Episiotomy Group Research Articles

Obstetric Anal Sphincter Injury After Episiometer-Guided Versus Conventional Episiotomy in Instrumental Deliveries: A Randomized Controlled Trial.

Guidelines recommend episiotomy for instrumental vaginal delivery with an optimal incision angle of 60° to protect the anal sphincter. The "Episiometer" is a new device promising a 60° incision angle. We compared the incidence of obstetric anal sphincter injury (OASI) and post-repair suture angle of episiotomies made with conventional "eyeballing" versus Episiometer guided during instrumental delivery. We conducted this randomized controlled trial in a tertiary care teaching institute in southern India after ethical committee approval, trial registration, and informed consent. We randomized (block) 328 pregnant women aged 18 years and above with term, singleton fetuses delivered by instruments into Episiometer-guided (164) or conventional episiotomy (164) groups (allocation concealed). We compared the OASI (identified clinically) and the suture angle measured from the midline (assessor blinded) in the two groups. We followed up on the subjects at 6 and 12 weeks to assess perineal pain and fecal/flatus incontinence. The incidence of OASI of 0.61% in the Episiometer group was significantly lower compared with 4.88% in the eyeballing group (Chi-squared = 5.6; p = 0.02; adjusted risk ratio = 5.9; CI 0.7-46.1; p = 0.09). A significantly higher proportion of subjects (59.1%) in the Episometer group had a post-suture angle between 36 and 40° compared with 36.6% in the eyeballing group (Chi-squared = 21.8, p < 0.001). We found no significant difference in the perineal pain or Wexner score during follow-up. The Episiometer-guided episiotomy during instrumental delivery resulted in a significantly higher suture angle and lower obstetric anal sphincter injuries than with conventional eyeballing.

Levator Ani Muscle Avulsion After Vaginal Delivery Comparing Routine Versus Restrictive Episiotomy: A Pilot Study.

The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy. This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening. Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups. In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs). Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge. Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052). Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Restrictive v/s Routine episiotomy in Primigravida

Introduction: Episiotomy is the surgical enlargement of the vaginal orifice by an incision on the perineum during the last part of the second stage of labour or delivery. Episiotomy is the most common surgical procedure experienced by women. In near past there were many studies pointed out its disadvantages like more post-delivery pain, wound complications and dyspareunia. So, this study was done to compare use of restrictive episiotomy and routine episiotomy in primigravidae undergoing vaginal birth. Aims and objectives: To assess the effects of restrictive use of episiotomy in comparison with routine episiotomy in primigravida during vaginal birth in terms of - (1) No. of episiotomies can be avoided (2) Perineal tear (3) Blood loss (4) Hematoma &amp; Healing complications (5) Faecal &amp; urinary incontinence (6) Dyspareunia. Material and methods: This study was descriptive analytic study conducted in the Department of Obstetrics and Gynecology, Surat municipal institute of medical education and research (SMIMER), Surat from January 2017 to June 2019 with sample size of 148 patients. Results: This study included total 148 patients, where 74 were selected randomly in each group. In Restrictive Episiotomy group, out of 74 patients, Episiotomy was required in 18 (24.32%) patients. Thus, Episiotomy was avoided in 56 (75.68%) patients. Mean duration of second stage of labour in Routine Episiotomy group was 31.88 ± 5.37min and in Restrictive Episiotomy group it was 32.35 ± 3.73min, which was suggestive of no statistically significant difference. (p value = 0.5375). Total 4.05% patients in Routine group and 13.51% patients in Restrictive group suffered from anterior vaginal tear which was statistically significant (p value = 0.021). There were 2 cases (18%) of 2nd degree perineal tear in routine episiotomy group which were 8(40%) in restrictive episiotomy group. The difference was statistically assessed by Chi-square and found to be significant (p value=0.2399). Not a single case of 3rd &amp; 4th degree perineal tear in either group. In Routine Episiotomy group, suturing was done in 100% patients. While restricted episiotomy group only 44.59% needed suturing which was statistically significant (p value:&lt;0.0001). Average blood loss in Routine group was 341.89 ± 49.33ml and in Restrictive group was 301.01 ± 52.41ml. So, there was significantly higher blood loss in Routine Episiotomy group. (p value= 0.000002). Complications rate in the form of episiotomy wound gap and hematoma was higher in routine group in 5.41% patients as compared to 1.35% patients in Restrictive group. Postpartum perineal pain at 1 week (14 v/s 5) and 2 weeks (5 v/s 1) was significantly higher in routine group as compared to the restrictive group. Postpartum perineal pain at 1 week and 2 weeks was significantly higher in routine group as compared to the restrictive group. Conclusion: In conclusion on the basis of our study, the immediate outcomes of routine episiotomy are no better than the restrictive use of episiotomy. Indeed, routine use is harmful to the degree that some proportion of women who would have had lesser injury instead had a surgical incision. The routine use of episiotomy has higher incidence of peripartum blood loss, requirement of suturing, postpartum perineal pain and healing complications. The policy of restrictive use of episiotomy is not associated with any third and fourth degree perineal tear or adverse neonatal outcomes.

Two year follow-up and comparison of pelvic floor muscle electromyography after first vaginal delivery with and without episiotomy and its correlation with urinary incontinence: A prospective cohort study.

Few prospective studies have revealed the long-term neuromuscular alterations of pelvic floor after vaginal delivery. The aim of this study was to evaluate the impact of episiotomy on the electrical activity of pelvic floor muscle 2 years following vaginal delivery, and explore the relation between surface electromyography (sEMG) amplitudes and urinary incontinence. A total of 427 primiparous women with full-term singleton vaginal delivery were included in the cohort and 362 with no further births within the 2 year follow-up completed observations. Of these, 200 underwent episiotomy and 162 underwent nonepisiotomy. Clinical demographic characteristics, vaginal EMG variables and urinary incontinence-specific questionnaire scores were collected at 6 weeks, 6, 12 and 24 months after childbirth, respectively. Primary outcomes were the comparison of sEMG values between the episiotomy and nonepisiotomy groups throughout 2 years. Secondary outcomes were the correlation between sEMG of both groups and the incidence and severity of urinary incontinence. Spearman's correlation analysis, Kruskal-Wallis test and ANOVA with Bonferroni correction were used to analyze the variables. Amplitude of maximal fast and endurance contractions on sEMG in the episiotomy group was significantly lower than the nonepisiotomy counterpart. Such difference of sEMG persisted for a long period after birth: endurance contraction, 33.12 ± 8.92 vs 35.085 ± 9.98, p < 0.01 at 24 months, and fast contraction, 36.53 ± 8.87 vs 39.05 ± 9.98, p=0.01 at 12-month. Although there was no significant difference in incidence and severity of urinary incontinence between both groups, a negative correlation existed between EMG values of muscle contraction and urinary incontinence symptoms throughout. Primiparous women delivered with episiotomy demonstrated lower contractile sEMG activity of pelvic floor muscle in the long term. The lower sEMG values of fast contraction were associated with urinary incontinence symptoms.

Examining the Association Between Episiotomy and Severe Perineal Tears in a Tertiary Care Center Implementing a Restrictive Episiotomy Policy.

Background Perineal lacerations are feared complications of vaginal delivery, especially the severe types (third- and fourth-degree tears). World Health Organization (WHO) recommended restrictive episiotomy practice after alarming literature linked the increase in severe tears with routine episiotomy. Therefore, this study aimed to measure the association between episiotomy and the incidence of third- and fourth-degree perineal tears and infections in women who underwent episiotomy versus those who did not at a tertiary care center implementing the restrictive episiotomy policy in Jeddah, Saudi Arabia. Methods This retrospective cohort study was conducted in the Department of Obstetrics and Gynecology at King Abdulaziz Medical City (KAMC), Western Region, between May 2016 and May 2018, targeting all pregnant women who underwent normal spontaneous vaginal delivery. The nonprobability convenient sampling technique was used for women who underwent episiotomy. Women without episiotomy (control group)were randomly selected in a 1:1 ratio. The prevalence (incidence) of episiotomy and its association with severe perineal tears were measured. Statistical data were analyzed using SPSS version 27 (IBM Corp., Armonk, NY). A p-value of less than 0.05 was considered significant. Result A total of 7436 deliveries were recorded. At KAMC, episiotomy had a prevalence of 10% and was more common in primipara. The incidence of third-degree tears was 3.3% in the episiotomy group and 0.8% in the control group (odds ratio, 4.1; p = 0.03). None had fourth-degree tears. Furthermore, the infection rate was not significantly different between the two groups (0.1% vs. 0.1%). Using Firth's logistic regression model, primipara emerged as an independent significant risk factor (OR, 3.5 [1.1-11.2]; p = 0.035)while the trend toward increased risk for tear development in the episiotomy group became statistically insignificant (OR, 2.3 [0.7-8.0]; p = 0.19). A post hoc examination to observe the association between episiotomy exposure and BMI using a stepwise logistic regression model showed that parity and age were independent risk factors for episiotomy, with OR values of 2.2 (1.6-3.2) and 0.9 (0.88-0.94), respectively (p < 0.001). The BMI became insignificant, with an OR of 1.0 (0.7-1.4) (p = 0.96). Conclusion The development of severe perineal tears in acenter with a restrictive episiotomy policy is rare. Parity has emerged as an independent risk factor for severe perineal tears.Prospective multicenter research with a larger sample size is recommended to validate this study's findings further and investigate other obstetric measures to reduce severe tears in primi mothers.

Perineal stress as a predictor of performing episiotomy in primiparous women: a prospective observational study

BackgroundEpisiotomy is a surgical solution to relieve perineal stress, resulting in an easily repairable incision, in comparison to the risks of serious vaginal trauma during delivery. The midwife typically adopts such a clinical decision, on experience and subjective judgment. However, the association between perineal stress and episiotomy is poorly characterized. Our aim was to identify a threshold value for perineal stress leading to episiotomy, which eventually may be employed as a clinical tool for assessing whether an episiotomy is required or not.MethodsIn total, 245 nulliparous women were investigated for perineal stress during non-instrumental vaginal delivery in Ningbo Women & Children’s Hospital. During the second stage of labor, a flexible membrane stress sensor was placed between the fetal head and perineal wall above the anal fissure. Once the entire fetal head pressed against the sensor, real-time perineal stress was measured, and the peak value was recorded. Cases were divided into non-episiotomy group (n = 173) and episiotomy group (n = 72). The correlations between perineal stress and episiotomy was assessed through logistic regression with adjustment for maternal age, estimated birthweight, duration of second stage of labor, maternal body mass index, and presence of analgesia. Midwives were blinded to all stress measurement values. The predictive value of perineal stress on performing episiotomy was evaluated, together with the ideal cut-off perineal stress value for performing episiotomy. A ROC analysis was also performed.ResultsThe episiotomy group had significantly higher levels of perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 N versus 118.37 ± 19.21 N, p < 0.01). The episiotomy group was linked to significantly higher perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 VS 118.37 ± 19.21 N, p < 0.01). ROC analysis between perineal stress and episiotomy revealed a high area under the curve (AUC 0.81, 95% CI 0.75–0.86) and a cut-off value for perineal stress of 124.49 N was identified for episiotomy decision.ConclusionThe level of perineal stress was an independent predictor of performing episiotomy in nulliparous women during non-instrumental vaginal delivery. Perineal stress exceeding 124.49 N was identified as the cut-off prompting midwives to perform episiotomy.

Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies

BackgroundTo assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes.MethodThis was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital.ResultsThe primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals.ConclusionSelective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China.

EVALUATION of WOUND HEALING in EPISIOTOMY and CESAREAN INCISIONS USING REEDA SCALE

Some factors that prevent wound healing delay healing. Therefore, evaluation and monitoring of wounds is an important intervention. The use of scales in wound assessment is one of the factors that facilitate nursing care and increase the visibility of nursing functions. This descriptive and comparative study was conducted to evaluate wound healing in episiotomy and cesarean section incisions with the REEDA (Redness, Edema, Ecchymossıs, Discharge, Approximation) scale. The population of the study consisted of patients hospitalized in the gynecology and obstetrics clinic of a university hospital between 20.06.2019 and 02.08.2019, and the sample consisted of a total of 107 women, 53 of whom had a vaginal delivery with episiotomy and 54 who had a cesarean section. Research data were collected using the Patient and Wound Diagnosis Form, the REEDA Scale, and the Numerical Rating Scale. Statistical evaluation of the data was done using IBM SPSS 22 program and R programming language. On the 1st follow-up day of the study, it was determined that the REEDA scale total scores were higher in the episiotomy group and the difference was statistically significant (p&lt;0.05). It was observed that the total scores of the scale did not create a significant difference between the groups on the 3rd and 7th follow-up days (p&gt;0.05). In episiotomy incisions, the sub-subscale scores of the scale were higher on all follow-up days for redness, on the 1st and 3rd follow-up days for edema, and on the 1st follow-up day for discharge (p&lt;0.05). The sub-subscale scores in cesarean section incisions were found to be higher and statistically significant on the 3rd and 7th follow-up days for ecchymosis and on the 7th follow-up day for discharge and approximation (p&lt;0.05). According to REEDA scale scores, it was determined that the healing process in cesarean section wounds was longer than in episiotomy incision wounds.

Selective episiotomy versus no episiotomy – A clinical study on primigravida

Background: Episiotomy is the incision given over the pudendum, i.e. on the external genitalia organ during the vaginal delivery.&#x0D; Aims and Objective: In this study it has been tried to evaluate the benefits and the risks of selective episiotomy over spontaneous lacerations.&#x0D; Materials and Methods: This is an institution based interventional longitudinal study carried out in the Department of Obstetrics &amp; Gynaecology of College Of Medicine &amp; JNM Hospital, Kalyani over a period of 18 months in 218 patients (109 in each group) fulfilling the inclusion criteria. The recruitment and allocation in episiotomy and non-episiotomy groups were random after proper consent from the participants.&#x0D; Results: The frequency of postpartum perineal pain was around 47% in no episiotomy group and around 60% in selective episiotomy group. There were no cases of dehiscence, haematoma or wound infection in either of the groups. Around 96.22% of the women in the non-episiotomy group were satisfied or very satisfied compared to 89.52% in the selective episiotomy group.&#x0D; Conclusion: An episiotomy rate of less than 1% found in no episiotomy group as compared to around 18% episiotomy rate in selective episiotomy group. However, they have almost same feto-maternal outcome which successfully establish the effectiveness of no episiotomy practice over the selective one.

Episiotomy and Its Complications

Objectives: This study aimed to evaluate the frequency of episiotomy and its early complications in natural vaginal delivery in the maternity ward of Ali Ibn Abitaleb (AS) Hospital in Zahedan from 2014 - 2016. Methods: In this cross-sectional study, which was conducted in 2017, the archives of women who gave birth between 2014 - 2016 were reviewed. Data were collected using information forms and analyzed by SPSS software. Results: Of 418 women were reviewed, the episiotomy rate was 54.5%; there was a significant association between parity and mother age with episiotomy rate. Moreover, 24-hour pain frequency, perineal rupture rate, hematoma rate was significantly higher in the episiotomy group. First- and fifth-minute Apgar of the neonates in the episiotomy group was significantly lower. Conclusions: In overall, the episiotomy rate was 54.5%, and there was a significant association between parity and mother age with episiotomy rate.

The effect of episiotomy on pelvic floor muscle function within six months after first childbirth through electromyography and questionnaires assessment

Objective: To compare the impact of mediolateral episiotomy on pelvic floor muscle (PFM) function through surface electromyography (sEMG) and quality of life questionnaire assessment. Methods: From January 2018 to June 2019, 1 250 eligible primiparous women were enrolled in Beijing Hospital and the First People's Hospital of Yunnan Province. Participants were divided into episiotomy group (n=676)and non-episiotomy group (n=574). Both groups underwent clinical pelvic examination, sEMG assessment, and quality of life (QOL) questionnaire assessment at two fixed time points: 6-8 weeks, 6 months after vaginal delivery. Follow-up of sEMG amplitudes and their correlation with QOL questionnaire scores were evaluated. Results: Among the women delivered with episiotomy, the peak amplitude of phasic contraction (PPC) was (17.7±5.3) μV at 6-8 weeks after childbirth and (29.6±8.7) μV at 6 months after childbirth. The mean amplitude of tonic contraction (MTC) was (14.8±7.4) μV and (22.2±8.9) μV, respectively. In the non-episiotomy group, PPC was (20.0±7.9) μV and (35.4±10.7) μV at 6-8 weeks and 6 months, and MTC was (17.8±9.0) μV and (27.5±8.9) μV, respectively. Compared with EMG amplitudes at 6-8 weeks, both PPC and MTC significantly improved at 6 months in both groups (all P<0.01). Moreover, episiotomy was related with significantly lower PPC and MTC at both fixed checkups. Besides, both IIQ-7 and PFIQ-7 questionnaire scores improved at 6 months compared with those at 6-8 weeks in both groups (all P<0.001). There was consistently significant difference in QOL scores between episiotomy and non-episiotomy group at two checkups (all P<0.05). A negative correlation was observed between PFM contractile amplitudes and QOL scores at both time points after childbirth (all P<0.05), and the correlation weakened with time. Conclusion: Episiotomy has a negative impact on the postpartum PFM contractile function within 6 months after childbirth. The negative correlation between the sEMG and QOL scores indicates that sEMG is a candidate assessment for PFM function follow-up after childbirth.

Effects of lateral episiotomy on the emergence of urinary incontinence during the first postpartum year in primiparas: prospective cohort study.

Aim of the studyLateral episiotomy is a widely used procedure, although it is rarely mentioned in the literature and its effects on the pelvic floor are largely unexplored. The purpose of this study is to evaluate the impact of lateral episiotomy on the incidence of urinary incontinence (UI) after vaginal delivery in primiparas.Material and methodsThe study design is a prospective cohort study. The primiparas were divided into two groups. The first group consisted of women who gave birth with lateral episiotomy, while the second group included women who gave birth with an intact perineum or with perineal tears of first and second degree. Assessments of UI were performed at 5 and 8 months after childbirth using the International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF) questionnaire followed by the stress test.ResultsThe results revealed no significant differences (p > 0.05) in emergence of stress urinary incontinence (SUI) between the groups at the two time points. There were no statistically significant differences in overall rate of UI, urge urinary incontinence (UUI), or mixed urinary incontinence according to the ICIQ-SF questionnaire. The overall incontinence rate on the first examination was 24% in the episiotomy group and 36% in the perineal laceration group, although the difference was not statistically significant (p = 0.064). On the second examination, rates were similar and without a statistically significant difference.ConclusionsLateral episiotomy has a neutral effect on the onset of UI in primiparous women in the first year after delivery.

Comparison of lateral episiotomy, traditional midwifery without episiotomy, and hands-off techniques delivery on pelvic floor function

BackgroundProlonged vaginal delivery times and episiotomy are associated with damage to the muscles of the pelvic floor, and with complications that include postpartum sexual dysfunction and urinary stress incontinence. This study was to compare the pelvic floor function among postpartum women who underwent three midwifery practices during labor: lateral episiotomy, traditional midwifery without episiotomy, and hands-off techniques delivery. MethodsWe included 320 primipara who were full-term pregnancy and underwent vaginal delivery in Department of Obstetrics, Peking University People’s Hospital, China. 117 women had episiotomy during labor and were classified into the lateral episiotomy group; 103 had traditional midwifery without episiotomy and were classified into the traditional midwifery practice group; and 100 experienced hands-off techniques during labor and were classified into the hands-off techniques delivery group. The duration of the second stage of labor, and postpartum pelvic floor muscle strength were compared between the three study groups. ResultsThere were no significant differences between the three groups for the duration of the second stage of labor and postpartum pelvic floor muscle strength (P ​> ​0.05). However, the incidence of postpartum urinary stress incontinence and sexual dysfunction in the hands-off techniques delivery group was significantly lower than in the lateral episiotomy groups and the traditional midwifery practice group (P ​< ​0.01). ConclusionsHands-off techniques delivery could reduce damage to the pelvic floor and improve the quality of life for women after delivery.

Postpartum perineal pain and dyspareunia related to each superficial perineal muscle injury: a cohort study.

To assess the association between superficial perineal muscle trauma and perineal pain and dyspareunia. Prospective cohort study of 405 women with a spontaneous vaginal birth comparing an intact perineum and first-degree perineal trauma group (n =205) with a second-degree perineal trauma and episiotomy group (n =200). Perineal pain was measured at 2days, 10days, 7weeks, 3months and 6months postpartum. Dyspareunia was assessed at 7weeks, 3months and 6months postpartum. All second-degree perineal traumas and episiotomies involved damage to the bulbospongiosus muscle (BSM), but not always to the superficial transverse perineal muscle (STPM). In case of second-degree trauma or episiotomy, the odds of pain at 10days and dyspareunia at 6 months postpartum were four- and five-fold greater, respectively, than if the perineum had remained intact or suffered a first-degree perineal trauma [OR 4.4 (95% CI: 2.8-6.9) and OR 5.5 (95% CI: 2.8-10.9), respectively]. When comparing injuries where > 50% BSM ± STPM against those with < 50% BSM torn, pain was significantly higher at 10days postpartum [OR 1.9 (95% CI: 1.1-3.6], with no difference at 7weeks, while dyspareunia was significantly higher at 6 months postpartum [OR 3.3 (95% CI: 1.4-7.8)]. There was no difference in perineal pain or dyspareunia when comparing first-degree with < 50% BSM traumas. When perineal muscle trauma encompasses > 50% BSM ± STPM, perineal pain and dyspareunia persisted until 10days and 6months postpartum, respectively.

Episiotomy related morbidities measured using redness, edema, ecchymosis, discharge and apposition scale and numerical pain scale among primiparous women in Mulago National Referral Hospital, Kampala, Uganda.

Introductionepisiotomy induced inflammatory signs like redness, edema, ecchymosis and pain may remain beyond the period of hospitalization and can be objectively measured using redness, edema, ecchymosis, discharge and apposition (REEDA) scale. Pain in the postpartum period is a common problem and can be measured using the numerical pain scale (NPS). Episiotomy is normally poorly executed and poorly repaired with little attention to the subtle pain-free scar. Postpartum perineal pain has been found to affect more people with episiotomy compared to spontaneous perineal tears or contusion in the first two weeks. This study was aimed at comparing NPS and REEDA scores in the first two weeks of postpartum among primiparous parturients with or without episiotomy in Mulago National Referral Hospital.Methodsa prospective cohort study conducted by recruiting primiparous women systematically on the first postnatal day and categorizing them into episiotomy and no episiotomy group. NPS and REEDA scale were taken at baseline and 2 weeks postpartum.Resultsthe mean total REEDA score for primiparous women among the episiotomy group was significantly higher both on day 1 and day 14 with p-values <0.0001 and <0.0001 respectively as well as the day 14 mean NPS p-value 0.001.Conclusionepisiotomy, a traumatic obstetric procedure, that heals slowly and with persistent perineal pain compare to spontaneous perineal contusion or tears.

1081: Suturing of episiotomy incision is not easier than repair of spontaneous perineal tears

Episiotomy is a common procedure worldwide; however, its value in prevention of various maternal and neonatal complications remains unproven. One of the common assumptions is that suturing of episiotomy, a straight incision which length and depth are determined by the obstetrician, might be easier compared to repair of unpredictable spontaneous perineal tears. The objective of our study was to examine this hypothesis. The data for this study was collected prospectively, as part of randomized controlled trial that examined the effects of episiotomy avoidance on advanced perineal tears in women towards their first vaginal delivery, compared to standard care. For the current analysis we compared suturing characteristics between two groups: vaginal deliveries in which episiotomy was performed, vs. deliveries with spontaneous perineal tears. Suturing characteristics included the duration of the repair, amount of suture packs and subjective rating of suturing difficulty (rated from 1 to 5). Of 525 vaginal deliveries, episiotomy was performed in 165 (31.5%) of the cases, 60 of which (36.4%) were accompanied by additional vaginal tears. Spontaneous vaginal tears without episiotomy were noted in 182 deliveries. The two groups did not differ in terms of various demographic and obstetric characteristics (age, body mass index, gestational age or birthweight); however, in the episiotomy group longer second stage and a higher percentage of vacuum extraction deliveries were noted (Table 1). No difference in the amount of suture packs or suturing difficulty was found between the two groups; however, in episiotomy group significantly higher rates of suturing duration above 10 minutes were noted (Table 1). According to our results, suturing of episiotomy is not easier, and might even be more complicated than the repair of spontaneous perineal tears. It might be related to the unpredictable nature of perineal tears, which might be shorter and shallower compared to the standard episiotomy incision.

658: Prophylactic episiotomy for prevention of perineal tears in women with high striae gravidarum score

Our study aims to assess the role of prophylactic episiotomy in multiparous women with high striae gravidarum score as a preventive measure for perineal tears Randomized controlled study. We included multiparous women with singleton full-term pregnancy. Striae gravidarum (SG) score was assessed according to Atwal score at four body site (Abdomen, breast, buttocks, hips). Women with moderate or severe SG (Total score >12) were randomized to Group (A): episiotomy was done after crowning of the fetal head during the second stage of labour and Group (B): no episiotomy was done. The primary outcome was the rate of third and fourth perineal tears. the secondary outcomes included the rate of first and second degree perineal tears, para-urethral tears, vaginal tears, cervical tears, number and length of perineal tears. Two-hundred fifty women were included in the study. The final analysis included 114 patients in group A and 119 patients in group B who delivered vaginally. Both groups were similar regarding the baseline characteristics (p >0.05). No statistical significant difference between both groups regarding the total striae score and the individual scores at each body site. Moreover, no difference between both groups regarding the duration of second stage of labor (p =0.121) and the neonatal birth weight (p = 0.827). The overall incidence of perineal tears was significantly high in women delivered without episiotomy than episiotomy group (90.4% vs. 23.5% respectively, p<0.001). In addition, the incidence of third and fourth degree perineal tears was significantly higher in delivery without episiotomy group (15% vs. 3.3%, p=0001). Similarly, the incidence of first and second degree perineal tears was significantly higher in delivery without episiotomy group (75.4% vs 20.2%, p=0.001) than episiotomy group. No statistical significant difference between both groups regarding the incidence of para-urethral, vaginal and cervical tears (p=0.127, 0.294 and 0.164 respectively). Additionally, no difference in the incidence of multiple tears (p=0.742) and the length of tears between both groups (p=0.284). Prophylactic episiotomy in multiparous women with high SG score seems to be an effective method in decreasing the rate of perineal tears during vaginal delivery especially the third and fourth degree perineal tears

Evaluation of Accuracy of Episiotomy Incision in a Governmental Maternity Unit in Palestine: An Observational Study.

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.

New approach to the evaluation of perineal measurements to predict the likelihood of the need for an episiotomy.

Episiotomy is performed selectively during vaginal delivery. Among the maternal anthropometric factors for episiotomy, the length of the perineal body (pb) and genital hiatus (gh) defined as per the POP-Q system have been studied. The objective of our study was to compare two perineal measurements (defined as per the POP-Q system and the anogenital distance [AGD] concept) to determine which of these can predict the likelihood of an episiotomy being performed. An observational prospective cohort study was designed. Anthropometric data (pb, gh, symphysis-coccyx distance, distance between ischial tuberosities, AGDaf [anus-fourchette], and AGDac [anus-clitoris]), duration of the second stage of labor, and neonatal biometric data were collected from 119 women included in this study. Statistical analysis was performed using Student's t test for unpaired data, Mann-Whitney, and Chi-squared tests. Receiver operating characteristic (ROC) curves were generated to compare AGDaf, AGDac, and "gh + pb" with the presence of episiotomy. A shorter "gh + pb" length and AGDac were risk factors for episiotomy. Compared with AGDac, gh + pb was a slightly better predictor in ROC curve analysis. Furthermore, a longer duration of second-stage labor was evident in the episiotomy group. This study introduces measures of AGD as risk factors for episiotomy. We propose that "gh + pb" length <77mm and AGDac <93mm may predict the likelihood of requiring episiotomy and may be useful for diminishing subjectivity in the decision to perform an episiotomy.