Routine Use Of Episiotomy Research Articles

A multifaceted intervention to increase prophylactic oxytocin use during the third stage of labor and to reduce routine episiotomies in Nicaragua

ObjectiveTo assess the effect of a multifaceted intervention among skilled birth attendants on the use of oxytocin during the third stage of labor, the active management of the third stage of labor (AMTSL), and the rate of routine episiotomy during vaginal births in two health districts in Nicaragua. MethodsAn uncontrolled before-and-after study design was used. The rates of oxytocin use in the third stage of labor, AMTSL, and episiotomy were measured for vaginal births occurring in eight hospitals and health centers during 2011–2012, before and after implementation of a multifaceted facility-based intervention. The intervention involved the use of opinion leaders, interactive workshops to develop and implement evidence-based guidelines, academic detailing, the use of reminders, and feedback on the rates of oxytocin use and episiotomy. ResultsOxytocin use during the third stage of labor increased significantly from 95.3% to 97.4% (P=0.003). The episiotomy rate dropped significantly from 31.2% to 21.2% overall, and from 59.6% to 40.5% in primiparous women (P<0.001 for both comparisons). ConclusionThe multifaceted intervention improved the targeted care practices during childbirth. However, a further decrease in the routine use of episiotomy would be desirable.

Can major systematic reviews influence practice patterns? A case study of episiotomy trends

Episiotomy is one of the most commonly performed procedures among women of childbearing age in the United States. In 2005, a major systematic review conducted by Hartmann and colleagues recommended against routine use of episiotomy and was widely covered in the media. We assessed the impact of the Hartman et al. study on episiotomy trend. Based on 100% hospital discharge data from eight states in 2003-2008, we used interrupted time series regression models to estimate the impact of the Hartman et al. review on episiotomy rates. We used mixed-effects regression models to assess whether interhospital variation was reduced over time. After controlling for underlying trend, episiotomy rates dropped by 1.4 percentage points after Hartman et al. publication (p < 0.01 for spontaneous delivery; p < 0.1 for operative delivery). The publication has smaller effect on government hospitals as compared to private hospitals. Mixed effects models estimated negative correlation between cross-time and cross-hospital variations in episiotomy rates, indicating reduced cross-hospital variation over time. Our results suggested that there has been a gradual decline in episiotomy rates over the period 2003-2008, and that synthesis of evidence showing harms from routine episiotomy had limited impact on practice patterns in the case of episiotomy. The experience of episiotomy illustrates the challenge of using comparative effectiveness and evidenced-based medicine to reduce use of unnecessary procedures.

Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two‐centre randomised controlled trial of restrictive versus routine use of episiotomy

ObjectiveTo explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy.DesignLongitudinal prospective cohort study embedded within a two‐centre randomised controlled trial (RCT).SettingTwo UK tertiary‐level maternity units.PopulationAntenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD.MethodsA self‐completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum.Main outcome measuresUrinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity.ResultsLongitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01–1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00–2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum.ConclusionsMorbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.

Risk factors for birth‐related perineal trauma: a cross‐sectional study in a birth centre

To identify maternal, newborn and obstetric factors associated with birth-related perineal trauma in one independent birth centre. Risk factors for birth-related perineal trauma include episiotomy, maternal age, ethnicity, parity and interventions during labour including use of oxytocin, maternal position at time of birth and infant birth weight. Understanding more about these factors could support the management of vaginal birth to prevent spontaneous perineal trauma, in line with initiatives to reduce routine use of episiotomy. Cross-sectional study. Data were retrospectively collected from one independent birth centre in Brazil, during 2006-2009. The dependent variable (perineal trauma) was classified as: (1) intact perineum or first-degree laceration, (2) second-degree laceration and (3) episiotomy (right mediolateral or median). There were 1079 births during the study period. Parity, use of oxytocin during labour, position at time of giving birth and infant birth weight were associated with second-degree lacerations and episiotomies. After adjusting for parity, oxytocin, maternal position at the expulsive stage of labour and infant birth weight influenced perineal outcomes among primiparae only. Although the overall rate of episiotomies in this study was low compared with national data, it was observed that younger women were most vulnerable to this intervention. In this age group in particular, the use of oxytocin as well as semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. The use of upright alternative positions for birth and avoidance of use of oxytocin could reduce the risk of perineal trauma from lacerations and need to perform episiotomy.

Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study

BackgroundThe role of episiotomy as a protective factor against pelvic floor disorders postpartum has been debated for many years, but its routine use has been hitherto discouraged in the literature. Comparisons between restrictive and routine use of episiotomy in existent literature, however, fail to include any consideration relating to quality of life. The aim of this study, therefore, is to state the role of episiotomy in preserving the perineum from damage, in order to prevent the influence of pelvic floor disorders on women's psycho-physical wellness after the sixth month postpartum.MethodsA follow-up telephone interview was performed among 377 primiparous and secondiparous Caucasian women who had a child by spontaneous or operative vaginal delivery in 2006 using a self-created questionnaire and King's Health Questionnaire (KHQ).ResultsThe mean age at delivery was 35.26 (±4.68) years and episiotomy was performed in 59.2% of women. Multivariate linear regression shows episiotomy associated to higher quality of life after the sixth month postpartum by correlating with inferior values of King's Health Questionnaire (p < 0.05).ConclusionsEpisiotomy appears to be a protective factor for women's wellness. Women who had episiotomy and who experienced perineal symptoms have a better psycho-physical health status in the 12.79 months (±3.3) follow-up.

Childbirth practices in Jordanian public hospitals: consistency with evidence-based maternity care?

In 1996, the World Health Organization stated that 'childbirth is a natural process and in normal birth, there should be a valid reason to interfere with this natural process' and encouraged practices that are evidence-based. The practices encouraged included avoiding unnecessary augmentation of labour, facilitating upright position for birth and restricting the use of routine episiotomy. Many countries have been slow to fully implement evidence-based practice in maternity care. The aim of this study was to examine maternity hospital practices in Jordan and assess their consistency with evidence-based maternity care. An explorative research design with non-participant observation was used. Data were collected from low-risk women during labour and birth using a questionnaire for maternal characteristics and an observational checklist. A proportional stratified sample was selected to recruit from three major public hospitals in Jordan. Data were analysed using descriptive statistics. A total of 460 women were observed during labour and birth. The majority were multiparous (80%). A range of interventions were observed in women having a normal labour including augmentation (95%), continuous external fetal monitoring (77%), lithotomy position for birth (100%), and more than one third (37%) had an episiotomy with varying degrees of laceration (58%). Childbirth practices were largely not in accordance with the World Health Organization evidence-based practices for normal birth. High levels of interventions were observed, many of which may not have been necessary in this low-risk population. Further work needs to occur to explore the reasons why evidence-based practice is not implemented in these hospitals.

Restricted use of episiotomy

Objective To compare the outcome of restricted versus routine use of episiotomy in a tertiary care center.

Lateral episiotomy protects primiparous but not multiparous women from obstetric anal sphincter rupture

To identify the risk factors for obstetric anal sphincter rupture (OASR). Retrospective population-based register study. A total of 514,741 women with singleton pregnancy and vaginal delivery between 1997 and 2007 in Finland. Primiparous (n = 2,315) and multiparous women (n = 534) with OASR were compared with primiparous and multiparous women without OASR by using stepwise logistic regression analysis. The OASR risk. Episiotomy decreased the likelihood of OASR for the primiparous [odds ratio (OR) 0.83, 95% CI (confidence interval) 0.75-0.92], but not the multiparous women (OR 2.01, 95% CI 1.67-2.44). The strongest risk factors for OASR among the primiparous women were forceps delivery (OR 10.20, 95% CI 3.60-28.90), birth weight over 4,000 g (OR 4.66, 95% CI 3.86-5.63), vacuum assisted delivery (OR 3.88, 95% CI 3.25-4.63), occiput posterior presentation (OR 3.17, 95% CI 1.64-6.15), and prolonged active second stage of birth (OR 2.06, 95% CI 1.65-2.58). Episiotomy was associated with decreased risks for OASR in vacuum assisted deliveries (OR 0.70, 95% CI 0.57-0.85). Risk factors for OASR among the multiparous women included forceps delivery (OR 10.13, 95% CI 2.46-41.81), prolonged active second stage of the birth (OR 7.18, 95% CI 4.32-11.91), birth weight over 4,000 g (OR 5.84, 95% CI 3.40-10.02), and vacuum assisted delivery (OR 4.17, 95% CI 3.17-5.48). The results support the restrictive use of episiotomy, since 909 episiotomies appear to be needed to prevent one OASR among primiparous women. Equivalent estimate in vacuum assisted deliveries among primiparous women was 66, favoring routine use of episiotomy in such cases.

A Randomized Controlled Trial of Routine Versus Restrictive Use of Episiotomy at Operative Vaginal Delivery: A Multicentre Pilot Study

The use of episiotomy as a routine component of operative vaginal delivery (OVD) is decreasing. Although a majority of physicians believe that routine use of episiotomy at OVD is protective against anal sphincter tears, the evidence on this issue is conflicting. A recent large retrospective Dutch study reported that episiotomy was highly protective against anal sphincter tears. This randomized controlled pilot study compared the maternal and neonatal outcomes of routine versus restrictive use of episiotomy at OVD in 200 nulliparous women expected to deliver at ≥37 weeks of gestation with live singleton cephalic pregnancies. The women were recruited in the antenatal period at 2 urban maternity units in Scotland and England between 2004 and 2006. Of the 200 study subjects, 99 were randomized to routine use of episiotomy (in all cases) and 101 to restrictive use of episiotomy (only if tearing becomes apparent). Anal sphincter tearing (third or fourth degree) was the primary outcome. Compared with restrictive use of episiotomy, routine use was associated with only a small and statistically insignificant difference in the rate of anal sphincter tears (8.1% routine vs. 10.9% restrictive); the odds ratio (OR) was 0.72, with a 95% confidence interval (CI) of 0.28 to 1.87. Routine use of episiotomy was associated with a slight but statistically insignificant increase in the incidence of both primary postpartum hemorrhage: 36.4% routine vs. 26.7% restrictive, with an OR of 1.57 and a 95% CI of 0.86 to 2.86, and neonatal trauma: 45.5% routine versus 43.6% restrictive, with an OR 1.08 and a 95% CI of 0.62 to 1.89. There were also no statistically meaningful differences between the 2 groups in prolonged postnatal stay, prolonged catheterization, urinary or fecal incontinence, perineal infection, rates of shoulder dystocia, or pain requiring moderate or strong analgesia. The findings of this small pilot study provide no evidence to support a policy of either routine or restrictive use of episiotomy at OVD and suggest the need for a large randomized controlled trial.

Avoidance of Routine Use of Episiotomy in Primigravida

Background and objective: The justification of the routine use of the episiotomy arouse at the beginning of 20th century. It was based on personal beliefs without scientific basis and this led to the incorporation of episiotomy in daily practice . High-quality methodological studies gave strong evidence that episiotomy should not be done routinely. The purpose of this study was to find out the rate and degrees of perineal tear in women with versus without episiotomy and to evaluate the severity of pain and complications including wound infection, wound dehiscence and dyspareunia. Methods: This is a prospective interventional study included 200 primigravida with term pregnancy, who attended the labor room at Maternity Teaching Hospital from 1st of January 2008 till 1st of July 2008. Episiotomy was done for a group and avoided in another group, then follow up was done to evaluate complications. Results: Perineal tears were significantly more in patients with episiotomy as episiotomy itself is regarded as second degree perineal tear. There was significant difference in the severity of pain, wound infection and dyspareunia among both groups but there was no significant difference in the Apgar score of the newborn in both group. Conclusion: This study does not supports maternal benefits of routine episiotomy.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study

To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy. Pilot randomised controlled trial (RCT). Two urban maternity units in Scotland and England. Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period. If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy. The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum. In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission. This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.

The Need to Avoid the Routine Use of Episiotomy

The justification of the routine use of the episiotomy arose at the beginning of 20th century. It was based on personal beliefs without scientific basis that endorsed this recommendation. This led to the incorporation of episiotomy in daily practice being a routine procedure, especially in nulliparous women. Since 1985 many researches of good experimental design were generated to verify if routine episiotomy was justified. High-quality methodological studies gave strong evidence that the episiotomy should not be done routinely in view of the fact that it does give benefits neither for the women nor for the newborns. Its use should be restricted to certain clinical situations. However, the episiotomy continues to be a customary practice even though the available evidence for more than one decade ago shows that it does not improve maternal or perinatal health. This suggests that there is a need for implementing interventions to change practitioners behaviour. Keywords: Episiotomy, review, female, women rights, labour

Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates from 1983 to 2000

Goldberg, Jay MD; Holtz, David O. MD; Hyslop, Terry PhD; Tolosa, Jorge E. MD, MS Author Information

Has the use of routine episiotomy decreased? examination of episiotomy rates from 1983 to 2000

Has the use of routine episiotomy decreased? examination of episiotomy rates from 1983 to 2000

Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates From 1983 to 2000

In Brief OBJECTIVE To determine if practice patterns have been altered by the large body of literature strongly advocating the selective use of episiotomy. METHODS An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 to 2000 was completed. Univariate and multivariable models were computed using logistic regression models. RESULTS Overall episiotomy rates in 34,048 vaginal births showed a significant reduction from 69.6% in 1983 to 19.4% in 2000. Significantly decreased risk of episiotomy was seen based upon year of childbirth (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86, 0.87), black race (OR 0.29, 95% CI 0.28, 0.31), and spontaneous vaginal delivery (OR 0.40, 95% CI 0.36, 0.45). Increased association with episiotomy was seen in forceps deliveries (OR 4.04, 95% CI 3.46, 4.72), and with third- or fourth-degree lacerations (OR 4.87, 95% CI 4.38, 5.41). In deliveries with known insurance status, having Medicaid insurance was also associated with a decreased episiotomy risk (OR 0.59, 95% CI 0.54, 0.64). CONCLUSION There was a statistically significant reduction in the overall episiotomy rate between 1983 and 2000. White women consistently underwent episiotomy more frequently than black women even when controlling for age, parity, insurance status, and operative vaginal delivery. The overall episiotomy rate had a statistically significant reduction between 1983 and 2000 from 69.6% to 19.4%.

Has the use of routine episiotomy decreased? Examination of episiotomy rates from 1983 to 2000.

To determine if practice patterns have been altered by the large body of literature strongly advocating the selective use of episiotomy. An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 to 2000 was completed. Univariate and multivariable models were computed using logistic regression models. Overall episiotomy rates in 34,048 vaginal births showed a significant reduction from 69.6% in 1983 to 19.4% in 2000. Significantly decreased risk of episiotomy was seen based upon year of childbirth (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86, 0.87), black race (OR 0.29, 95% CI 0.28, 0.31), and spontaneous vaginal delivery (OR 0.40, 95% CI 0.36, 0.45). Increased association with episiotomy was seen in forceps deliveries (OR 4.04, 95% CI 3.46, 4.72), and with third- or fourth-degree lacerations (OR 4.87, 95% CI 4.38, 5.41). In deliveries with known insurance status, having Medicaid insurance was also associated with a decreased episiotomy risk (OR 0.59, 95% CI 0.54, 0.64). There was a statistically significant reduction in the overall episiotomy rate between 1983 and 2000. White women consistently underwent episiotomy more frequently than black women even when controlling for age, parity, insurance status, and operative vaginal delivery.

Female circumcision and episiotomy: both mutilation?

Many women worldwide undergo some form of female circumcision. The practice of female circumcision is more common in communities with high poverty levels and is usually undertaken by unqualified practitioners. The practice is deemed harmful by many health professionals because of the health problems associated with it. Episiotomy is a surgical procedure which is common in western cultures. It is strongly linked to an increased use of technology. The practice has been promoted by the medical and midwifery professions because it is perceived to be beneficial for the woman and her baby. However, a growing body of evidence suggests that the routine use of episiotomy is unlikely to confer any advantage on the woman and overuse of the procedure leads to short- and long-term morbidity. In this article, the two procedures are critiqued from a rational, scientific standpoint and the reasons for the enduring popularity of both procedures are explored.

A critical evaluation of the past 25 years of perinatal nursing practice: opportunities for improvement.

Changes in perinatal nursing over the past 25 years have been abundant. Nursing advocacy has contributed to the introduction of innovations such as single-room maternity care and family-centered care, and to the end of restrictive practices such as the use of hand and leg restraints during birth, routine use of episiotomy, and routine general anesthesia for normal births. Perinatal nursing involves complex clinical interventions, intensive patient and family education, empathetic support and evaluation of family dynamics, and a wide range of opportunities to make a difference in the lives of mothers, babies, and families. The strengths and weaknesses of perinatal nursing practice at the beginning of the new century are chronicled, and suggestions for improvements are made.

The Value of Routine Episiotomy in Forceps Deliveries

Objective: to determine the risk of third and fourth degree tears if episiotomy precedes operative forceps deliveries.Methods: a retrospective analysis was performed, identifying 319 women who had a forceps delivery. Two hundred and seventy-two women met our inclusion criteria term, singleton, cephalic presentation, with mid, low or outlet forceps). Patients having forceps deliveries with an episiotomy were compared to those with forceps deliveries and no episiotomy. Maternal age, parity, use of an epidural, gestational age, and birth weight were examined for each group. The incidence of third and fourth degree tears and the odds ratio between the two groups were determined.Results: there were no differences in demographic or clinical variables between the two groups. Compared to the patients without episiotomy (n = 46), patients having forceps deliveries with an episiotomy (n = 226) had a significantly higher incidence of third and fourth degree tears (odds ratio 2.8; 95% confidence interval 1.5–5.6).Conclusion: the routine use of episiotomy is possibly associated with an increased incidence of sphincteric injuries in patients undergoing forceps deliveries. The routine use of episiotomy with forceps delivery should be re-evaluated.

Episiotomy for vaginal birth.

Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear. The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth. We searched the Cochrane Pregnancy and Childbirth Group trials register. Randomised trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy. Trial quality was assessed and data were extracted independently by two reviewers. Six studies were included. In the routine episiotomy group, 72.7% (1752/2409) of women had episiotomies, while the rate in the restrictive episiotomy group was 27.6% (673/2441). Compared with routine use, restrictive episiotomy involved less posterior perineal trauma (relative risk 0. 88, 95% confidence interval 0.84 to 0.92), less suturing (relative risk 0.74, 95% confidence interval 0.71 to 0.77) and fewer healing complications (relative risk 0.69, 95% confidence interval 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (relative risk 1.79, 95% 1.55 to 2.07). There was no difference in severe vaginal or perineal trauma (relative risk 1.11, 95% confidence interval 0.83 to 1.50); dyspareunia (relative risk 1.02, 95% confidence interval 0.90 to 1.16); urinary incontinence (relative risk 0.98, 95% confidence interval 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison. Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.