Indications for episiotomy performance – a cross-sectional survey and review of the literature

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.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis

INTRODUCTION

Postpartum sexual health is indicated by a resumption of sexual activity as well as arousal, desire, orgasm, and sexual satisfaction. The issue of resuming sexual intercourse after childbirth has received limited attention because healthcare professionals rarely provide adequate care to postnatal women. The present study aimed to ascertain the overall prevalence of early resumption of sexual intercourse among most women.

METHODS

Searches were conducted in PubMed, Web of Science, Science Direct, Google Scholar, African Journals Online, and the Cochrane Library. Data were extracted using Microsoft Excel, and STATA version 14 was used for analysis. Publication bias was checked by funnel plot, Egger, and Begg regression tests. A p-value of 0.05 was regarded to indicate potential publication bias. Using I2 statistics, the heterogeneity of the studies was evaluated. By country, a subgroup analysis was conducted. A sensitivity analysis was carried out to determine the effect of each study's findings on the overall estimate. The random effects model was used to assess the overall effect of the study and then measured using prevalence rates and odds ratio with 95% CI.

RESULTS

Twenty-one studies with 4,482 postpartum women participants were included in the study. The pooled prevalence of early resumption sexual intercourse among post-partum women was 57.26% (95% CI 50.14, 64.39) with significant heterogeneity between studies (I2  =  99.2%; P-value ≤ 0.000) observed. Current contraceptive use (AOR = 1.48, 95%CI = 1.03, 6.21), primipara (AOR = 2.88, 95%CI = 1.41, 5.89), and no history of severe genital injury on the last delivery (AOR = 2.27, 95%CI = 1.05, 4.93) were significantly associated with early resumption of sexual intercourse.

CONCLUSION

This study found that more than half of women resumed sexual intercourse early after giving birth. This suggests that a significant number of women may be at higher risk of unwanted pregnancies, short birth intervals, and postpartum sepsis. Thus, stakeholders should improve the integration of postpartum sexual education with maternal health services to reduce the resumption of postpartum sexual intercourse.

Women acceptance of episiotomy procedure before and after receiving educational materials: Pretest posttest study

Objectives

Episiotomy is a frequently performed surgical procedure by obstetricians and midwives during vaginal birth. It is defined as a surgical incision in the perineal area through the second stage of delivery. Therefore, this study aimed to evaluate women’s acceptance toward episiotomy before and after providing education.

Methods

A Quasi-experiment pretest posttest study was conducted on a total of 234 patients attending antenatal clinics in Maternity and Children hospital and Heraa General hospital in Makkah during June-August 2021. Participants were personally interviewed and provided with evidence-based information about the procedure then re-evaluated by the investigators. The statistical analysis was carried using Two Tailed Tests. Statistical significance was set on a P value of 0.05 or less.

Results

Total of 234 participant fulfilling the inclusion criteria were interviewed. Females mean age is 26.2 ± 9.7 years. Exact of 115 (49.1%) women heard about episiotomy. And 79 (33.8%) correctly described it as a surgical incision. Also, 89 (38%) understood that it is not recommended for all, and 109 (46.6%) knew that anesthesia is required. The most reported source of information was internet/ social media (49%; 72), followed by friends/relatives (35.4%; 52). Before education, 112 (47.9%) would accept episiotomy if required which was significantly improved to be among 173 (73.9%) of them after receiving the educational materials.

Conclusion

Due to the controversial opinions and practices of episiotomy, ensuring patients awareness and understanding is crucial. Providing correct information from trusted sources will help minimizing the chances of receiving inaccurate information from unreliable sources. Therefore, making wrong decisions, and refusing needed episiotomy. Health practitioners should be encouraged to discuss patients’ concerns and correct their misconceptions.

Mediolateral episiotomy and risk of obstetric anal sphincter injuries and adverse neonatal outcomes during operative vaginal delivery in nulliparous women: a propensity-score analysis

Background

The potential protective effect of mediolateral episiotomy for obstetrical anal sphincter injuries (OASIs) remains controversial during operative vaginal delivery because of the difficulties to take into account the risk factors and clinical conditions at delivery; in addition, little is known about the potential benefits of mediolateral episiotomy on neonatal outcomes.

The objectives were to investigate the associations between mediolateral episiotomy and both OASIs and neonatal outcomes, using propensity scores.

Methods

We performed a retrospective population-based observational study from a perinatal registry that includes all births in a French region between 2010 and 2017. All nulliparous women with singleton pregnancy delivering by operative vaginal deliveries at 37 weeks gestational age or later were included. Inverse-probability-of-treatment weighting with propensity scores was used to minimize indication bias. OASIs was defined as third and fourth-degree tears according to Royal College of Obstetricians and Gynecologists. Two neonatal outcomes were studied: condition at birth (5-min Apgar score less than 7 and/or umbilical artery pH less than 7.10), and admission to neonatal intensive care unit.

Results

The study population consisted of 7589 women; 2880 (38.0%) received mediolateral episiotomy. After applying propensity scores, episiotomy was associated with a lower rate of OASIs in forceps/spatula delivery (2.3 vs 6.8%, Risk Ratio (RR) 0.38, 95% Confidence Interval (CI) 0.28–0.52) and in vacuum delivery (1.3 vs 3.4%, RR 0.27, 95% CI 0.20–0.38) as compared with no episiotomy. Mediolateral episiotomy was associated with better condition at birth in case of forceps/spatula delivery (4.5 vs 8.8%, RR 0.56, 95% CI 0.39–0.81). In cases of fetal distress (40.7%), mediolateral episiotomy was associated with better condition of infant at birth in women who delivered by forceps/spatula (4.2 vs 13.5%, RR 0.52, 95% CI 0.31–0.89). No association was found with neonatal unit admission (RR 0.93, 95% CI 0.50–1.74).

Conclusions

Use of mediolateral episiotomy was associated with a lower rate of OASIs during operative vaginal delivery, and in infants it was associated with better condition at birth following forceps/spatula delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04396-6.

A nationwide cross-sectional survey of episiotomy practice in China

Background

A 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.

Methods

The 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.

Findings

The 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 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 medically 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

National Natural Science Foundation of China and Shanghai Health Commission Programme.

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

OBJECTIVES

Correct 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 DESIGN

A 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.

RESULTS

We 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).

CONCLUSIONS

Doctors 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.

Effect of lubricant gel on the length of the first stage of labour and perineal trauma in primiparous women

The objective of this study was to investigate the effects of obstetric gel application on the length of the first stage of labour and perineal trauma in primiparous women. This randomised controlled trial included 110 primiparous women. Women were randomly assigned to the two groups: lubricant gel group and control group. In the intervention group, during cervical dilatation of 4 cm until complete cervical dilatation, 5 ml of water-soluble lubricant gel was used at each vaginal examination. In the control group, routine care was performed. Mean duration of the total length (p = .025), the first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than control group. Perineal health was significantly better in the gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect perineal health.IMPACT STATEMENTWhat is already known on this subject? Prolonged labour and perineal injuries are a major problem in natural childbirth for primiparous mothers.What the results of this study add? The first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than in the control group. Perineal health was significantly better in gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect against perineal injury.What the implications are of these findings for clinical practice and/or further research? Obstetrical gel lubricant usage in the first stage of labour during the active phase of nulliparous women could shorten the total length, the first and the second stage of labour and could protect perineal health.

Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia

BACKGROUND

Episiotomy is a surgical incision of the perineum to hasten the delivery. There is a scarce of information related to episiotomy practice, and its associated factors, in developing countries, including Ethiopia. Thus, this study was aimed to determine the level of episiotomy practice and to identify its determinants at public health facilities of Metema district, northwest, Ethiopia.

METHODS

Institutional-based cross sectional study was conducted among 410 delivered mothers from March 1 to April 30, 2020. We recruited study participants using systematic random sampling technique. Data were entered to Epi data version 3.1 and exported to STATA version 14 for statistical analysis. Stepwise backward elimination was applied for variable selection and model fitness was checked using Hosmer and Lemshows statistics test. Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.

RESULTS

In this study, the magnitude of episiotomy practice was found 44.15% (95% CI 39.32-48.97). Vaginal instrumental delivery (AOR 3.04, 95% CI 1.36-6.78), perineal tear (AOR 3.56, 95% CI 1.68-7.55), age between 25 and 35 (AOR 0.11, 95% CI 0.05-0.25), birth spacing less than 2 years (AOR 4.76, 95% CI 2.31-9.83) and use of oxytocin (AOR 2.73, 95% CI 1.19-6.25) were factors significantly associated with episiotomy practice.

CONCLUSIONS

Magnitude of episiotomy practice in this study is higher than the recommended value of World Health Organization (WHO). Instrumental delivery, age, oxytocin, birth spacing and perineal tear were significant factors for episiotomy practice. Thus, specific interventions should be designed to reduce the rate of episiotomy practice. Plain English summary The routine use of episiotomy practice is not recommended by WHO. A study that compares routine episiotomy with restrictive episiotomy suggests that the latter is associated with less posterior perineal trauma, less need for suturing, and fewer complications related to healing. In addition, though, the rate of episiotomy has been declined in developed countries, still it remains high in less industrialized countries. The data for this study were taken at public health facilities of Metema district, northwest, Ethiopia. We included a total of 410 delivered mothers. The magnitude of episiotomy practice was found 44%. This result was higher than the recommended value of WHO. The WHO recommends an episiotomy rate of 10% for all normal deliveries. The result of this study showed that episiotomy practice is common among mothers whose age group are 18-24. In addition, mothers whose labor were assisted by instrumental vaginal delivery are more likely to have episiotomy as compared to those delivered by normal vaginal delivery. Laboring mothers who had used oxytocin were about three times more likely to be exposed for episiotomy than laboring mothers who did not use oxytocin drug. Moreover, episiotomy practice was nearly five times more likely among mothers who had birth spacing of 2 years and less as compared to mothers who had birth spacing of more than 2 years.

The perception and knowledge about episiotomy: A cross-sectional survey involving healthcare workers in a low- and middle-income country

BACKGROUND

Episiotomy was introduced into clinical practice without clear evidence of its benefits.The knowledge and understanding of episiotomy guidelines and practice by healthcare workers is substandard in our setting; hence, the injudicious use of this procedure have led to high rates.

AIM

To assess the knowledge, perception and practice of episiotomy by healthcare workers.

SETTING

Research was conducted in a Pietermaritzburg complex, South AfricaMethods: A questionnaire-based survey was conducted amongst healthcare workers regarding episiotomy practice. In addition to providing demographic data, the participants were requested to respond to 35 proposed statements regarding episiotomy practice. Data were analysed using SPSS (Statistical Package for the Social Sciences) software.

RESULTS

One hundred and forty-two midwives and 66 medical practitioners completed the questionnaires. There were variations in responses to several statements on episiotomy practice by medical practitioners and nurses based on their level of experience. This study found that the majority of HCWs did not have access to a protocol or policy on episiotomy practice in their units; furthermore, nor knowledge of the South African guidelines for maternity care on episiotomy practice. Significantly, more medical practitioners felt a need for more in-service training and an increase in the number of episiotomies performed under supervision. The commonly reported reason for performing an episiotomy by both medical practitioners and midwives was to reduce 3rd - 4th degree perineal tears.

CONCLUSION

Healthcare workers in our setting displayed poor knowledge about the practice of episiotomy and were not aware of existing national guidelines on episiotomy practice.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

OBJECTIVE

Episiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards the practice of episiotomy among obstetricians and midwives in China's public hospitals and consider strategies to reduce its practice.

METHODS

A cross-sectional web survey using a self-administered questionnaire was conducted among obstetricians and midwives in 90 public hospitals in Henan Province, China.

RESULTS

900 (82.21%) participants completed the questionnaire. Average knowledge level (4.15, SD=1.10) on complications and overuse was identified among participants. Episiotomy was performed more frequently in secondary hospitals than in tertiary hospitals (p<0.05). Senior clinicians were more likely to perform episiotomy than younger ones (p<0.05). Almost half of the clinicians (42.11%) considered the current rate of episiotomy (45%) to be right or too low. The most common reason for performing episiotomy identified by obstetricians (83.94%) and midwives (79.69%) was to reduce third-degree or fourth-degree perineal laceration. Both obstetricians (80.29%) and midwives (82.57%) agreed that the most significant obstacle to reducing the rate of episiotomy was lack of training on reducing perineal tears.

CONCLUSION

In sum, episiotomy was driven by previous training, practitioners' experience and local norms rather than the latest medical evidence. Clinicians in secondary hospitals and senior clinicians are key training targets. It is urgent to improve current clinical policies and surgical procedure guidelines for obstetricians and midwives regarding episiotomy.

In women with spontaneous vaginal delivery, repair of perineal tears might be easier compared to episiotomy

INTRODUCTION AND HYPOTHESIS

To examine a common assumption that suturing of episiotomy, a straight performer-controlled incision, might be easier compared to repair of unpredictable spontaneous perineal tears.

METHODS

Data for this study were collected prospectively, as part of a randomized controlled trial examining the outcomes of episiotomy avoidance. Suturing characteristics were compared between vaginal deliveries with episiotomy vs. spontaneous perineal tears. Primary outcomes included the duration of the repair, number of suture packs used for the repair, and subjective rating of suturing difficulty (rated from 1 to 5 by practitioner performing the suturing).

RESULTS

Of 525 vaginal deliveries, episiotomy was performed in 165 (31.4%) of the cases, 59 of which (35.8%) were accompanied by additional vaginal tears. Spontaneous vaginal tears without episiotomy were noted in 272 deliveries (51.8%). Compared to spontaneous perineal tears, episiotomy performance was associated with an adverse effect on all three suturing characteristics in the overall cohort and in subgroup of non-operative deliveries. When comparing episiotomy only to second-degree tear suturing, in the subgroup of non-operative vaginal deliveries a higher rate of suturing duration < 10 min was noted in favor of spontaneous tears. However, in sub-analysis of vacuum-assisted deliveries, a benefit was noted in favor of the episiotomy-only group in terms of fewer suture packs and lower subjective difficulty.

CONCLUSIONS

In women with non-operative vaginal delivery, suturing of spontaneous perineal tears was easier and shorter compared to episiotomy repair. This might be related to the unpredictable nature of perineal tears, which might be shorter and shallower compared to the standard episiotomy incision.

Understanding the perspectives and values of midwives, obstetricians and obstetric registrars regarding episiotomy: qualitative interview study

OBJECTIVES

Insight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values.

SETTING

Maternity care in the Netherlands.

PARTICIPANTS

Midwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perspectives and values of care providers which were explored using semistructured in-depth interviews.

RESULTS

The following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: 'Care providers' vision on childbirth', 'Discrepancy between restrictive perspective and daily practice', 'Clinical expertise versus literature-based practice' and 'Involvement of women in the decision'. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers' underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women's autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language.

CONCLUSIONS

Care providers' underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.

Dispareunia en mujeres después de parto vaginal. Prevalencia en dos clínicas de Armenia, Colombia, 2012-2017

Se realizó un estudio de corte transversal que tuvo como objetivo determinar la prevalencia de la dispareunia en mujeres con parto vaginal, evaluar posibles factores de riesgo y la asociación con la episiotomía. Ingresaron mujeres atendidas por parto vaginal entre 2012 y 2017 en dos clínicas de alta complejidad en Armenia (Colombia). Se utilizó el cuestionario Índice de Función Sexual Femenina (IFFS-6) para evaluar la función sexual. Los resultados reportan una prevalencia de dispareunia del 59,37%, siendo más prevalente en mujeres sometidas a episiotomía (OR: 68,17; IC95 %: 60,57-79,15). Respecto a la asociación de la episiotomía con la presencia de dispareunia se encontró asociación significativa con la episiotomía medio-lateral (OR: 8,17; IC95%: 2,15-56,32), lesión del esfínter (OR: 7,32; IC95%: 4,86-12,75) y dehiscencia de la sutura (OR: 6,48; IC95%: 4,92-14,28). Se observaron como factores de riesgo: antecedente de endometriosis (OR: 11,6; IC95 %: 9,15-17,52), dolor pélvico crónico (OR: 3,56; IC95%: 2,21–6,32) e ITS (OR: 2,67; IC95%: 1,54–5,14), p=0,003). Se concluye que la prevalencia de dispareunia en mujeres con parto vaginal, atendidas en Armenia, varía en función de la realización de episiotomía, asociándose tanto a las complicaciones de esta como a otros antecedentes.

Is it time to abandon episiotomy use? A randomized controlled trial (EPITRIAL)

INTRODUCTION AND HYPOTHESIS

The objective of this trial was to evaluate whether avoidance of episiotomy can decrease the risk of advanced perineal tears.

METHODS

In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into "avoidance of episiotomy" (the study group in which episiotomy was allowed only in cases of fetal distress) or "standard care." The primary outcome was the incidence of advanced (3rd- and 4th-degree) perineal tears.

RESULTS

The participants were randomized into "standard care" (n = 337) vs. "no episiotomy" (n = 339) groups, not differing in any demographic or obstetric characteristics. Episiotomy rates were significantly lower in the study group (19.6%) compared with the standard care group (29.8%, p = 0.004). Five (1.5%) advanced tears were diagnosed in the study group vs. ten = 3.0% in the controls, yielding an odds ratio of 0.50 (95% CI 0.17-1.50) in favor of the "no episiotomy" group (p = 0.296). No differences were noted in any secondary outcomes. By per protocol analysis (omitting cases in which episiotomy was performed for indications other than fetal distress in the study group), a trend to decreased risk of advanced tears in the study group was noted (p = 0.0956). By per protocol analyses, no severe tears were noted in the 53 vacuum deliveries in the study group vs. 4/65 (6.2%) tears in the controls (p = 0.126).

CONCLUSIONS

Since decreased use of episiotomy was not associated with higher rates of severe tears or any other adverse outcomes, we believe this procedure can be avoided in spontaneous as well as vacuum-assisted deliveries. Trial registration no. NCT02356237.

Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction

INTRODUCTION

Women's sexual health is a vital and important part of life at any age. In particular, pregnancy and childbirth bring biological, psychological, and social changes which may influence sexual health. It has been shown that sexual function declines during pregnancy and does not return to its baseline levels during the postpartum period. Despite the complexity and significance of this subject, health providers often neglect sexual aspects during pregnancy and postpartum.

AIM

We believe that clarifying the risk factors will help open conversations and improvements in sexual function.

METHODS

In this review, we focus on how postpartum sexual function is affected by mode of delivery, perineal trauma during delivery, episiotomy, and lactation.

CONCCLUSIONS

We conclude that the mode of delivery has no significant effect on short- and long-term postpartum sexual function. On the other hand, 3rd and 4th degree tears are strongly associated with postpartum sexual dysfunction. We found that episiotomy does not adversely affect sexual function, and lactation has a slightly negative effect. We believe that shedding light on this topic will lead to a better understanding for pregnant and postpartum women and the obstetrician. Further studies may elucidate more useful treatment approaches. Ola Gutzeit, Gali Levy, Lior Lowenstein. Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction. Sex Med 2019;8:8-13.

A novel classification for evaluating episiotomy practices: application to the Burgundy perinatal network

Background

Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to facilitate the analysis of episiotomy practices and to evaluate whether episiotomy is associated with a reduction in the rate of obstetric anal sphincter injuries (OASIS) for each subgroup.

Methods

This population-based study included all the deliveries that occurred in the Burgundy Perinatal Network from 2011 to 2016. The main outcome was episiotomy, which was identified thanks to the French Common Classification of Medical Procedures. An ascending hierarchical cluster analysis was performed to build the classification. A clinical audit using the classification was conducted yearly in all obstetric units. The episiotomy rates were described throughout the study period for each subgroup of the classification. The OASIS rates were evaluated by subgroup and the association between mediolateral episiotomy and OASIS was investigated for each subgroup.

Results

Our analyses included 81,290 pregnant women. The classification comprised 7 subgroups: ₍₁₎ nulliparous single cephalic at term, ₍₂₎ nulliparous single cephalic at term with instrumental delivery, ₍₃₎ multiparous single cephalic at term, ₍₄₎ multiparous single cephalic at term with instrumental delivery, ₍₅₎ all preterm deliveries (< 37 weeks gestation), ₍₆₎ all breech deliveries, ₍₇₎ all multiple deliveries.

Episiotomy rates ranged from 6.2% in Group 3 to 40.9% in Group 2. From 2011 to 2016, every group except breech deliveries experienced a significant decrease in episiotomy rates, ranging from − 28.1 to − 61.0%.

The prevalence of OASIS was the highest in Groups 2 (3.0%) and 4 (2.2%). Overall OASIS rates did not significantly differ with episiotomy use (P = 0.25). However, we found that the use of episiotomy was associated with a reduction in OASIS rates in Groups 1 and 2 (odds ratio 0.6 [95% CI 0.4–0.9] and 0.4 [0.3–0.5], respectively). This reduction was only observed in Group 4 with forceps delivery (odds ratio 0.4 [0.1–0.9]).

Conclusion

We developed the first classification for the evaluation of episiotomy practices based on 7 clinically relevant subgroups. This easy-to-use tool can help obstetricians and midwives improve their practices through self-assessment.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2424-2) contains supplementary material, which is available to authorized users.

Risk factors for episiotomy during vaginal childbirth: A retrospective cohort study in Western China

OBJECTIVE

To assess the incidence rates and risk factors for episiotomy during vaginal childbirth in a Western China context.

METHODS

A retrospective hospital-based cohort study was conducted using computerized data of 3721 singleton vaginal deliveries after 28 weeks of gestation. Women who underwent episiotomy were compared with those who did not.

RESULTS

The overall prevalence of episiotomy was 44.0% (1636/3721); 52.9% (1458/2756) among primiparas and 18.4% (178/965) among multiparas (P < 0.001). Adjusted risk factors significantly associated with episiotomy included primiparity, prolonged second stage of labor, and labor-management personnel. Risk factors specific to primiparas were increasing maternal age (per year) (OR = 1.04, 95% CI 1.01 to 1.07, P = 0.035), increasing biparietal diameter (per centimeter) (OR = 1.40, 95% CI 1.06 to 1.84, P = 0.017), first stage of labor beyond 10-hour (OR = 1.36, 95% CI 1.10 to 1.68, P = 0.005), and birth weight (per 100 g) (OR = 1.06, 95% CI 1.03 to 1.09, P < 0.001). Birth weight resulted in an adjusted risk increase of 6.1% among primiparas for every 100 additional grams of birth weight. For the analysis stratified by labor-management personnel, moderately experienced midwifery was a risk factor of episiotomy (OR = 1.76, 95% CI 1.21 to 2.56, P = 0.003); midwives with bachelor's degree (OR = 1.47, 95% CI 1.15 to 1.88, P = 0.002), and obstetricians with doctor's degree (OR = 2.00, 95% CI 1.18 to 3.39, P = 0.010) were most likely to perform episiotomy.

CONCLUSION

Episiotomy is still commonly performed in Western China. A survey of maternity care professionals' knowledge of and attitudes towards episiotomy is urgently required to explore the complex reasons for conducting episiotomy.

The Awareness Regarding the Episiotomy Procedure Among Women in Saudi Arabia

Introduction:

Episiotomy is an intended incision made through the perineal body to enlarge the vaginal orifice during the second stage of labor to ease the parturition. A cross sectional study in Jeddah, Saudi Arabia, showed that 35% of the females in 2012 had an episiotomy, this slightly increased in 2015 to (36.4%). Given the increase rates of episiotomy and the significance of patients’ awareness, there were very limited data on the awareness of episiotomy among women.

Aim:

Aim of this study is to estimate the extent of the awareness regarding the episiotomy procedure among women in Saudi Arabia.

Material and methods:

Participants aged 15 and above filled a questionnaire distributed online to different regions of Saudi Arabia. Descriptive statistics were used.

Results:

a total of 626 women participated in this study with a mean age 34.7 years. The majority (63.6%) of women reported being informed about the procedure. Still, only (40%) of them were able to describe the procedure correctly. Only age, parity and history of previous episiotomy were predictors for episiotomy awareness. Women aged 35 or less were more aware of episiotomy than those aged more than 35 with a p-value (<0.001). However, the multigravida were more aware of episiotomy than primigravida with a p-value (< 0.001).

Conclusion:

The awareness of episiotomy is still not accomplish in Saudi Arabia, which poses the need for further modalities to educate women and increase their awareness regarding selective episiotomy rather than the old method of routine episiotomy.