Selective Episiotomy: Indications, Techinique, and Association with Severe Perineal Lacerations

Abstract

Introduction Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively. Objectives To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it. Methods A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected. Results A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective. Conclusions Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.

Episiotomy practice in six Palestinian hospitals: a population-based cohort study among singleton vaginal births

“…There is no general agreement on the indications for episiotomy, 16 and various studies included acute fetal distress, instrumental deliveries, shoulder dystocia, fetal malpresentation, poorly healed OASIS and primiparity as possible indications. 15–17 However, the RCOG, the ACOG and the WHO recommended that episiotomy must be used only on clinical indications.…”

The Awareness Regarding the Episiotomy Procedure Among Women in Saudi Arabia

“…Many campaigns been done in Saudi Arabia in hospitals as well as public centers to increase the awareness and advocate for selective episiotomy and to abandon the routine episiotomy uses, which subsequently can reduce the possible complications of episiotomy, in addition to a better control of perineal pain in the postpartum period ( 3 ). Our aim of this study was to estimate the extent of the awareness regarding the episiotomy procedure among Women in Saudi Arabia.…”

“…In addition, around (27.3%) of those with past episiotomy experience, told they were doing it because they were primigravida. None of these is an actual indication of episiotomy, this shows that the health care providers are still not following the new ACOG guidelines on episiotomy ( 3 ), and (22.7%) did not know about the indication of the procedure, this shows the magnitude of insufficient communication between the health care providers and the patients. Almost close to the finding of the Canadian study, that found many women exceeded (15%) reported uncertainty about the benefits and risks episiotomies ( 14 ).…”

“…Many obstetricians consider episiotomy as a controversial procedure ( 3 ), especially because of its wide variety of indications among them primiparity, shoulder dystocia, assisted delivery with vacuum, fetal weight more than 4 kg and fetal distress, previous history of complicated perineal tear, increased labor 2nd stage and subjectively choosing episiotomy with no specific cause contribute to justify episiotomy needs ( 4 ). Although many literatures indicates that episiotomy should be selectively rather than routinely performed ( 5 ).…”

“…Although many literatures indicates that episiotomy should be selectively rather than routinely performed ( 5 ). because of its complications as it could increase the rate of infections, perineal pain, dyspareunia, blood loss and of course perineal 3 rd degree and 4 th degree tears ( 3 ).…”