angle do you cut to the midline?

ObjectiveAlthough episiotomies are the commonest obstetric procedure performed the technique of performing one varies amongst obstetricians and midwives. The angle of episiotomy to the midline in particular has been shown to influence the risk of developing obstetric anal sphincter injuries (OASIS). In order to identify the differences in technique and to identify targets for training we undertook a practice survey of episiotomies to analyse the differences in technique between grades of obstetricians and midwives. Study designA prospective practice survey of staff working on delivery suite in a tertiary referral unit with 9000 deliveries/year was conducted between 01/10/2014 to 01/03/2015. Each participant was provided with a pictoral representation of a perineum and a pair of standard episiotomy scissors and asked to perform an episiotomy as per their usual practice. The profession and grade of each participant was recorded along with information regarding the incision including the angle to the midline, length of incision and lateral starting distance from the midline. One way ANOVA (unrelated) was used to perform statistical analysis using IBM SPSS v23. Results101 staff members participated in the practice survey including 63 midwives, 9 junior trainees, 15 senior trainees and 14 consultants. The mean angle of incision to the midline of episiotomies was 47°, 51°, 66° and 77° for midwives, junior trainees, senior trainees and consultants respectively. The mean angle of incision performed by midwives was significantly different to senior trainees (p>0.01) and consultants (p<0.01). 45% of all episiotomies undertaken by midwives were done at an angle <45° to the midline, compared to 7% by senior trainees and none by consultants. ConclusionsThis study identified clear deficiencies in the performance of episiotomies amongst obstetric trainees and midwives. Both midwives and obstetric trainees need to improve their technique if episiotomies are going to influence the incidence of OASIS and, more importantly the development of faecal incontinence. These results should be used to inform future training programmes to reduce the risks of OASIS.

Evaluation of training programme uptake in an attempt to reduce obstetric anal sphincter injuries: the SUPPORT programme

The objective was to assess the feedback from a quality improvement training programme to reduce obstetric anal sphincter injuries (OASIS). Training sessions were organised that included evidence-based information on OASIS risk factors and training on models to measure perineal body length (PBL), perform episiotomies with standard and 60° fixed angle scissors (EPISCISSORS-60®), and measure post-delivery episiotomy suture angles with protractor transparencies. Feedback forms using a Likert scale (1-4) were completed and analysed. The setting was an evidence-based quality improvement programme (Strategy for Using Practical aids for Prevention of OASIS, Recording episiotomies and clinician Training [SUPPORT]) at two National Health Service (NHS) Hospitals in the UK. The participants were midwives and doctors attending the SUPPORT training programme RESULTS: All of the participants (100%) would recommend the training programme to a friend or colleague. 92% felt that the training session improved their knowledge of the impact of PBL and perineal distension and their knowledge of the relationship between episiotomy angle and OASIS "a lot" or "somewhat". Based on this feedback, we recommend the addition of the knowledge content of the SUPPORT programme to other centres providing perineal assessment and repair courses.

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI. A PubMed search (1989–2014) of studies and systematic reviews on risk factors for OASI. Perineal distension (stretching) of 170 % in the transverse direction and 40 % in the vertical direction occurs at crowning, leading to significant differences (15–30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43–50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute ( 60°) are associated with an increased risk of OASI. Suture angles of 40–60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10 mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40–50 %, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head. Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.

Comparison of obstetric anal sphincter injuries in nulliparous women before and after introduction of the EPISCISSORS-60(®) at two hospitals in the United Kingdom.

AimTo assess whether the introduction of episiotomy scissors specially designed to achieve a cutting angle of 60°, EPISCISSORS-60®, in two hospitals in the UK would result in a reduction in obstetric anal sphincter injuries (OASIS) in nulliparous women.MethodsA structured training program for all doctors and midwives provided a theoretical framework around OASIS including risk factors and the role of episiotomies and a practical hands-on training element to use EPISCISSORS-60® correctly and to measure perineal body length and post-suturing angles. Data for perineal body length, post-suturing angles, user feedback, episiotomy use, and incidence of OASIS were collected through specifically designed forms and the general hospital data collection system.ResultsData were available for 838 nulliparous vaginal deliveries. Mean perineal body length was 37 mm in spontaneous vaginal delivery group (standard deviation [SD] =8.3, 95% confidence interval [CI] =34–39) and 38 mm in the operative vaginal delivery group (SD=8, 95% CI=35–40). Post-suturing episiotomy angles were 53° (SD=6.5, 95% CI=50.7–55.8) in spontaneous vaginal deliveries and 52° (SD=9.6, 95% CI=49–54) in operative vaginal deliveries. EPISCISSORS-60® were rated as “good” to “very good” by 84% of users. There was a 47% increase in the number of episiotomies in nulliparous spontaneous vaginal deliveries at Poole (P=0.007) and a 16.5% increase in the number of episiotomies in nulliparous operative vaginal deliveries in Hinchingbrooke (P=0.003). There was an overall 11% increase in episiotomy numbers in nulliparous vaginal deliveries (P=0.08). There was a statistically significant OASIS reduction of 84% in nulliparous spontaneous vaginal deliveries in women who received an episiotomy (P=0.003).ConclusionInitial results after introduction of EPISCISSORS-60® show that the majority of health care professionals achieve post-suturing episiotomy angles between 40° and 60°. The results also show a significant increase in the use of episiotomies in the delivery of nulliparous women. There has been a statistically significant reduction in OASIS in nulliparous spontaneous vaginal deliveries.

Differences in characteristics of mediolateral episiotomy in proffesionals at the same hospital

Objectives: The objective of our study was to compare the theoretical concept of the accoucheur in our institution with regard to the characteristics of the mediolateral episiotomy (MLE), with a crowning head and after a delivery. Methods: We devised two simple pictorial questionnaires (one with a crowning head and the other in rest after a delivery) in order to explore possible differences in clinical practice between the accoucheurs of our institution with respect to the MLE characteristics. Results: With a crowning head, we found more acute angles when the age of accoucheurs was greater than 35 years old and more than 15 years of experience, but no with the perineum at rest. No difference was found between doctors and midwives, nor between males and females. 28.1% of accoucheurs indicated an acuter episiotomy angle with a crowning head. Conclusion: This study confirmed that the individual interpretation of MLE differed widely among professionals at the same hospital. These differences which have been shown could predispose women to a greater risk of anal sphincter injuries. For this reason, there is a need to standardize this practice, to make the technique more homogeneous, particularly in the context of future research into the risks and benefits of episiotomy with respect to major perineal trauma.

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions.

Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI. A PubMed search (1989-2014) of studies and systematic reviews on risk factors for OASI. Perineal distension (stretching) of 170% in the transverse direction and 40% in the vertical direction occurs at crowning, leading to significant differences (15-30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43-50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute (<30°) and too lateral (>60°) are associated with an increased risk of OASI. Suture angles of 40-60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40-50%, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head. Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.

Randomized trial comparing episiotomies with Braun-Stadler episiotomy scissors and EPISCISSORS-60(®).

IntroductionEpisiotomy angle is a crucial factor in causation of obstetric anal sphincter injuries (OASIS), which are the major cause of female bowel incontinence. Sutured episiotomies angled too close to the midline (<30 degree) or too far away from the midline (>60 degree) fail to unload the perineum sufficiently and predispose to OASIS. A 25-degree post-delivery episiotomy suture angle has a 10% risk of OASIS while 45-degree episiotomy is associated with 0.5% risk. To account for perineal distension at crowning, a 60-degree episiotomy incision is required to achieve 43–50 degree suture angles. We compared episiotomy suture angles with commonly used Braun-Stadler episiotomy scissors with the new fixed angle EPISCISSORS-60®.MethodsEthical approval was obtained. A prospective cluster randomization design was chosen. Thirty-one patients were required in each group for a 12-degree difference with power at 90% and 5% significance. Sutured episiotomy angles and post-delivery linear distance from caudal end of the sutured episiotomy to the anus were measured with protractors and rulers. Two-tailed t-tests were used to compare the two groups.ResultsThirty-one nulliparae had episiotomies with EPISCISSORS-60®, 32 with Braun-Stadler. Mean age (25 versus 24.8 years) was similar. EPISCISSORS-60® episiotomies were angled 12 degrees more laterally away from the anus compared to Braun-Stadler (40.6 degrees, 95% confidence interval [CI] ±2, interquartile range [IQR] 35–45 versus 28.3 degrees, 95% CI ±2, IQR 25–30, P<0.0001). The post-delivery linear distance from caudal end of the sutured episiotomy to the anus was 15 mm more with the EPISCISSORS-60® compared to Braun-Stadler (35 mm, 95% CI ±2.2, IQR =30–39 versus 19.5; 95% CI ±1.3, IQR =14.75–22.25 P<0.0001). EPISCISSORS-60® episiotomies measured longer (47 mm versus 40 mm, P<0.0001). There were no OASIS cases in the EPISCISSORS-60® group versus one in the Braun-Stadler group.ConclusionThe EPISCISSORS-60® sutured episiotomies are much further away from the midline in angular and distance measures, hence at lower OASIS risk.

The correct episiotomy: does it exist? A cross-sectional survey of four public Israeli hospitals and review of the literature.

Our objective was to assess episiotomy technique used in Israeli hospitals, to determine factors influencing incision parameters, and to review relevant up-to-date professional literature. Using anonymous questionnaires, a survey was conducted among obstetricians and midwives in the four public hospitals in northern Israel over a 1-year period commencing in October 2013. In addition to demographic and professional data, the accoucheurs were asked to describe the technique they usually use to perform an episiotomy (length, angle, and distance of initiation point from midperineum). Overall, 84 obstetricians and 32 midwives participated in the survey. Only 37.6% reported performing a mediolateral episiotomy, while the rest described the lateral type, placing the initiation point at an average distance of 2.45 ± 0.88 cm from the fourchette. Compared with midwives, obstetricians reported performing a significantly longer episiotomy (3.53 ± 1.01 vs. 2.73 ± 0.81 cm, p = 0.0002). According to our study and relevant literature review, the technique of episiotomy varies significantly between health professionals and is not uniformly congruent with international practice guidelines. In part, this is derived from unclear literature evidence and lack of consensus definition for proper technique of this procedure by the national guidelines. Thus, further higher-quality research, uniform protocols, and educational programs are needed to guide episiotomy practice.

Cutting an episiotomy at 60 degrees: how good are we?

Episiotomy is regarded as the most common maternal obstetric surgical procedure. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with a perineal tear. We tested the hypothesis that all doctors and midwives can perform an episiotomy when prompted to, specifically cut at 60° from the midline (in a simulation model). Doctors and midwives attending the BMFMS Annual Meeting (2014), Croydon Perineal Trauma Course and staff at Poole General Hospital were invited to cut a paper replica of the perineum with a commonly used episiotomy incision pad. Participants were prompted to cut an episiotomy at 60° to the perineal midline with the anus as a reference point. The angles and distances were measured using protractors and rulers. A 58-62° band was deemed acceptable to account for measurement errors. A total of 106 delegates participated. Only 15 % of doctors and midwives cut an episiotomy between 58 and 62°. Over one third (36 %) cut the episiotomy between 55 and 65° (inclusive). Nearly two thirds either underestimated the angle (<55°; 44 %), or overestimated the angle (>66°; 18 %). Thirty-six and 7.5 % of episiotomies were cut at <50 and >70° respectively. The origination point of the episiotomy was 5 mm away from the midline (IQR 1-8 mm). This original observational study shows that doctors and midwives were poor at cutting at the prompted episiotomy angle of 60°. This highlights the need to develop structured training programmes to improve the visual accuracy of estimating angles or the use of fixed angle devices to help improve the ability to estimate the desired angle.

Trigonometric characteristics of episiotomy and risks for obstetric anal sphincter injuries in operative vaginal delivery

The objective of this study was to investigate the association between the trigonometric properties of episiotomy in operative vaginal delivery (OVD) and obstetric anal sphincter injuries (OASIS). The study included 72 primiparous women who had an OVD and episiotomy. Cases (n = 36) had sustained OASIS at birth, while controls (n = 36) had not. The groups were matched for instrumental delivery. The episiotomy scar was identified and its trigonometric characteristics were measured at 8-12 weeks postpartum. Data were analysed using conditional logistic analysis. The angle of episiotomy behaves as a factor associated with anal sphincter injury, so women with a mediolateral episiotomy and an angle greater than 20° have an 87% less risk of having an OASIS (odds ratio 0.13, 95% confidence interval 0.03-0.58). The study showed that scarred episiotomies at 8-12 weeks after OVD with an angle ≤ 20°, depth and distance between the episiotomy and anus ≤ 15 mm, total upper triangle perimeter ≤ 75 mm, para-anal triangle perimeter ≤ 15 mm and areas between scar and midline ≤ 250 mm(2) were significantly associated with higher risk of OASIS. When a mediolateral episiotomy is performed in OVD the technique has a strong effect on the occurrence of OASIS. Additional research is needed to determine if the optimal technique for mediolateral episiotomies produces less OASIS than deferring the performance of episiotomy.