Restrictive Use Of Episiotomy Research Articles

Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain.

Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. Observational cross-sectional study. Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy. There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. No patient or public contribution.

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.

French guidelines for restrictive episiotomy during instrumental delivery were not followed by an increase in obstetric anal sphincter injury

The objective was to assess the influence of the French guidelines in favor of a restrictive use of episiotomy on both episiotomy and obstetric anal sphincter injury (OASI) rates during instrumental delivery. It was aulticenter study involving 193 maternities between 2000 and 2016. We included women with a singleton pregnancy, with cephalic presentation at 34 weeks of gestation or more who underwent an instrumental delivery. The study period was divided into three phases: 2000–2005 (reference) 2006–2011, and 2012–2016. We calculated the adjusted relative risk (aRR) of episiotomy and OASI and investigated for changes in episiotomy and OASI rates over time by using Prais–Winsten regression. We considered 96,035 deliveries. The episiotomy’s risk was lower in 2006–2011 (69.4%) and 2012–2016 (59.1%) compared to 2000–2005 (81.2%), respectively: aRR 0.93 [0.92–0.95] and 0.89 [0.87–0.90]. The OASI’s risk was higher in 2006–2011 (2.5%) and 2012–2016 (3.1%) compared to 2000–2005, respectively: aRR 1.30 [1.10–1.53]) and 1.57 [1.33–1.85]. However, Prais–Winsten regression showed no difference in the OASI rate during the study period. We observed a massive decrease in episiotomy use and a moderate increase in crude OASI’s rate but multivariate analysis failed to report an association between these outcomes.

Attitudes and knowledge regarding episiotomy use and technique in vacuum extraction: A web-based survey among doctors in Sweden

ObjectivesCorrect episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women. Study designA web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length ≥ 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy. ResultsWe received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in<50% of vacuum extractions. We obtained 308 illustrated episiotomies with a median angle of 53°, incision point distance from the midline of 21 mm, and length of 36 mm, corresponding to a lateral episiotomy. Few doctors combined these parameters correctly resulting in 167 (54.2%) incorrectly drawn episiotomies. Residents drew shorter episiotomies than obstetricians and gynecologists. Doctors ranked episiotomy the least important intervention to prevent obstetric anal sphincter injuries in vacuum extraction. Doctors contributing to an ongoing randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction were more able to draw a protective episiotomy (OR 3.69, 95% confidence interval 1.94–7.02). ConclusionsDoctors in Sweden reported restrictive use of episiotomy in vacuum extraction and depicted lateral type episiotomies, although the majority were incorrectly drawn. Preventive episiotomy was ranked of low importance. Our results imply a need for education, training, and guidelines to increase uptake of correct episiotomy technique, which could result in improved prevention of obstetric anal sphincter injuries.

A nationwide cross-sectional survey of episiotomy practice in China

SummaryBackgroundA restrictive use of episiotomy was recommended by the obstetric society in China, but limited information on the epidemiology and the effects of restrictive use of episiotomy on maternal and fetal outcomes have been published.MethodsThe China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016 with the aim to describe detailed epidemiology of labor and delivery in China. We calculated the episiotomy rate by parity using the survey data. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched women.FindingsThe episiotomy rate among vaginal births was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3rd or 4th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits.InterpretationEpisiotomy was performed more than medically necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3rd and 4th degree perineal laceration in nulliparae without neonatal benefits.FundingNational Natural Science Foundation of China and Shanghai Health Commission Programme.

National Trends in Utilization of Episiotomy and Factors Associated with High-Utilization Centers in the United States

Background: Restrictive use of episiotomy has been recommended given potential risks of routine use. However, recent trends in episiotomy utilization and disparities in its use have not been examined at the national level in the United States. The present study aimed to characterize trends in episiotomy use and examine factors associated with high utilization.

Episiotomy Practice in China

Background: A restrictive use of episiotomy was recommended by the obstetric society in China, but limited information has been published on the episiotomy practice at a country level. While midline episiotomy has been demonstrated as a risk factor for 3 rd or 4 th degree lacerations, the effects of mediolateral episiotomy (the more common type) in China, remain unclear. Methods: The China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016. We calculated the episiotomy rate by parity at national and regional levels. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched “normal” women. Findings: The episiotomy rate was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3 rd or 4 th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits. Interpretation: Episiotomy was performed more than medical necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3 rd and 4 th degree perineal laceration in nulliparae without neonatal benefits. Funding: The project was supported by National Natural Science Foundation of China (81273091) and Shanghai Health Commission Programme (GWIV-26.2). Declaration of Interest: The authors declare that they have no competing interests. Ethical Approval: The study protocol was approved by the Research Project Review Panel of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction at the Department of Reproductive Health and Research of WHO, and the WHO Research Ethics Review Committee, Geneva, Switzerland, and the ethics committees at the Xinhua Hospital and all participating centers.

Factors Associated with Episiotomy Practices in Bahirdar City, Ethiopia: A Cross-Sectional Study.

BackgroundEpisiotomy is the surgical enlargement of the vaginal orifice during the last part of the second stage of labor or childbirth by an incision to the perineum. The World Health Organization advises the use of episiotomy on a restricted and selective basis. Indeed, the rate of episiotomy in developed countries is decreasing, but in developing countries, including Ethiopia, it still remains high. Therefore, this study tried to assess the proportion and factors associated with episiotomy among women who gave birth at Felege Hiwot Referral Hospital, Bahir Dar City, North West Ethiopia, 2017.MethodsAn institution-based cross-sectional study was conducted among 411 mothers from February to April 2017. Data were collected through face-to-face interviews and supported by observation using standard checklist with systematic random sampling technique. Data was entered by Epi Info and analyzed by SPSS version 23. The association between variables was analyzed using bivariable and multivariable logistic regression model. P-value <0.05 at 95% CI was considered to be statistically significant.ResultsThe proportion of episiotomy was 41.1% with 95% CI (36.5%, 46.2%). Multivariable logistic regression showed that primiparity (AOR=6.026, 95% CI (3.542,10.253)), prolonged second stage of labor (AOR=4.612, 95% CI (2.247,9.465)), instrument delivery (AOR =3.933, 95% CI (1.526,10.141)), using oxytocin (AOR=2.608, 95% CI (1.431,4.751)), medical resident attendant (AOR =3.225, 95% CI (1.409,7.382)) and birth weight ≥4000 grams (AOR=5.127,95% Cl (1.106,23.772)) were significantly associated with episiotomy practice.ConclusionThe proportion of episiotomy was high. Parity, using oxytocin, second-stage labor duration, instrument delivery, birth weight, and delivery attendant were statistically significant factors for episiotomy practice. Therefore, as per our findings, we suggest awareness creation, and the setting and use of new national guidelines, the practice of routine episiotomy should be abandoned, and selective and restrictive use of episiotomy is highly advised.

Qualitative views on episiotomy amongst accouchers and pregnant women in a tertiary hospital in Southern Nigeria

Background: In 2018, the World Health Organization recommended the restrictive use of episiotomy by midwives and obstetricians on pregnant women undergoing vaginal birth. Unfortunately, the use of episiotomy is still fairly common in Africa. Aim: We examined the qualitative views on episiotomy amongst accouchers and pregnant women at the Rivers State University Teaching Hospital in southern Nigeria. Methods: A cross-sectional design was employed. Census sampling was used to enrol 19 accouchers (house officer doctors = 7 and nurse-midwives = 12) and 43 third-trimester pregnant women. Narrative data were collected through focused group discussion using an interview guide and a digital audio recorder. Collected data were transcribed and subjected to coding, content and thematic analysis to enable categorisation of themes. Results: Respondents were 22–46 years old. The accouchers mentioned several indications for episiotomy which were not consistent with current evidence in literature. In contrast to pregnant women's views, the accouchers reported that episiotomy is a clinician's choice, so pre-informing the pregnant woman about it is optional. Pregnant women were of the view that they should be more involved by being the ones to decide whether they want to receive episiotomy or not. Even when the accouchers viewed episiotomy as having some clinical uses, the pregnant women suggested that episiotomy should be banned. Conclusion: The views of the accouchers and pregnant women were not totally aligned with each other. More sensitisation of accouchers and pregnant women is required to ensure re-alignment of views based on available evidence.

Mediolateral Episiotomy: Technique, Practice, and Training.

Episiotomy is one of the most common obstetric procedures. However, restrictive use of episiotomy has led to a decrease in its use in the United States. Historically, mediolateral episiotomy has been performed less often than median episiotomy in the United States, but both have purported advantages and disadvantages. Emerging research on episiotomy and obstetric anal sphincter injuries has led to an examination of the effects of mediolateral episiotomy. This article describes performance of a mediolateral episiotomy in a situation of fetal bradycardia. Technical aspects of the incision and repair are described, and outcome data and knowledge gaps are summarized. Implications for practice, clinical competency, and education are reviewed.

Review of Episiotomy and the Effect of its Risk Factors on Postepisiotomy Complications at the University of Port Harcourt Teaching Hospital.

Aim:This study aimed to determine the prevalence of episiotomy and postepisiotomy complications and to assess the relationship between the risk factors and postepisiotomy complications in the University of Port Harcourt Teaching Hospital.Methodology:This was a descriptive longitudinal study, in which 403 consecutive women who had episiotomy in the labor ward were recruited for the study. They were followed up and reviewed at the postnatal clinic on the 1st and 6th weeks postdelivery. Data regarding age, marital status, occupation, educational status, address, parity, booking status, postepisiotomy complications, and the associated risk factors were entered adequately into a prestructured pro forma, and statistical analysis was done using statistical software (SPSS for Windows® version 19.0). t-test was used to explore the association of risk factors to postepisiotomy complications.Results:The episiotomy rate was 22.1%. The prevalence of postepisiotomy complications was 52.1%. The mean age of the women was 23.8 (standard deviation ± 3.2) years. Seventy-two (34.3%) patients had perineal pain, which lasted for 72 h or more; 61 (29.1%) had difficulty in walking, while 37 (17.6%) had perineal discomfort. Four (1.9%) had wound infection and only one (0.4%) had wound dehiscence. The development of postepisiotomy complications was not statistically significantly associated with risk factors such as gestational age (T = 1.4, P = 0.1), packed cell volume on admission (T = 1.0, P = 0.2), duration of first stage of labor (T = 0.5, P = 0.1), duration of second stage of labor (T = 0.7, P = 0.3), duration of rupture of fetal membranes (T = 0.8, P = 0.4), delivery repair interval (T = 0.6, P = 0.2), estimated blood loss (T = 0.9, P = 0.2), duration of Sitz bath (T = 1.0, P = 0.2), duration of analgesic (T = 1.2, P = 0.1), duration of antibiotics (T = 1.3, P = 0.1), or the operator who performed or repaired the episiotomy (P = 0.2).Conclusion:The prevalence of episiotomy and postepisiotomy complications in this study was high. Necessary attention should be given to ensure adequate pain relief for all parturients who had episiotomy, and the policy of restrictive use of episiotomy should be fully implemented in the department in line with the best practices and evidence-based recommendations. This will further reduce the incidence of episiotomy rate as well complications that may arise from it and ensure a positive pregnancy experience for pregnant women.

Evaluation of episiotomy in present day obstetric practice

Background: Episiotomy, a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is one of the most performed surgical procedures in the world, especially for nulliparous women. Episiotomy itself is comparable to a 2nd degree perineal injury. The concept of restrictive episiotomy came where its use is restricted to only high-risk cases such as shoulder dystocia, short rigid perineum, face to pubis delivery, vaginal breech delivery, and instrumental deliveries. We decided to carry out a study to evaluate this common obstetric procedure and try to decipher its role in the present day obstetric practice. Methodology: This was a prospective cohort study on 200 women admitted to the labor room and satisfying the inclusion/exclusion criteria. The cases were then divided into two groups of 100 each by simple randomization by chit method. The participants of one group (Group A) were not given episiotomy unless it was inescapable and was considered as the study group and in the other group (Group B) episiotomy was given to all the patients and was considered as the control group. Results: The overall rate of episiotomy in the control group was 100% as per study protocol and that in study group 27%. The restricted use of episiotomy resulted in a significant reduction in overall episiotomy rate. Conclusion: This study was conducted to evaluate the practice of restrictive episiotomy and compare it with routine episiotomy. We found that the net outcome of restrictive episiotomy was better than routine episiotomy and this was statistically significant with respect to parturition-related perineal trauma, postpartum pain, and maternal satisfaction of the entire birthing process.

The study and use of Episiotomy Evaluation Form in the restrictive use of episiotomy

Objective To be good for the different working age midwives to carry out the same evaluation of the pregnant woman, we build and use the Episiotomy Evaluation Form for reducing the rate of episiotomy with ensuring the safety of mother and baby. Methods Consult relevant literature, combine clinical practice, discuss, report to the hospital ethics committee many times and at last it was made after approval. The details included: perineal lesions, perineum elasticity, perineal length, maternal coordination, gestational age, age, fetal distress degree, amniotic fluid situation, the weight of fetus estimated, the second time of labor and so on,to score by 0, 1, 3, 5, 20. A total of 600 patients with low risk of natural childbirth were randomly divided into observation group and control group according to method of random number table with 300 cases each.The observation group was graded according to the perineal incision evaluation and we operated according to its use method. The control group was judged according to the experience of midwife and subjective cognition. At last compared the effects on the mother and baby. Results The rates of lateral episiotomy and I degree laceration were 15.00% (45/300) and 63.00% (189/300) in the observation group and 48.33% (145/300) and 21.67% (65/300) in the control group, respectively. The difference between the two groups was statistically significant (χ2=16.238, 21.507, P 0.05). Conclusions By using the episiotomy evaluation form, we can improve the accuracy and homogeneity of the midwife's assessment about the episiotomy which is benefit to reduce rate of episiotomy. It is worth promoting in clinical practice but we should ensure the safety of maternal and child. Key words: Episiotomy Evaluation Form; Restrictive use of episiotomy

Restricted Use of Episiotomy

ABSTRACT Aim There is extensive disagreement about the necessity and benefits of routine episiotomy for all. The American Congress of Obstetricians and Gynecologists Committee on Practice Bulletins, 2006 based on good scientific evidence recommends restricted use of episiotomy to be preferred, yet its restricted use is not being practiced. Keeping these in mind, the study was done with the aim to assess the effects of restrictive use of episiotomy during vaginal birth. Materials and methods This was a prospective study. Singleton primigravida term vaginal deliveries over 3 months were included. Under the policy of restricted use of episiotomy, great restraint was observed in giving an episiotomy. Mediolateral episiotomy was given in women where expected baby weight &gt;3 kg or perineal tear was anticipated, and in cases of instrumental deliveries. Perineal tears, postpartum status, and satisfaction level of women were compared between patients with or without episiotomy. Data so obtained were analyzed. Results About 29.8% women delivered with episiotomy, 65.5% had intact perineum; 5.67% women had first-degree perineal tear and only 1.42% women had second-degree perineal tear using a policy of restricted use of episiotomy. None of the women had third- and fourth-degree perineal tear. Patients delivered without episiotomy were more comfortable in terms of less perineal pain, early evacuation of bladder, and ambulation. Conclusion With the restricted use of episiotomy using precise clinical judgment, the unnecessary episiotomies could be avoided, giving better care and patient satisfaction with minimum maternal morbidity. Clinical significance The policy of restricted use of episiotomy would result in considerable reduction in maternal morbidity, decreased hospital stay and overall cost, and good patient satisfaction level. How to cite this article Dadhich B, Hooja N, Sharma A, Aseri S, Sharma A, Kumawat B. Restricted Use of Episiotomy. J South Asian Feder Obst Gynae 2017;9(3):260-262.

Third and fourth degree perineal tears: incidence and risk factors in an Italian setting

Vaginal delivery is associated to spontaneous perineal tears. They can be classified into mild (I and II degree) and severe (III and IV degree), the latter involving damage of anal sphincter. III and IV degree laceration rate is considered a useful quality indicator of obstetrical care. Prevalence rates vary from 0.6% to 8%. They can produce significant long-term morbidity. Complications can include fecal incontinence and dyspareunia. Fistula or abscess formation can require secondary surgical repair. Great effort was given in last years to identify women at risk of developing severe perineal tears and methods to prevent them. There are conflicting data about some other risk factors and there is no consensus about preventive measures. This study aimed to identify risk factors for severe perineal tears in an Italian setting. This retrospective study analyzed deliveries from January 2011 to December 2015. Data were extracted from dedicated software of a single Italian hospital. Singleton pregnancy, cephalic presentation and vaginal delivery after 20 weeks of g.a. were inclusion criteria. Patients who developed a severe perineal tear as consequence of the delivery were included in group A, otherwise in group B (control). Data regarding population characteristics, antenatal care, labour and delivery characteristics and fetal parameters were analyzed. Statistical analysis was performed with JMP statistical software. Pearson Chi-square test and Wilcoxon test were performed. A p < 0.05 was considered significant. 10,133 patients were analyzed. 62 patients (0.61%) had a severe perineal tear and were included in group A. Group B consisted of remaining 10,071 patients. Results are shown in Table 1 as percentage or mean ± standard deviation. Anal sphincter or mucosal injuries are identified in 3–4% of all vaginal births and this rate does not seem to be reduced by restrictive use of episiotomy. Established risk factors recognized by Royal Collage of Obstetricians and Gynecologists are birth weight > 4 kg, persistent occipitoposterior position, nulliparity, induction of labour, epidural analgesia, II stage longer than 1 h, shoulder dystocia, midline episiotomy, operative delivery. This is the first work evaluating III and IV degree tears in a pure Italian scenario. Our experience confirmed that birth weight > 4 kg, longer II stage, shoulder dystocia, operative delivery and nulliparity are risk factors for severe perineal tears. Moreover we found out that delivery after 40 weeks of g.a., moderate and severe obesity, non-vertex presentations, use of oxytocin in pushing stage, major fetal biometry and lithotomy position during delivery could be additional risk factors for III and IV degree tears. Several risk factors were identified. In addition to well established risks factors, we found out some new interesting risk factors that requires confirmation from other studies.

Rate and Risk Factors for Episiotomy at King Hussein Medical Center : A One Year Review from the Department of Obstetrics and Gynecology King Hussein Medical Center

Objective: To determine the rate and risk factors for episiotomies at King Hussein medical center Jordan-Amman. Methods: This was a record review study conducted at King Hussein medical centre during a 12month period between January 2013 and January 2014 on all women who had vaginal deliveries of a term alive single fetus in cephalic presentation. Information on age, parity, mode of vaginal delivery, birth weight of the newborn, and episiotomy rate, were recorded. Simple descriptive statistics, (Frequency and percentage), were used to describe the variables. Results: The episiotomy rate was 52% in our hospital. The most common indications were nulliparous, instrumental deliveries, rigid perineum, fetal weight above 3,500 g, and prolonged second stage of labor. Conclusion: The episiotomy rate is high at our hospital (52%) in the face of current evidence based literature that supports restricted use of episiotomy. Nulliparity and instrumental deliveries appear to be the risk factors for episiotomy.

Influence d’une forte diminution du recours à l’épisiotomie appliquée à une situation à haut risque périnéal : le dégagement en occipito-sacré

Occiput-posterior presentation represents 5% of all deliveries and is a high-risk situation for perineal tears requiring, for some authors, an episiotomy. The aim of this study was to evaluate the impact of an ultra-restrictive policy in the use of episiotomy on perineal tears in this high-risk situation. This is a retrospective cohort study in a tertiary maternity comparing perineal outcome of occipito-posterior (OP) to occipito-anterior deliveries. We included all, spontaneous or assisted, live single pregnancies that delivered after 37 weeks in OP from January 2008 to December 2012. This group was then compared to a control group of occipito-anterior pregnancies. Episiotomy rate was similar in both groups (1.3 versus 1.8 in OP; p=0.5). We found more second degree perineal tears in the OP group (p<0.001) but severe perineal tears rate was similar. There was no increase in post-partum haemorrhage rate. Neonatal outcome was less favourable in the OP group. A restrictive use of episiotomy in OP does not increase the risk of severe perineal tears and does not worsen perineal prognosis.

Variation in and factors associated with use of episiotomy.

Episiotomy is a common obstetric procedure, estimated to be performed in 25% of vaginal deliveries in the United States in 2004.1 Restrictive use of episiotomy has been recommended given the risks of the procedure and unclear benefits of routine use. In 2006, the American Congress of Obstetricians and Gynecologists recommended against routine episiotomy,2 and, in 2008, the National Quality Forum recognized limiting routine episiotomy as an important measure of quality and patient safety, noting increased risks of pain, laceration, and anal incontinence with the procedure.

The role of episiotomy in prevention of genital lacerations during vaginal deliveries--results from two European centers.

There is an ongoing debate regarding the routine versus restrictive use of episiotomy The study aim was to investigate if episiotomy during vaginal deliveries can reduce both, the number and severity of genital lacerations. The study included all women who gave vaginal birth at AOU. "G. Martino" Messina (n=382) and the Clinic for Ob/Gyn Clinical Center of Serbia, Belgrade (n=4227) during 2011. Lacerations during birth were recorded and divided according to location and severity Women with lacerations were subdivided into two groups: with or without mediolateral episiotomy We assessed potential risk factors for laceration: maternal age, parity use of labor stimulants and epidural analgesia, participation in antenatal classes, fetal presentation, neonatal birth weight, and duration of the second stage of labor. Older women had higher grade perineum or combined lacerations. Children with higher birth weight in occipito-posterior presentation caused higher grade lacerations. Performance of episiotomy was connected with fewer perineum and labial lacerations. There were no differences in laceration grade between patients with and without episiotomy Assessed parameters proved to be good discriminating factors between lacerations sites. According to logistic regression, laceration site was the most important risk factor for laceration grade. Combined lacerations had the highest grade. Episiotomy can significantly reduce the number of genital lacerations, but it does not influence laceration grade. Advanced maternal age, higher parity occipitoposterior presentation and fetal macrosomia can cause lacerations during vaginal birth. Therefore, we suggest analysis of maternal and fetal factors to prevent widespread genital lacerations.

313: Maternal and neonatal outcomes following implementation of a policy of restricted use of episiotomy

313: Maternal and neonatal outcomes following implementation of a policy of restricted use of episiotomy