Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population

The impact of selective episiotomy on maternal short-term morbidity: a retrospective study

BACKGROUND

The aim is to investigate the risk of short-term maternal morbidity caused by the selective clinical use of episiotomy (rate < 0.02), and to compare the risk of severe perineal tears with the statewide risk.

METHODS

In this retrospective cohort study, we investigated the effect of selective episiotomy on the risk of severe perineal tears and blood loss in singleton term deliveries, using propensity scores with inverse probability weighting.

RESULTS

This study included 10992 women who delivered vaginally between 2008-2018. Episiotomy was performed in 171 patients (1.55%), three of whom (1.75%) experienced severe perineal tears compared to 156 (1.44%) in the control cohort. The adjusted odds ratio of severe perineal tears was 2.06 (95% confidence interval [CI]: 0.51, 8.19 with 0.3 p value). Multivariate linear regression showed that episiotomy increased blood loss by 96.3 ml (95% CI: 6.4, 186.2 with 0.03 p value). Episiotomy was performed in 23% (95% CI: 0.228, 0.23) of vaginal deliveries in the state of Hessen, with a risk of severe perineal tears of 0.0143 (95% CI: 0.0139, 0.0147) compared to 0.0145 (95% CI: 0.0123, 0.0168) in our entire cohort.

CONCLUSIONS

Selective use of episiotomy does not increase the risk of higher-grade perineal tears. However, it may be associated with maternal morbidity in terms of increased blood loss.

Episiotomy: history, present and future - a review

Childbirth has always carried traumatic stress to the woman's body. To deliver with less perineal trauma, obstetricians have used episiotomies. Episiotomy is still a common practice despite the controversy regarding its use. Weighing the risks and benefits, the scientific literature supports its selective use. With the worldwide trend to reduce the rate of episiotomy, several techniques have been proposed to achieve that. However, further research is still needed to prove their efficacy. This review will shed light on the historical background of episiotomy, its different techniques, indications, and the future of its practice.

Vacuum extraction vaginal delivery: current trend and safety

Operative vaginal birth retains an important role in current obstetric practice. However, there is an increasing trend in the rate of cesarean section in Korea. Surgical delivery is more advantageous than cesarean section, but the rate of operative vaginal delivery is decreasing for various reasons. Furthermore, there is no unified technique for vacuum extraction delivery. In this context, this review was performed to provide details of the necessary conditions, techniques, benefits, and risks of operative vaginal delivery. Future research should focus on overcoming the limitations of operative vaginal delivery.

Interprofessional collaborative practice in obstetrics and midwifery

As the health care system transforms to accommodate an increased need for primary care services and more patients, new models of health care delivery are needed that can provide quality health care services efficiently. An integrated collaborative practice of certified nurse-midwives, obstetrician-gynecologists, and perinatologists is best suited to meet the rapidly changing needs of the maternity health care delivery system. This article reviews the literature on interprofessional collaborative practice and describes the structure, function, and essential elements of successful collaboration in health care.

Episiotomy in the United States: has anything changed?

OBJECTIVE

The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice.

STUDY DESIGN

The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy.

RESULTS

The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004.

CONCLUSION

Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial

OBJECTIVE

To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown.

METHODS

This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum.

RESULTS

One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations.

CONCLUSION

By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082.

LEVEL OF EVIDENCE

I.

Selective vs routine midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women

OBJECTIVE

The purpose of this study was to determine whether selective midline episiotomy contributes to the prevention of third- or fourth-degree perineal lacerations.

STUDY DESIGN

A randomized controlled clinical trial was performed with 446 nulliparous women with deliveries after 28 weeks of pregnancy. Patients were randomized to undergo either routine episiotomy or selective episiotomy. In the selective episiotomy group, episiotomies were performed only in cases of imminent lacerations, fetal distress, or forceps delivery.

RESULTS

In the group of 223 patients who underwent routine episiotomy, 32 (14.3%) had third- or fourth-degree perineal lacerations, as compared to 15 (6.8%) in the group of 222 patients undergoing selective episiotomy (relative risk, 2.12; 95% confidence interval, 1.18-3.81). Only reduction in third-degree lacerations was significant when analyzed separately. Moreover, periurethral, labia minora, and superficial vaginal lacerations were significantly more frequent in the selective episiotomy group.

CONCLUSION

The policy of performing selective midline episiotomy in nulliparous patients results in a reduction in the risk of third-degree perineal lacerations.

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

OBJECTIVE

To determine the risk factors for anal sphincter injuries during operative vaginal delivery.

SETTING AND DESIGN

A population-based observational study.

POPULATION

All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.

METHODS

Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.

MAIN OUTCOME MEASURES

Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.

RESULTS

Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.

CONCLUSIONS

Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.

Is anterior genital tract trauma associated with complaints of postpartum urinary incontinence?

We evaluated whether anterior genital trauma is associated with urinary incontinence after vaginal birth. A prospective cohort of midwifery patients consented to mapping of trauma at birth and assessment of continence postpartum. Trauma was categorized into intact, anterior (periuretheral, clitoral, labial), perineal or both. Incontinence was defined as a positive response to the question, "Since the birth of your baby, have you leaked urine when you did not mean to?" and social impact assessed by the Incontinence Impact Questionnaire-7 (IIQ-7). Of 554 eligible women, 436 (79%) provided incontinence data 3 months postpartum. Genital trauma was common, occurring in 80% of women: in 148 (34%) trauma was anterior, 119 (27%) had both anterior and perineal trauma and 80(18%) had only perineal trauma. Since delivery, 27% (118/436) women leaked urine. Fewer had IIQ-7 scores greater than 0, at 55/436 (12%). Women with anterior trauma, 29/148 (20%), were less likely to complain of incontinence than all others, 89/288 (31%) (P = 0.01). Urinary incontinence is common after giving birth, although most women have mild symptoms. Anterior trauma is not associated with increased complaints of urinary incontinence.

Operative vaginal delivery and midline episiotomy: a bad combination for the perineum

OBJECTIVE

The purpose of this study was to determine the impact of operative vaginal delivery (forceps or vacuum) and midline episiotomy on the risk of severe perineal trauma.

STUDY DESIGN

In this retrospective cohort study, we assessed the impact of maternal and obstetric factors on the risk of development of severe perineal trauma (third- and fourth-degree perineal lacerations) for all singleton, vertex vaginal live births (n = 33,842) between 1996 and 2003.

RESULTS

Among nulliparous women, 12.1% had operative vaginal delivery, 22.4% had midline episiotomy, and 8.1% experienced severe perineal trauma. Among multiparous women, 3.4% had operative vaginal delivery, 4.2% had midline episiotomy, and 1.2% experienced severe perineal trauma. Controlling for maternal age, ethnicity, birth weight and head circumference, evaluation of the interaction of episiotomy and delivery method revealed that forceps (nulliparous women: odds ratio [OR] 8.6, 95% CI 6.5-10.7; multiparous women: OR 26.3, 95% CI 18.1-34.5) and episiotomy (nulliparous women: OR 4.5, 95% CI 3.7-5.4; multiparous women: OR 14.6, 95% CI 10.4-20.5) were consistently associated with the increased risk of anal sphincter trauma. In fact, the magnitude of effect of the statistically significant synergistic interaction was evidenced by more than 3-fold excess of risk of using operative vaginal delivery alone.

CONCLUSION

The use of operative vaginal delivery, particularly in combination with midline episiotomy, was associated with a significant increase in the risk of anal sphincter trauma in both primigravid and multigravid women. Given the reported substantial long-term adverse consequences for anal function, this combination of operative modalities should be avoided if possible.

Episiotomy: Beliefs, practice and the impact of educational intervention

OBJECTIVE

To assess the potential effect of educational intervention on episiotomy practice.

STUDY DESIGN

A survey of the attitude of obstetrical caregivers toward episiotomy was conducted among obstetricians and midwives in the three public hospitals in Haifa. Data regarding episiotomy rates was collected for the years 2001-2003. At the beginning of 2002, lectures on the risks and benefits of episiotomy were given in two hospitals. Episiotomy rates before and after the lecture were compared.

RESULTS

A significant and lasting reduction in episiotomy rates was observed in the two hospitals where lectures were given. There were no clinically significant and consistent changes in the episiotomy practices in the third hospital.

CONCLUSION

Education may play an important role in changing common medical practices, as in episiotomy. It was clearly shown that our beliefs are not always up to date. We call for periodic reassessment of all medical procedures, as common and accepted as they are.

Freqüência e critérios para indicar a episiotomia

Trata-se de estudo exploratório com o objetivo de identificar a freqüência, os tipos e os critérios adotados para indicar a episiotomia. Foram entrevistados 12 médicos e 12 enfermeiras que prestam assistência à parturiente no Hospital Universitário da Universidade de São Paulo. A episiotomia ocorreu em 76,2% dos partos normais; as indicações mais freqüentes foram: rigidez perineal (28,7%), primiparidade (23,7%), feto macrossômico (11,9%), prematuridade (10,2%). O tipo mais citado foi médio-lateral direito (92,0%), justificado por: aprendizado durante a formação acadêmica (25,9%), ser adotada rotineiramente (19,4%), menor chance de lesar o esfíncter anal (16,1%), menor risco de complicações (16,1%). É necessário rever as práticas de atendimento à parturiente, considerando as evidências científicas e condutas individualizadas.

Episiotomy and Vaginal Trauma

The era of routine episiotomy is gradually ending. Previously perceived benefits gradually have been disproved as evidence-based scientific clinical studies have shown the detrimental effects of episiotomy; however, circumstances always will exist in which prudent clinical judgment may dictate the necessity for an episiotomy. In most of these situations, however, an episiotomy often can be avoided. Perhaps more hospital perinatal review committees should evaluate episiotomy rates and strive to convince their staff to reduce their rates. We can learn to be more patient and allow the natural forces of labor to gradually stretch the perineum. In reviewing the extensive volume of published literature on episiotomy and perineal-vaginal trauma, the best advice lies in the dictum "Don't just do something, sit there!"

Decreased anal sphincter lacerations associated with restrictive episiotomy use

OBJECTIVE

To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy.

STUDY DESIGN

This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables.

RESULTS

The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7).

CONCLUSION

With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.

Compliance as strategy: the importance of personalised relations in obstetric practice

This paper highlights the importance of personalised relations in institutionalised obstetric care. It seeks to explore the link between objectification and agency, by examining the way in which women find a new subjectivity in motherhood within the walls of the obstetric institution. The paper focuses on obstetric encounters through the lens of labour and intrapartum routine procedures, and argues that when expectant women enter the obstetric institution, a series of relations ensue through their efforts to become connected with the official obstetric system. The hospital organisation and network of relations that originate in it reflect and reproduce a passive role for expectant women and mothers; however, it would be misleading to represent their behaviour as simply "compliant". Expectant mothers value the connectedness with the obstetric system exemplified by personalised patient-practitioner relations because it is a guarantee of safety. They are happy to follow clinicians' instructions, even when this implies significant sacrifice or suffering because they are projected towards fulfilling their parenting desires. Compliance, like resistance then, is here intended to be understood as yet another maternal strategy, and as such it is the most widespread, deployed by women in order to achieve their ideals and desires.

Immediate Maternal and Neonatal Effects of Forceps and Vacuum-Assisted Deliveries

OBJECTIVE

To estimate the differences in immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries.

METHODS

We conducted a medical record review of all forceps and vacuum-assisted deliveries that occurred from January 1, 1998, to August 30, 1999, at Winthrop-University Hospital. Maternal demographics and delivery characteristics were recorded. Maternal outcomes, such as use of episiotomy and presence of lacerations, were studied. Neonatal outcomes evaluated were Apgar scores, neonatal intensive care unit admissions, cephalohematomas, instrument marks and bruising, and caput and molding.

RESULTS

Of 508 operative vaginal deliveries, 200 were forceps and 308 were vacuum assisted. Forceps were used more often than vacuum for prolonged second stage of labor (P =.001). There was a higher rate of epidural (P =.02) and pudendal (P <.001) anesthesia, episiotomies (P =.01), maternal third- and fourth-degree perineal (P <.001) and vaginal lacerations (P =.004) with the use of forceps, whereas periurethral lacerations were more common in vacuum-assisted (P =.026) deliveries. More instrument marks and bruising (P <.001) were found in the neonates delivered by forceps, whereas there was a greater incidence of cephalohematomas (P =.03) and caput and molding (P <.001) in the neonates delivered with vacuum. Multivariable logistic regression analysis showed that forceps use was associated with an increase in major perineal and vaginal tears (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.27, 2.69; P =.001), an increase in instrument marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P <.001) and a decrease in cephalohematomas (OR 0.49; 95% CI 0.29, 0.83; P =.007) compared with the vacuum.

CONCLUSIONS

Maternal injuries are more common with the use of forceps. Neonates delivered with forceps have more facial injuries, whereas neonates delivered with vacuum have more cephalohematomas.

LEVEL OF EVIDENCE

II-3

Childbirth-induced trauma to the urethral continence mechanism: review and recommendations

To summarize the literature on immediate pelvic floor damage from childbirth and episiotomy, a MEDLINE search of English language articles published from 1983 to 2001 was performed. Vaginal delivery causes varying degrees of muscular, neuromuscular, and connective tissue damage. This damage may result in urinary and/or fecal incontinence. Routine midline episiotomy increases the risk of third- and fourth-degree perineal lacerations, which may lead to fecal incontinence. Routine use of mediolateral episiotomy does not prevent urinary incontinence (UI) or severe perineal tears. It is possible to reduce the rate of mediolateral episiotomy to as low as 20% in primiparas without increasing the risk of anal sphincter damage. Control of obesity before delivery, as well as pelvic floor exercises and regular physical exercise both before and after delivery, seem to reduce the risk of postpartum UI.

The role of episiotomy in current obstetric practice

This review traces the clinical use of episiotomy from the eighteenth century to the present and explains why the procedure has a restricted function in current practice. The types of episiotomy are described, and the controversies surrounding the sequelae associated with the procedure are explored. The modern indications for episiotomy including the procedure's place at operative vaginal delivery are discussed. Although the role of the episiotomy in modern obstetrics may be limited, the procedure is important in situations involving nonreassuring fetal status, shoulder dystocia, and perhaps operative vaginal delivery. The optimal type of episiotomy, if any, at forceps or vacuum delivery is yet to be determined.

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals

OBJECTIVE

To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies.

DESIGN

A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies.

SETTING

A large regional public hospital, New South Wales, Australia.

PARTICIPANTS

The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997.

RESULTS

After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies.

IMPLICATIONS FOR PRACTICE

Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Episiotomy, operative vaginal delivery, and significant perinatal trauma in nulliparous women

OBJECTIVES

The aim of this study was to determine whether choice of obstetric instrument at operative vaginal delivery is associated with any differences in the rate of significant perineal trauma and whether this rate is modified by the use of episiotomy.

STUDY DESIGN

The occurrence of significant perineal trauma among 323 consecutive operative vaginal deliveries was evaluated according to type of instrument used and performance of episiotomy. These findings were compared with spontaneous vaginal deliveries during the same period.

RESULTS

Among forceps deliveries the use of episiotomy was not associated with a difference in the occurrence of significant perineal trauma (55% vs 46%; relative risk, 1.2; 95% confidence interval, 0.8-1.9). Among vacuum extraction deliveries an increased rate of such trauma was noted when episiotomy was used (34.9% vs 9. 4%; relative risk, 3.7; 95% confidence interval, 1.2-11.2). There was no difference in the rate of significant perineal trauma according to type of forceps used. In a logistic regression analysis forceps delivery with or without episiotomy was associated with an increase of >10-fold in the rate of significant perineal trauma with respect to vacuum extraction deliveries without episiotomy.

CONCLUSIONS

Our data suggest that in forceps delivery neither the type of forceps nor episiotomy influences the risk of significant perineal trauma. When vacuum extraction delivery is performed, the use of episiotomy is associated with a higher risk of significant perineal trauma.

Routine use of episiotomy in modern obstetrics. Should it be performed?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. It has been associated with a more difficult and lengthy repair as measured by the need for suture material and operating room time. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. The value of episiotomy use on a routine basis bears scientific examination in prospective, randomized, controlled trials. These types of trials are certainly achievable, ethically correct, and much needed. Until these trials are completed and published, obstetricians should not routinely perform the procedure but rather determine the need for episiotomy on a case-by-case basis.

Changed pattern in the use of episiotomy in Sweden

OBJECTIVE

To study changes in the use of episiotomy since 1989, controlling for variables such as severe tears, epidural anaesthesia, duration of the second stage of labour, instrumental deliveries, birthweight and maternal position at delivery.

DESIGN

Retrospective study. Data were obtained from original birth records and questionnaires.

SETTING

Huddinge University Hospital and all labour wards (n = 62) in Sweden.

POPULATION

10,661 women who were delivered vaginally (4575 nulliparae, 6086 multiparae) between 1992 and 1994, and 3366 nulliparae delivered in all Swedish hospitals during the month of March 1995.

MAIN OUTCOME MEASURES

Episiotomy rates, severe tears and instrumental deliveries.

RESULTS

The rate of episiotomy was 1% and of severe tears 0.6% among multiparae delivered vaginally (including instrumental deliveries) at Huddinge University Hospital between 1992 and 1994. The rate of episiotomy was 6.6% and of severe tears 2.3% among nulliparae. Vacuum extraction and epidural anaesthesia were more commonly associated with episiotomy. Factors significantly associated with severe tears were infant birthweight > or = 4000 g, vacuum extraction and episiotomy. In all Swedish labour wards in 1995 the mean incidence of episiotomy in nulliparae was 24.5%, a significant decrease from 33.7% in 1989. Wide variations occurred between hospitals (4%-50%).

CONCLUSION

The use of episiotomy was much reduced at Huddinge University Hospital, with a consistently low rate of severe tears. This supports the growing evidence for individualised and restrictive use of episiotomy at childbirth.