Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta‐analysis

Abstract

Background The role of episiotomy in vacuum deliveries is controversial.Objectives To perform a meta-analysis of the literature examining this subject.Search strategy The search was conducted in four databases.Selection criteria Two investigators independently selected original research examining the effects of episiotomy on any neonatal and maternal outcomes during vacuum delivery.Data collection and analysis The effect estimates were presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).Main results Fifteen articles were included, encompassing a total of 350 764 vacuum deliveries. A non-significant relationship was shown between mediolateral episiotomy and obstetric anal sphincter injuries (OASIS) in nulliparous women (OR 0.68, 95% CI 0.43-1.07; six studies), whereas an increased risk was demonstrated in parous women (OR 1.27, 95% CI 1.05-1.53; two reports). A higher risk of OASIS with median episiotomy use was shown in nulliparous (OR 5.11,; two studies) as well as in parous (OR 89.4, 95% CI 11.8-677.1; one study) women. Lateral episiotomy was related to lower OASIS risk in nullipara (OR 0.59, 95% CI 0.49-0.70; single paper). Mediolateral episiotomy was linked to increased rates of postpartum haemorrhage (OR 1.82, 95% CI 1.16-2.86) and analgesia use (OR 2.10, 95% CI 1.39-3.17; two reports). Overall, the quality of evidence was rated as low to very low.Author's conclusions Mediolateral and median episiotomy in parous woman may increase the rate of OASIS at vacuum delivery, whereas lateral episiotomy in nulliparous women could be associated with a decreased risk of OASIS. The suboptimal quality of the available evidence necessitates high-quality welldesigned randomised trials.Keywords Episiotomy, obstetric anal sphincter injury, vacuum extraction delivery.Tweetable abstract Episiotomy in vacuum delivery does not appear to be of benefit, and might even increase maternal morbidity.

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

“…However, looking at episiotomy as a single variable is insufficient and therefore we additionally analyzed the use of mediolateral episiotomy according to birth mode. Midline episiotomy has been abandoned in Austria because of the markedly increased risk of obstetric anal sphincter injuries, supported by several lines of evidence 21, 22, 23, 24. When it comes to mediolateral episiotomy, evidence is inconsistent as mediolateral episiotomy has previously been reported to be a risk,20 a protective,25, 26 or an insignificant factor 7, 27.…”

Management of the Perineum during Delivery with the Kiwi Omnicup: Effects of Mediolateral Episiotomy on Anal Sphincter Tears in Nulliparous Women

“…Despite higher failure rates vacuum extraction has been proposed to be the instrument of first choice, as it causes fewer maternal injuries [2][3][4]. Since proposed benefits of episiotomy included reduction of obstetric anal sphincter injuries and fastened labor process in case of foetal distress, this procedure was often routinely performed by obstetricians during vacuum delivery [5]. However, a proven evidence for the value of episiotomy in vacuum delivery is still lacking and most guidelines recommend restrictive use and individual evaluation [6][7][8].…”

“…Unfortunately, indications for the selective use of this procedure have not been clearly defined so far. In literature, no uniform agreements exist regarding the necessity of episiotomy during vacuum delivery [5]. Nevertheless, in up to two thirds of vacuum extractions, episiotomy is performed [5].…”

“…In literature, no uniform agreements exist regarding the necessity of episiotomy during vacuum delivery [5]. Nevertheless, in up to two thirds of vacuum extractions, episiotomy is performed [5]. This discrepancy highlights the importance for more research on this topic to define precise guidelines for this common procedure.…”

Concerning the Article by Bodner-Adler et al: “Management of the Perineum during Delivery with the Kiwi Omnicup: Effects of Mediolateral Episiotomy on Anal Sphincter Tears in Nulliparous Women”

“…Instead, the analysis is focused in whether women needed perineal repair (significantly less frequent in the women without episiotomy) or not, and the occurrence of severe perineal trauma (less common in the restricted episiotomy group and without statistical significance when an instrumental delivery was attempted) [2]. Two systematic reviews addressing the use of episiotomy in vacuum-assisted deliveries did not consider surgically cut perineum as “intact.” Only one of them assessed severe perineal trauma (with episiotomy deemed as protective) [3], and the other concluded that episiotomy increases the odds of severe trauma; thus, they considered intact perineum in the episiotomy group to be zero [4]. …”