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Muraca GM, Desai A, Hébert V, Mann GK, Park M, Lisonkova S, Joseph KS. Variation in Episiotomy Use Among Nulliparous Individuals by Maternity Care Provider and Associated Rates of Obstetric Anal Sphincter Injury. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102415. [PMID: 38387834 DOI: 10.1016/j.jogc.2024.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVES To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs). METHODS Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders. RESULTS The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48). CONCLUSIONS In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, ON; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON; Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden.
| | - Anvi Desai
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Vanessa Hébert
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Gurkiran K Mann
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Meejin Park
- Department of Global Health, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Levaillant M, Loury C, Venara A, Hamel-Broza JF, Legendre G. Is there still an indication for episiotomy? Results from a French national database analysis. Int J Gynaecol Obstet 2023; 160:880-885. [PMID: 35942710 DOI: 10.1002/ijgo.14385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS). METHODS Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery. RESULTS Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67). CONCLUSIONS The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.
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Affiliation(s)
- Mathieu Levaillant
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
| | - Charlotte Loury
- Faculté de Santé, Département de Médecine, Angers, France.,Service de gynécologie-Obstétrique, CHU d'Angers, Angers, France
| | - Aurélien Venara
- Faculté de Santé, Département de Médecine, Angers, France.,Service de chirurgie digestive, CHU d'Angers, Angers, France.,UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Jean-François Hamel-Broza
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France.,Faculté de Santé, Département de Médecine, Angers, France.,Service de chirurgie digestive, CHU d'Angers, Angers, France.,UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Guillaume Legendre
- Faculté de Santé, Département de Médecine, Angers, France.,Service de gynécologie-Obstétrique, CHU d'Angers, Angers, France
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Muraca GM, Liu S, Sabr Y, Lisonkova S, Skoll A, Brant R, Cundiff GW, Stephansson O, Razaz N, Joseph KS. Episiotomy use among vaginal deliveries and the association with anal sphincter injury: a population-based retrospective cohort study. CMAJ 2020; 191:E1149-E1158. [PMID: 31636163 DOI: 10.1503/cmaj.190366] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify the association between episiotomy and obstetric anal sphincter injury. METHODS Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders. RESULTS The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017, p < 0.0001) and spontaneous vaginal deliveries (13.5% in 2004 to 6.5% in 2017, p < 0.0001). Episiotomy was associated with higher rates of obstetric anal sphincter injury among spontaneous vaginal deliveries (4.8 with episiotomy v. 2.4% without; adjusted rate ratio [RR] 2.06, 95% confidence interval [CI] 2.00-2.11) and this association remained after stratification by parity and obstetric history. In contrast, episiotomy was associated with lower rates of obstetric anal sphincter injury among forceps deliveries in nulliparous women (adjusted RR 0.63, 95% CI 0.61-0.66), and women with vaginal birth after cesarean (adjusted RR 0.71, 95% CI 0.60-0.85), but not among parous women without a previous cesarean (adjusted RR 1.16, 95% CI 1.00-1.34). INTERPRETATION Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.
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Affiliation(s)
- Giulia M Muraca
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Shiliang Liu
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Yasser Sabr
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Sarka Lisonkova
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Amanda Skoll
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Rollin Brant
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Geoffrey W Cundiff
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - K S Joseph
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
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