A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery

Abstract

Objective To evaluate the maternal and neonatal morbidity of operative vaginal delivery in relation to the use of episiotomy.Design Prospective cohort study.Setting Two urban maternity units in Scotland and England.Population All nonrandomised nulliparous women delivered by forceps or vacuum during the recruitment period of a clinical trial evaluating the use of episiotomy at operative vaginal delivery.Methods Use of episiotomy was compared to no episiotomy for all operative vaginal deliveries with sub-group analyses for forceps or vacuum deliveries.Main outcome measures The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage, neonatal trauma and pelvic floor symptoms up until 10 days postpartum.Results A total of 1360 women were included in the study, of whom 294 (21.6%) did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy than forceps (56.1 versus 89.4%, OR 0.15, 95% CI 0.11-0.20). Anal sphincter tear rates were not statistically different with use of episiotomy compared with no episiotomy (9.9 versus 7.1%, adjusted OR 1.11, 95% CI 0.66-1.87). Episiotomy use was associated with higher rates of postpartum haemorrhage (28.5 versus 18.4%, adjusted OR 1.72, 95% CI 1.21-2.45), need for moderate or strong analgesia (90.5 versus 67.6%, adjusted OR 3.70, 95% CI 2.60-5.27), perineal infection (5.1 versus 1.4%, adjusted OR 4.04, 95% CI 1.44-11.37) and neonatal trauma (38.1 versus 22.0%, adjusted OR 1.65, 95% CI 1.20-2.27). Use of episiotomy did not reduce the risk of shoulder dystocia (3.5 versus 1.7%, adjusted OR 1.42, 95% CI 0.53-3.85).Conclusions The use of episiotomy did not reduce or greatly increase anal sphincter tears and was associated with greater maternal and neonatal morbidity. This may reflect the complexity of deliveries. The role of episiotomy at operative vaginal delivery should be evaluated in a randomised controlled trial.Keywords Anal sphincter tear, episiotomy, operative vaginal delivery, prospective cohort study.

Risk factors for episiotomy: a case-control study

“…1,2,17 On the contrary, a study evaluating 1,360 nulliparas submitted to forceps delivery or vacuum extraction showed that the use of episiotomy was associated with an increase in the rate of fetal contusions and skin abrasions, while having no effect on neonatal outcomes such as Apgar score, fetal acidosis or admission to a neonatal intensive care unit. 15 History of a previous Cesarean section, characterizing a woman who has not yet delivered vaginally, was not associated with any increase in the risk of having an episiotomy, contrary to the findings of another study carried out in Pernambuco, Brazil. 18 On the other hand, having had a previous episiotomy was found to have a protective effect in the bivariate analysis, although this association was no longer present in the multivariate analysis.…”

“…Recent studies recommend that this combination be avoided. [14][15][16] Even so, many professionals continue to believe that instrumental delivery constitutes an indication for episiotomy.…”

“…Another possible explanation is that when faced with a situation in which fetal vitality is compromised, some professionals may have opted to use forceps, and the majority of obstetricians still believe, as discussed previously, that episiotomy is fundamental when performing an instrumental delivery. 1,[14][15][16][17] With respect to macrosomia (fetal birth weight ≥ 4 kg) no statistically significant association was found with the practice of episiotomy. This fact may have occurred as a result of the obstetricians having no information on the weight of the concept prior to delivery.…”

Prevalência e fatores associados à prática da episiotomia em maternidade escola do Recife, Pernambuco, Brasil

“…Contrarily, the use of episiotomy was associated with an increase in cutaneous contusions and abrasions and had no influence on birth conditions, such as Apgar score, fetal acidosis or admission in neonatal intensive care unit. 23 In the sample studied no association between episiotomy and signs of fetal distress (fetal cardiac frequency alteration and meconium elimination) during labor was found, and the newborns' birth conditions, assessed by Apgar score lower than 7 in the first and fifth minutes, which were also observed in a study assessing neonatal morbidity related to operative birth. 23 The association between episiotomy and perineal protection in operative births (forceps and extracting vacuum) is the object of other studies.…”

“…23 In the sample studied no association between episiotomy and signs of fetal distress (fetal cardiac frequency alteration and meconium elimination) during labor was found, and the newborns' birth conditions, assessed by Apgar score lower than 7 in the first and fifth minutes, which were also observed in a study assessing neonatal morbidity related to operative birth. 23 The association between episiotomy and perineal protection in operative births (forceps and extracting vacuum) is the object of other studies. 17,18 However, in the sample studied, no births with the use of forceps were observed, due to their low incidence in the service.…”