Does episiotomy always equate violence in obstetrics? Routine and selective episiotomy in obstetric practice and legal questions

Intrapartum ultrasound and mother acceptance: A study with informed consent and questionnaire

Introduction

Intrapartum ultrasound (IU) is used in the delivery ward; even if IU monitors the labouring women, it could be perceived as a discomfort and even as an" obstetric violence", because it is a young technique, not often well "accepted". A group of clinicians aimed at obtain an informed consent from patients, prior to perform a translabial ultrasound (TU). The aim of this study was to evaluate the acceptance of both translabial and transabdominal IU.

Methods

In this study, performed at the University Hospital of Bari (Unit of Obstetrics and Gynecology), were enrolled 103 patients in the first or second stage of labor in singleton cephalic presentation. A statistical frequency and an association analysis were performed. As a significant result, we consider the peace of mind/satisfaction and the" obstetric violence". IU was performed both transabdominal and translabial to determine the presentation, head positions, angle of progression and head perineum distance. During the first and second stage of labor, the ASIUG questionnaires (Apulia study intrapartum ultrasonography group) were administered.

Results

74 (71, 84%) patients underwent IU and 29 had a vaginal examination (28, 15%). Significant less "violence" has been experienced with a IU (73 out 74/98, 65%) and only one person (1 /1, 35%) recorded that. On the contrary, 10 patients (10/29) perceived that "violence" (34, 48%) while 19 (65, 52%) did not respond on a similar way, after a vaginal examination (VE). More patients felt satisfaction (71 out 74/95, 95%) with the use of IU and only 3 (3/4, 05%) felt unease. A different picture was evident in the vaginal examination group. Only 17 patients (17 out 29/58, 62%) felt comfort while 12 (41, 38%) felt unease.

Conclusions

In our study, IU use is well accepted by most of patients, because it could reassure women about their fetal condition. Moreover, they can see the fetus on the screen, while the obstetrician is performing the US and this is important for a visual feedback, in comparison with the classical VE.

Effectiveness of small-angle episiotomy on incisional laceration rate, suturing time, and incisional bleeding in primigravida: A meta-analysis

Objective

To investigate the effect of small-angle lateral perineal incision on postoperative perineal rehabilitation in primiparous women.

Method

The Cochrane Library, PubMed, Embase, CINAHL, CNKI, WanFang, VIP, and the Chinese Biomedical Literature Database were searched for randomized controlled trials (RCTs) on the effect of small-angle episiotomy on postoperative maternal perineal wound rehabilitation in puerpera until April 3, 2022. Two researchers independently performed literature screening, data extraction and evaluation of risk of bias in the included literature, and statistical analysis of the data was performed using RevMan 5.4 and Stata 12.0 software.

Result

A total of 25 RCTs were included, with a total sample of 6,366 cases. Meta-analysis results showed that the use of small-angle episiotomy reduced incisional tearing [OR = 0.32, 95% CI (0.26, 0.39)], shortened incisional suture time [MD = −4.58 min, 95% CI (−6.02, −3.14)] and reduced incisional bleeding [MD = −19.08 mL, 95% CI (−19.53, −18.63)], with statistically significant differences (all p < 0.05). There was no significant difference in the rate of severe laceration between the two groups [OR = 2.32, 95% CI (0.70, 7.70), p > 0.05].

Conclusion

The use of a small-angle episiotomy during vaginal delivery can reduce the incision tear rate without increasing the incidence of severe perineal laceration, while shortening the incisional suturing time and reducing incisional bleeding. It can be used clinically according to birth canal conditions of the maternal, the intrauterine condition of the fetus and maternal needs.

Systematic Review Registration

PROSPERO International Prospective Register of Systematic Reviews [CRD42022369698]; [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=369698].

Quality aspects relating to giving birth in Switzerland: An analysis of quality indicators in inpatient obstetrics from 2013 to 2017

Quality transparency supports the reduction of information asymmetries in the health care system and enables the targeted regulation of health care. This study examines quality variation in inpatient obstetric care using the official Federal Office of Public Health Inpatient Quality Indicators (CH-IQI; vaginal births with 3rd- and 4th-degree perineal tears, vaginal births with episiotomy, and Caesarean section for low-risk births). It includes 101 maternity hospitals and 425,810 births between 2013 and 2017. For births with perineal laceration of 3rd and 4th degree, Switzerland performs 0.9% poorer in comparison to Germany (D-IQI) and Austria (A-IQI). For births with episiotomy, Switzerland is 1.1% above Germany. The Caesarean section rate for low-risk births was 26.8% in Switzerland in 2017 (Germany: 25.9%). When comparing Swiss clinics, private clinic locations in particular stand out. One possible reason for this may be the density of care, patient demands or the system of affiliated physicians at these clinics.

Episiotomy Practice and Its Associated Factors in Africa: A Systematic Review and Meta-Analysis

Background

Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.

Methods

Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared (I²) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).

Result

A total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0–47.4), I² = 99.3%, P < 0.001). Primiparity [OR: 6.796 (95% CI (4.862–9.498)), P < 0.001, I²: 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034–6.640)), P < 0.001, I²: 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252–7.199)), P < 0.001, I²: 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100–5.709)), P < 0.001, I²: 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285–7.260)), P < 0.001, I²: 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738–10.339)), P < 0.001, I²: 95.1%] were factors associated with episiotomy practice.

Conclusion

In this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.

Effectiveness of Olea Herbal Ointment on Episiotomy Wound Healing Among Primiparous Women: A Randomized Clinical Trial

Background: Episiotomy is a surgical incision in the perineal region to increase the vaginal diameter during delivery. Since the perineal region is not well visible to the mothers and there is a possibility of infection for the episiotomy wound by vaginal and rectal bacteria, such a cut is associated with infection and delay in wound healing. Objectives: This study aimed to detect the effect of Olea ointment on episiotomy wound healing among primiparous women. Methods: This randomized controlled clinical trial included 73 women referring to the Al-Zahra Education, Research, and Remedial Center in Rasht, Iran, during 2017 - 18. Women were randomly assigned into two groups: Intervention group (n = 39) and control group (n = 34). Episiotomy wound healing was assessed using the REEDA scale prior to the intervention, 2 and 24 hours following the first intervention, and 5 and 10 days after delivery. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, independent t-test, repeated-measure test, Friedman test, and chi-square. Results: The mean baseline scores of REEDA was 2.72 ± 0.46 in the Olea ointment group and 2.71 ± 0.46 in the control group; however, there was no statistically significant difference between the two groups. On the other hand, the episiotomy healing scores in the Olea ointment group were significantly lower than those of the control group at four intervals in the follow-up assessments: -0.34 (95% CI: -0.56 to -0.12) two hours after intervention, -0.63(95% CI: -0.89 to -0.37) 24 hours after intervention, -0.30 (95% CI: -0.48 to -0.12) on Day 5 postpartum, and -0.29 (95% CI: -0.46 to -0.13) on Day 10 postpartum. Conclusions: The present findings suggested that the Olea ointment facilitated wound healing of episiotomy; however, further studies are suggested to support these data.