The incision angle of mediolateral episiotomy before delivery and after repair

Kališ, Vladimír; Karbanová, Jaroslava; Horak, Miroslav; Lobovský, Libor; Králíčková, Milena; Rokyta, Z

doi:10.1016/j.ijgo.2008.05.026

Cited by 73 publications

(63 citation statements)

References 8 publications

(16 reference statements)

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“…Kalis et al were the first to report data on the difference between the incision angle and suture angle of the episiotomy [35,36]. A 40°premarked episiotomy results in a postdelivery suture angle of 22°, while a 60°premarked episiotomy results in a suture angle of 45°.…”

Section: Perineal Deformation/distensionmentioning

confidence: 99%

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Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

2015

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Section: Perineal Deformation/distensionmentioning

confidence: 99%

“…The biomechanics of birth have been studied by clinical observation [33,35,36], MRI studies [39] and stereophotogrammetry [21]. The anal orifice has been found to dilate to 25 mm in the anteroposterior and transverse diameters during crowning, implying a circular dilatation [33].…”

Section: Perineal Deformation/distensionmentioning

confidence: 99%

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

2015

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“…Within this process, protecting perineal integrity emerges as a major concern, as it is impossible to achieve it when an episiotomy is performed, regardless of its angle, length, or depth. Several studies have investigated antenatal and intrapartum perineal protection strategies, 3,4 and thus we understand that any study aiming to identify predictive factors for perineal trauma should mandatorily include these techniques, particularly those addressing OASIS.…”

Section: Sirmentioning

confidence: 99%

“…However, based on studies investigating scar formation following episiotomy, we do consider that there has been a shrinkage of tissue after birth, indicating that the episiotomy resulting in a scar angle <15°w as larger at the time of incision. 3,4 We consider that the scar angles do represent the angles of episiotomy that have been associated with increased OASIS at the time of birth and at 3 months after birth in other studies. 5,6 Kalis et al 1 also state that we extrapolate evidence from studies investigating angle shrinkage of mediolateral episiotomies, and use this to support our findings concerning healed lateral episiotomy.…”

Section: Authors' Replymentioning

confidence: 99%

Episiotomy characteristics and risk for obstetric anal sphincter injuries: a case–control study

Stedenfeldt¹,

Pirhonen²,

Blix³

et al. 2012

BJOG

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Avoiding episiotomy is the best strategy to prevent OASIS: response to the article 'Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study ' Sir, We have read with interest the article by Stedenfeldt et al. 1 published in the last edition of BJOG. However, some points need to be addressed. The conclusion seemed to suggest that increased episiotomy length and depth should be adopted for preventing severe perineal injuries, including obstetric anal sphincter injuries (OASIS).The study findings differ markedly from those reported in randomised trials already summarised in a recent Cochrane Systematic Review, 2 which observed a reduction in the risk of severe perineal trauma among women under a restrictive episiotomy policy (RR 0.67 versus routine episiotomy, 95% CI 0.49-0.91).The Cochrane Review states that the restrictive use of episiotomy seems to improve maternal outcomes without increasing adverse perinatal ones. Moreover, a women-centered, less interventionist model of care for childbearing women has been discussed and gradually implemented worldwide. Within this process, protecting perineal integrity emerges as a major concern, as it is impossible to achieve it when an episiotomy is performed, regardless of its angle, length, or depth. Several studies have investigated antenatal and intrapartum perineal protection strategies, 3,4 and thus we understand that any study aiming to identify predictive factors for perineal trauma should mandatorily include these techniques, particularly those addressing OASIS.This was a case-control study that enrolled women receiving an episiotomy with or without OASIS. The lack of an adequate control group is an obvious bias of this approach because it is expected that a lower risk of OASIS would be found in women NOT receiving episiotomy. Case-control studies are more prone to bias by nature, but the inclusion of women who had not undergone an episiotomy would at least allow for the comparison of OASIS risk for each modality of episiotomy versus no episiotomy.Additionally, the small sample could overestimate the risk and increase the probability of random error or selection bias (i.e. if women without OASIS more often declined to participate in the study). Furthermore, it is reasonable to argue that the accuracy of episiotomy angle, length and depth assessment would be more reliable if it was conducted immediately after birth, not years later. Another limitation is the lack of control for several potential confounding factors in the multivariate analysis: birth position, fundal pressure, guided pushing, perineal techniques, etc.Although some of these limitations have been disclosed by the authors, we are deeply concerned about the possible misuse of their findings to justify a return to the systematic use of episiotomy. In fact, the abstract has been released in the media and, without an accurate critical appraisal of the full article, readers may interpret that the problem is not the episiotomy per se, but an insufficient length or d...

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“…15 Few studies have proven a wider angle of episiotomy may prevent an anal sphincter injury where as a narrow angle would predispose OASI. 16 There is a 75% reduced risk of obstetric anal injuries for each 5.5-mm increase in the length of the episiotomy, and there is an increased risk of sustaining such an injury when the angle is either <15 or >60. 18 Manual perineal protection was given to all delieveries.…”

mentioning

confidence: 99%

OASIS: clinical audit in a tertiary care centre

Soman¹,

Nair²,

Janani³

et al. 2018

Int J Reprod Contracept Obstet Gynecol

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Background: Obstetric anal sphincter injury involves injury to the anal sphincter and rectal mucosa sustained at time of vaginal delivery and can result in significant long-term morbidity. These injuries have been defined as 3rd and 4th degree lacerations that involve disruption of the anal sphincter and rectal mucosa respectively. Objectives of this study were to find out the incidence of obstetrical anal sphincter injuries, to identify the risk factors for of OASIS and the outcome of primary repair in terms of anal incontinence and its associated complications.Methods: We did a descriptive study of OASIS by retrospective analysis of the labour case records. The study period was 1 year between August 2016 to July 2017. Inclusion criteria were singleton pregnancy, vertex presentation, instrumental and normal vaginal delivery. Exclusion criteria were multiple pregnancy, non-vertex presentation and caesarean section. Proforma was developed to capture the age, parity, gestational age in weeks, induction of labour, epidural analgesia, delivery duration, type of episiotomy, instrumentation, shoulder dystocia, occipito posterior position,manual support, weight of the baby, suturing method. Postnatal evaluation after 6 weeks and 6 months for perineal discomfort, pain, incontinence, wound infection, breakdown, fistula were noted. Results: The incidence of OASIS was 1.4%. 81.8% women had 3rd degree perineal and 18.1% had 4th degree perineal tear. The mean age of the patients were 27.9 years, gestational age of 39.45 weeks, 72.7% were primiparous. Induction of labour with prostaglandins was done in 36.36% and Pitocin augmentation for 81.81%. The duration of second 36.36% had 60-89 min and 27.27% had duration more than 90 min. 54.54% had epidural analgesia, 36.36% had shoulder dystocia, 36.36% had instrumental delivery. 72.72% babies had birth weight between 3-3.5 kg, 9% between 3.5-4 kg. Ano vaginal fistula developed in 9%.Conclusions: Appropriate training, anticipating and identifying major degrees of perineal tear helps in reducing the complications. Anovaginal fistula is distressing and disabling the patient and to her near ones.

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The incision angle of mediolateral episiotomy before delivery and after repair

Abstract: The suture angle cannot currently be used to assess the adequacy of the incision angle; moreover, an incision angle of 40 degrees is probably too acute to prevent potential sphincter damage.

Cited by 73 publications

References 8 publications

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

Episiotomy characteristics and risk for obstetric anal sphincter injuries: a case–control study

OASIS: clinical audit in a tertiary care centre

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