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

Ankarcrona, Victoria; Hesselman, Susanne; Kallner, Helena Kopp; Wendel, Sophia Brismar

doi:10.1016/j.ejogrb.2021.12.017

Cited by 3 publications

(3 citation statements)

References 31 publications

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“…However, the average number needed to treat should be acceptable also in settings where episiotomy is used restrictively. 35 The rate of obstetric anal sphincter injury in the total study population is also consistent with the current rate among Swedish primiparous women delivered with vacuum extraction. 36 Episiotomy has been associated with greater blood loss and perineal pain, 13 although this was not confirmed in our trial.…”

Section: Strengths and Limitationssupporting

confidence: 80%

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

Bergendahl,

Jonsson,

Hesselman

et al. 2024

BMJ

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Objective To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction. Design A multicentre, open label, randomised controlled trial. Setting Eight hospitals in Sweden, 2017-23. Participants 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site. Intervention A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable. Main outcome measures The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI). Results From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was −7.0% (96% CI −11.7% to −2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence. Conclusions Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury. Trial registration ClinicalTrials.gov NCT02643108 .

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Section: Strengths and Limitationssupporting

confidence: 80%

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

Bergendahl,

Jonsson,

Hesselman

et al. 2024

BMJ

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“…13 However, increased use of episiotomy has raised concerns about how episiotomy, like OASIS, may have negative effects on subsequent childbirths. 3,14 Importantly, episiotomy does not extinguish the risk of OASIS, and a woman can sustain both, especially in VE. Whether episiotomy, OASIS, or both in VE will have consequences for future mode of delivery has not been evaluated.…”

Section: Introductionmentioning

confidence: 99%

“…With increasing observational data favoring episiotomy in VE in nulliparous women, the episiotomy rate at VE may increase even in low‐use hospitals and countries 13 . However, increased use of episiotomy has raised concerns about how episiotomy, like OASIS, may have negative effects on subsequent childbirths 3,14 . Importantly, episiotomy does not extinguish the risk of OASIS, and a woman can sustain both, especially in VE.…”

Section: Introductionmentioning

confidence: 99%

The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study

Wendel

Liu

Stephansson

2023

Acta Obstet Gynecol Scand

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Introduction Severe perineal injuries at childbirth affect women's postnatal health, including future childbirths. First births with vacuum extraction carry an increased risk of obstetric anal sphincter injuries (OASIS). Lateral or mediolateral episiotomy at vacuum extraction may decrease the risk of OASIS. Our aim was to assess whether lateral or mediolateral episiotomy, or OASIS, at vacuum extraction in nulliparous women is associated with prelabor cesarean delivery in the subsequent childbirth. Material and methods This is a nationwide observational study using data from the Swedish Medical Birth Register, including women having a first birth with vacuum extraction and a second birth in 2000–2014. Both births were live, single, cephalic, ≥34 gestational weeks without malformations. The association between episiotomy or OASIS in the first birth and prelabor cesarean delivery in the second birth was examined using univariate and multivariate logistic regression with inverse probability of treatment weighting, and interaction analysis. Main outcome measure was prelabor cesarean delivery in the second birth. Results In total, 44 656 women with vacuum extraction at their first birth were included. The rate of prelabor cesarean delivery in the second birth was 5.9% (824 of 13 950) in women with episiotomy, compared with 6.0% (1830 of 30 706) in women without episiotomy. Thus, women with episiotomy did not have an increased risk of prelabor cesarean delivery (adjusted odds ratio [aOR] 1.00, 95% confidence interval [95% CI] 0.83–1.20) compared with women without episiotomy. For comparison, the rate of prelabor cesarean delivery in the second birth was 20.6% (1275 of 6176) in women with OASIS, compared with 3.6% (1379 of 38 480) in women without OASIS (aOR 6.57, 95% CI 5.97–7.23). There was no interaction between episiotomy and OASIS. Conclusions Lateral or mediolateral episiotomy at vacuum extraction in nulliparous women did not increase the risk of prelabor cesarean delivery in the subsequent childbirth. OASIS increased the odds of prelabor cesarean delivery more than sixfold.

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Episiotomy: Are Indian Obstetricians Getting the Angle Right?

Okeahialam,

Sultan

2023

J Obstet Gynecol India

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Background A mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle. Methods Workshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement. Results One hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (− 0.01 to 0.36) with a SEM of ± 12.2° Conclusions Knowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

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

Cited by 3 publications

References 31 publications

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

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