Evaluation of Accuracy of Episiotomy Incision in a Governmental Maternity Unit in Palestine: An Observational Study

Abstract

Episiotomy should be cut at certain internationally set criteria to minimize risk of obstetric anal sphincter injuries (OASIS) and anal incontinence. The aim of this study was to assess the accuracy of cutting right mediolateral episiotomy (RMLE). An institution-based prospective cohort study was undertaken in a Palestinian maternity unit from February 1, to December 31, 2016. Women having vaginal birth at gestational weeks ≥24 or birthweight ≥1000 g and with intended RMLE were eligible (n=240). Transparent plastic films were used to trace sutured episiotomy in relation to the midline within 24-hour postpartum. These were used to measure incisions' distance from midline, and suture angles were used to classify the incisions into RMLE, lateral, and midline episiotomy groups. Clinical characteristics and association with OASIS were compared between episiotomy groups. A subanalysis by profession (midwife or trainee doctor) was done. Less than 30% were RMLE of which 59% had a suture angle of <40° (equivalent to an incision angle of <60°). There was a trend of higher OASIS rate, but not statistically significant, in the midline (16%, OR: 1.7, CI: 0.61–4.5) and unclassified groups (16.5%, OR: 1.8, CI: 0.8–4.3) than RMLE and lateral groups (10%). No significant differences were observed between episiotomies cut by doctors and midwives. Most of the assessed episiotomies lacked the agreed criteria for RMLE and had less than optimal incision angle which increases risk of severe complications. A well-structured training program on how to cut episiotomy is recommended.

Art and craft of episiotomy

“…4 Mediolateral and midline episiotomies are the most commonly used incisions. 5 A mediolateral episiotomy begins at the perineal midline but directed laterally and downwards at an angle of atleast 60 degrees in the direction of the ischial tuberosity, well away from the rectum. 6,7 However there is always a disparity in the angle of the episiotomy while it is cut and the postsuturing angle, probably due to the distension of the perineum at crowning.…”

“…Accordingly, an episiotomy incision angle of 40°-60° was considered equivalent to a suture angle of 25°-40°. 5 The royal college of obstetricians and gynaecologists (RCOG) recommends a 60 degrees angled episiotomy at the time of cutting. 8 More important is the post delivery suture angle of the episiotomy after primary repair which is the angle formed by the midline and the line of epidermal suturing ,which can be very acute (<30*) or too lateral (>60*) as they do not relieve the pressure on the perineum and can directly injure the anal sphincter or increase the risk of OASIS (Obstetric anal sphincter injuries).…”

“…8 More important is the post delivery suture angle of the episiotomy after primary repair which is the angle formed by the midline and the line of epidermal suturing ,which can be very acute (<30*) or too lateral (>60*) as they do not relieve the pressure on the perineum and can directly injure the anal sphincter or increase the risk of OASIS (Obstetric anal sphincter injuries). 5,9 Certainly there are some drawbacks of episiotomy like asymmetry or excessive narrowing of the introitus, excessive blood loss, extension of the incision, haematomas, pain, edema, infection and dehiscence leading on to some form of sexual dysfunction, so an indicated episiotomy is ideal. 5 Midline episiotomies are associated with an increased risk of OASIS which represent the most determinant factor for fecal anal incontinence.…”

“…5,9 Certainly there are some drawbacks of episiotomy like asymmetry or excessive narrowing of the introitus, excessive blood loss, extension of the incision, haematomas, pain, edema, infection and dehiscence leading on to some form of sexual dysfunction, so an indicated episiotomy is ideal. 5 Midline episiotomies are associated with an increased risk of OASIS which represent the most determinant factor for fecal anal incontinence. 5 Mediolateral episiotomy has a significantly lower OASIS rate than midline episiotomies, 2% versus 12%-20%.…”

Perspectives of skilled birth attendants and pregnant women regarding episiotomy: a quantitative approach

“…It is a cut into the perineum by obstetrical caregivers that was historically thought to expedite vaginal birth 1 , 2 . Over the years, mediolateral episiotomy became widespread and was at some point used on routine basis by midwives and obstetricians 3 . In recent times however, rigorous empirical research have queried the clinical benefits of routine episiotomy 4 , 5 .…”