Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial

Abstract

Objective To determine whether restrictive or routine episiotomy in term pregnant Southeast Asian women results in fewer complications.Design A multicentre randomised controlled trial.Setting Two tertiary and two general hospitals in Thailand.Population 3006 singleton pregnant women 18 years or older, ≥37 weeks of gestation, cephalic presentation and planned vaginal delivery.Methods This randomised controlled trial compared routine versus restrictive episiotomies in Thai women giving birth vaginally. Participants were singleton, term pregnant women with cephalic presentation. Block randomisation was stratified by study site and parity. Risk ratios (RR) and 95% confidence intervals (CI) were calculated to indicate between-group differences.Main outcome measures Primary outcome was severe perineal laceration. Secondary outcomes included vaginal laceration, cervical laceration, and pregnancy outcomes.Results 3006 women were randomly assigned to restrictive (1502) and routine (1504) episiotomy. There was no difference in severe perineal laceration between the groups (RR 0.72, 95% CI 0.46-1.12). Restrictive episiotomy resulted in more intact perineums in multiparous women (RR 3.09, 95% CI 2.10-4.56). Restrictive episiotomy increased the risk of vaginal laceration in primiparous (RR 1.96, 95% CI 1.62-2.37) and multiparous women (RR 2.21, 95% CI 1.77-2.75) but did not lead to more suturing. There were comparable risks of cervical laceration, postpartum haemorrhage, wound complication, birth asphyxia, and admission to neonatal intensive care unit.Conclusions Restrictive episiotomy results in more intact perineum in multiparous women. Risks of maternal and neonatal outcomes were comparable between the two practices. These results strengthen the certainty of the existing Cochrane review findings in supporting restrictive episiotomy.Tweetable abstract Restrictive episiotomy results in more intact perineums after vaginal birth in multiparous Southeast Asian women.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

“…The rates of episiotomy are still very high in Asian nations, such as 86% in Vietnam, 27 60% in India 14 and 94.5% in Cambodia. 12 China had been considered to have a high rate of episiotomy for a long time. When referring to high rates of episiotomy, China is often cited as an example, with an episiotomy rate of around 80%.…”

“…9 Another study also suggested that episiotomy is used only if there was an indistinct indication of imminent tearing. 7 There is wide variation in the rates of episiotomy all over the world, from developed countries such as Denmark (4%), 10 Sweden (9.7%), the UK (12%-15%) and the USA (11.6%) 11 12 to developing countries including Saudi Arabia (45%), 13 India (60%), 14 Jordan (67%), Yemen (75.1%), 15 Cambodia (94.5%) 16 and China Taiwan (100%), 12 which are still very high compared with the 10% recommended by the WHO. 6 However, in 2010, the prevalence of third-degree or fourth-degree tears was not significantly different in Denmark (4.1%), Sweden (3.5%), the UK (2.4%-3.2%), the USA (4.9%), India (2.1%) and China (4.9%).…”

“…Women who had an episiotomy had a doubled risk of second-degree laceration in subsequent vaginal delivery compared with those without an episiotomy, which may be due to the decrease in pelvic floor muscle strength caused by the previous episiotomy. 12 It is imperative to reduce the rate of episiotomy among nulliparas in the context of the two-child policy. A considerable number of obstetricians and midwives chose episiotomies to prevent neonatal distress.…”

Authors' reply re: Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial

“…We thank Barnfield et al for using our paper for the discussion in their journal club and raising a few questions about the methodology for clarification.…”

Re: Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial

“…We read with interest the article ‘Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial’ which generated good discussion in our Journal Club. We congratulate the authors Sangkomkamhang et al for writing a paper on this very pertinent topic.…”