|Year : 2020 | Volume
| Issue : 5 | Page : 529-534
Evaluation of episiotomy in present day obstetric practice
Manasi Thakur1, Himadri Bal2, Vikas Tambe2, Nikhila Singireddy2
1 Department of Obstetrics and Gynaecology, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Obstetrics and Gynaecology, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||13-Jan-2020|
|Date of Decision||11-Dec-2019|
|Date of Acceptance||13-Mar-2020|
|Date of Web Publication||7-Sep-2020|
Department of Obstetrics and Gynaecology, Dr. DY Patil Vidyapeeth, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Episiotomy, a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is one of the most performed surgical procedures in the world, especially for nulliparous women. Episiotomy itself is comparable to a 2nd degree perineal injury. The concept of restrictive episiotomy came where its use is restricted to only high-risk cases such as shoulder dystocia, short rigid perineum, face to pubis delivery, vaginal breech delivery, and instrumental deliveries. We decided to carry out a study to evaluate this common obstetric procedure and try to decipher its role in the present day obstetric practice. Methodology: This was a prospective cohort study on 200 women admitted to the labor room and satisfying the inclusion/exclusion criteria. The cases were then divided into two groups of 100 each by simple randomization by chit method. The participants of one group (Group A) were not given episiotomy unless it was inescapable and was considered as the study group and in the other group (Group B) episiotomy was given to all the patients and was considered as the control group. Results: The overall rate of episiotomy in the control group was 100% as per study protocol and that in study group 27%. The restricted use of episiotomy resulted in a significant reduction in overall episiotomy rate. Conclusion: This study was conducted to evaluate the practice of restrictive episiotomy and compare it with routine episiotomy. We found that the net outcome of restrictive episiotomy was better than routine episiotomy and this was statistically significant with respect to parturition-related perineal trauma, postpartum pain, and maternal satisfaction of the entire birthing process.
Keywords: 2nd stage of labor, episiotomy, perineal trauma, restrictive
|How to cite this article:|
Thakur M, Bal H, Tambe V, Singireddy N. Evaluation of episiotomy in present day obstetric practice. Med J DY Patil Vidyapeeth 2020;13:529-34
| Introduction|| |
Episiotomy, a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is one of the most commonly performed surgical procedures in the world, especially for nulliparous women. It is itself comparable to a 2nd degree perineal injury. At present, in most of our institutions, it is a routine component of first deliveries with the aim of avoiding injury to the posterior perineum. Hence, it is commonly experienced by women during the birthing process. From time immemorial, it is a well-known fact that episiotomy is the most common obstetric intervention.
The ethos behind episiotomy has been the avoidance of a spontaneous laceration of the perineum at the time of delivery by a planned preempted incision. Another projected benefit of routine use of episiotomy is protection to the pelvic floor, thus reducing the risk of urinary incontinence and pelvic floor dysfunction.
During 1970s and 1980s, with the “Naturalist Movement” flourishing, the routine use of episiotomy along with “medicalization of childbirth” began to be questioned. The fall out of this thought process was a review of unnecessary medical interventions during normal childbirth.
There is now a re-thinking of the benefits, necessity and indications of an episiotomy. The accepted benefits of episiotomy include substitution of a straight surgical incision for a ragged laceration, prevention of trauma to fetus, reduction of perineal lacerations, and prevention of future pelvic laxity. However, episiotomy per se is a predisposing factor for severe perineal lacerations and maternal morbidity. The best maternal outcome of pregnancy is a normal vaginal delivery with an intact perineum. There is increase in up to 300 ml or more blood loss among the women undergoing episiotomy.
The concept of restrictive episiotomy, where its use is restricted to only high risk cases such as shoulder dystocia, short rigid perineum, face to pubis delivery, vaginal breech delivery, and instrumental deliveries, is a later development in obstetrics.
Despite all available evidence corroborating the selective use of episiotomy and the recommendation of not to perform routine episiotomies, dilemma remains about the real indications for performing episiotomy in modern obstetrical practice. A Cochrane systematic review has questioned the actual indication of an episiotomy. The World Health Organization in its technical working group report in 1996 recommended an episiotomy rate of 10% as “a good goal to pursue.”
With this background, we decided to carry out a study to evaluate this common obstetric procedure and try to decipher its role in the present obstetric practice.
| Methodology|| |
This was prospective cohort study.
Two hundred women at term undergoing vaginal birth. Assuming 69% perineal lacerations in control group and 36% in study group at significance level of 1% and power of 90% with continuity corrected sample size comes around 72 in each group rounded off to 100. Statistical package used is WinPepi.
This prospective cohort study was conducted on 200 women at term undergoing vaginal delivery. The women included were primigravida and second gravida with tight perineum, having singleton pregnancy at term with vertex presentation, who were in active labor with >7 cm cervical dilatation. The women with absolute indication for caesarean section, estimated fetal weight >3.5 kg and second gravida with lax perineum (3 fingers easily accommodated in posterior vaginal introitus) were excluded from the study.
The participants were explained the entire study and the need to conduct the study. Written informed consent was taken from all the participants. The cases were then divided into two groups of 100 each by simple randomization.
Group A: Study group was the ones who were not given episiotomy unless it was inescapable. Episiotomy was performed at the discretion of the accoucheur in the following situations:
- Impending perineal trauma
- Prolonged second stage of labor >60 min
- Fetal distress in 2nd stage
- Instrumental delivery.
Group B: Control group was the ones where episiotomy was given to all the patients.
In the cases that required episiotomy, 2% xylocaine in 5 ml syringe was used for infiltration in a fan shaped manner on the right side of the posterior fourchette. Mediolateral episiotomy was given at the height of contraction during crowning. Vaginal delivery was conducted with proper perineal support in both the groups. After delivery, the whole perineum and the surrounding areas were inspected for any anterior vaginal lacerations such as paraurethal tears, lateral vaginal lacerations, or anterior labial lacerations. The perineum was also looked for extension of episiotomy and perineal tears. The degree of perineal tears, where applicable, was determined. The episiotomies or the perineal tears were appropriately sutured with vicryl rapide suture.
After delivery all mothers were monitored for their vital parameters, vaginal bleeding, any perineal swelling, and ability to pass urine freely. Neonates were monitored closely according to standard protocol.
On postpartum Day1 and 2 mothers were enquired about their well-being. Perineal pain, if any, was assessed on a 100 mm VAS (visual analogue scale) by asking the patient to point the position on the 100 mm scale as per intensity of pain.
The scale was demarcated as “0” for “No pain” and “10” for severe pain. Accordingly, followings were the cutoff points VAS:
- Insignificant pain (0–4 mm)
- Mild pain (04–50 mm)
- Moderate pain (50–75 mm)
- Severe pain (75–100 mm).
The satisfaction level of the mothers about the whole process of labor and delivery was documented on the lines of the Likert scale as: highly satisfied, satisfied, dissatisfied, and highly dissatisfied.
Data were entered into excel and analyzed using epi7. Qualitative data were summarized by mean and standard deviation and quantitative using percentage or proportion. Appropriate statistical tests such as Chi-square and t-test were performed.
Ethical clearance was obtained for the study from the Institutional Ethical Committee with Ref: DPU/R&R (M)/31/(110)/2018. Date of approval: January 12, 2018.
| Results|| |
The overall rate of episiotomy in the control group was 100% as per study protocol and that in study group 27%. The restricted use of episiotomy resulted in a significant reduction in overall episiotomy rate. These data were further stratified by parity. In Group B (Control Group), all 56 primigravidas and 44 s gravidas received an episiotomy. In Group A (Study Group), 22 primigravidas (44.9%) and 5 s gravidas (9.8%) delivered with an episiotomy [Table 1].
|Table 1: Distribution of episiotomy in primigravida and 2nd gravida in both the groups|
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Indications for episiotomy in study group
Episiotomy was performed in the restrictive episiotomy group in the following situations. Out of a total of 27 patients with episiotomy, 15 were due to impending perineal tear, 6 were due to fetal distress, 3 were due to 2nd stage of labor >60 min and 3 were due to instrumental delivery [Figure 1].
The perineal status after delivery in both the groups
In the study group, 38 women had an intact perineum with neither perineal tear nor anterior vaginal lacerations. The control group had no women with intact perineum as episiotomy was given to all as per the protocol. In study group, 25 patients sustained 1st degree perineal tear, 26 had 2nd degree perineal tear (21 were those who were given episiotomy and 5 were those who were not given episiotomy but suffered a perineal tear). Only 9 women had severe 3rd and 4th degree perineal tears, of them 3 were not given episiotomy and suffered a perineal tear and 6 patients who were given episiotomy had extension of the episiotomy to severe tears. In the control group, 10 patients had 3rd and 4th degree perineal tear due to extension of episiotomy and the rest 90 had no extension of their episiotomy. Anterior vaginal laceration was higher in the study group 15 versus 8 in the control group [Figure 2].
|Figure 2:*Cases with elective episiotomies considered as 2nd degree perineal tears|
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Perineal status in both the study groups
The rate of perineal trauma in the study group was 62% whereas in control group it was 100% as episiotomy was given as a routine. P ≤ 0.001 (statistically significant) [Figure 3].
In the present study, 60 women of study group had pain, of which 5 patients had mild pain, 40 patients had moderate pain and 15 had severe pain, while 100 patients of control group had pain out of which 21 patients had mild pain, 65 patients had moderate pain, and 14 patients had severe pain. The difference was statistically significant (P < 0.001) [Figure 4].
Patient satisfaction level was measured on lines of Likert scale just before discharge from hospital. The patient satisfaction level was more in the study group than the control group. Nineteen patients were highly satisfied in the study group and most of them were those who were neither given an episiotomy nor did they have any perineal trauma. While only 4 patients were highly satisfied in the control group. The number of satisfied patients was similar in both the groups. On the other hand, 32 patients were dissatisfied in the control group while this number was less (n = 18) in the study group. No patients were highly dissatisfied [Figure 5].
| Discussion|| |
Routine use of episiotomy has always been a topic of debate. There should be convincing evidence of a benefit for mothers and babies for an intervention to become routine in obstetrics. For these reasons, it is important to determine the effect of episiotomy on managing the perineum in vaginal deliveries. This study has been compared with the trials done at various centers.
Mean age of the patient, gestational age, birth weight, and obstetrical comorbidities such as hypertension and diabetes were comparable in both the groups and therefore did not alter the outcome in this study.
In the current study, there is a remarkable reduction in the rate of episiotomy. 27% women delivered with an episiotomy in the study (restrictive) group compared to 100% women in the control (routine episiotomy) group.
As per Saxena et al., in the restricted episiotomy group, 64% women delivered with intact perineum without perineal trauma be it episiotomy or tear. In the current study, 38% of the patients in the study group delivered with an intact perineum compared to none in control group as all were given an episiotomy, as per the study protocol.
Amorim et al., in their article on selective episiotomy, commented that further research should evaluate the need of episiotomies in the situations commonly described as indications, like a nonreassuring fetal heart rate, instrumental deliveries, macrosomia, shoulder dystocia, and prolonged second stage of labor. The most common indication of episiotomy in our study group was impending perineal tear (15%). Other indications were fetal distress, prolonged second stage of labor and instrumental delivery.
The decrease in the incidence of episiotomy increased the rate of 1st and 2nd degree perineal tears. A study by Gebuza et al. has shown that episiotomy protects women from 3rd and 4th degree perineal tear.
In the present study, the two groups were compared in terms of anterior vaginal lacerations and it showed that 15% in the study group and 8% in the control group had anterior vaginal lacerations. The increase in anterior vaginal lacerations in the restrictive group must have been due to less space in the posterior perineal compartment due to lack of stretch-ability and not being facilitated by episiotomy. This factor may have led to trauma to the anterior vaginal wall during delivery of head by extension. However, these lacerations were mild compared to an episiotomy. Many of them did not require any suturing.
In the present study, it was observed that the proportion of cases sustaining severe 3rd and 4th degree perineal tears in the control group was 10% due to extension of episiotomy and the remaining 90% who had routine elective episiotomy were classified as 2nd degree tear for the purpose of comparison. In the study group (Restrictive episiotomy) 51% cases had 1st and 2nd degree tear. The 2nd degree tears also included cases where episiotomy was unavoidable. 9% cases had severe 3rd and 4th degree tears.
Tehran, Moini et al., found that there was a significant higher rate of severe perineal tears in routine episiotomy group than in restrictive episiotomy group. They concluded that routine episiotomy increases the risk of severe perineal tears and subsequent complications such as pain, dyspareunia, and incontinence.
Shalini et al., in their study showed that the incidence of 3rd and 4th degree perineal tears in their population of nulliparous women were significantly less in those with episiotomy compared to women delivering without episiotomies.
In the current study, in Group B (routine episiotomy), all patients underwent suturing of episiotomy. In Group A (restrictive group), 60% required suturing which were either due to perineal tears or unavoidable episiotomy. Superficial lacerations did not require suturing in either group. Similar observation of less suturing in the restrictive episiotomy group compared to routine episiotomy group was made by Carroli et al.
The mean duration of second stage of labor in the study group was 39.6 min and in the control group it was 37.8 min. It was slightly more in the study group but there was no significant difference. Clemons et al. also found that there was no significant effect on duration of second stage of labor in both the groups
In the present study, Apgar score at 1 min and 5 min was compared. There was no significant difference in Apgar score in both groups. The neonatal outcome was similar in the two groups. There were 9 admissions to neonatal intensive care unit in the study group and 7 admissions in the control group. Similarly, in a study by Saxena et al., there was no difference found in the neonatal outcome in the two groups. Rosália Silva et al., in 2014, found the selective use of episiotomy was associated with better early maternal outcomes, with no differences in neonatal morbidity. Thus, the routine practice of episiotomy showed no benefits.
In the present study, routine group complained more perineal pain in immediate postpartum period than the restrictive group. Moini et al., also found that compared to routine episiotomy, restrictive episiotomy resulted in less severe pain immediately, 24 and 48 h after vaginal delivery.
In our study, we found out about the maternal satisfaction level and concluded that it was more in the restrictive group than in the routine group and this difference was statistically significant. Thus, ultimate goal of patient satisfaction was achieved.
| Conclusion|| |
This study was conducted to evaluate the practice of restrictive episiotomy and compare it with routine episiotomy. We found that the net outcome of restrictive episiotomy was better than routine episiotomy and this was statistically significant with respect to parturition-related perineal trauma, postpartum pain, and maternal satisfaction of the entire birthing process. It was also found that, decision to give episiotomy is not affected by the birth weight of the baby, and restricted use of episiotomy does not increase the duration of second stage of labor.
We also reached the opinion with fair to good degree of evidence that the policy of routine episiotomy did not have any significant deleterious effect on maternal and fetal outcome. Therefore, episiotomy should not be considered as a taboo, but it should be used selectively for definitive maternal and fetal indications. All said and done, there is definite reduction in maternal morbidity from perineal injuries by adopting the policy of restricted use of episiotomy. A larger study on restrictive episiotomy will be able to further validate our findings
To conclude, even with our limited experience from this study, we feel that it will be prudent to use episiotomy selectively, when it is inescapable after due deliberation, in modern day obstetric practice. Episiotomy should be performed only when the expected benefits outweigh the potential risks and institutional protocols should be formulated accordingly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]