Selective Episiotomy: Indications, Techinique, and Association with Severe Perineal Lacerations

Corrêa Junior, Mário Dias; Passini Júnior, Renato

doi:10.1055/s-0036-1584942

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Ginecologia e Obstetrícia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review Article • Rev. Bras. Ginecol. Obstet. 38 (06) • June 2016 • https://doi.org/10.1055/s-0036-1584942 copy

Selective Episiotomy: Indications, Techinique, and Association with Severe Perineal Lacerations

Episiotomia seletiva nos dias atuais: indicações, técnica e associação com lacerações perineais graves

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively.

Objectives

To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it.

Methods

A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected.

Results

A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective.

Conclusions

Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.

Keywords:
episiotomy; perineal lacerations; obstetrical delivery

Condition assessed	N	OR	CI
Occurrence of any subsequent laceration	2,079	0.88	0.84–0.92
Severe perineal laceration	4,404	0.67	0.49–0.91
Occurrence of any previous laceration	4,896	1.84	1.61–2.10
Perineal pain at discharge	2,422	0.72	0.65–0.81
First minute APGAR score < 7	3,908	1.04	0.76–1.43

Study	N	Method	Result
Revicky et al⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146	10,314	Cross-sectional study of 10,314 patients submitted to vaginal delivery in England	The rate of third and fourth-degree lacerations was 3.2%, and not performing episiotomy was a risk factor: OR: 1.4; CI: 1.21–1.98
Landy et al⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635	82,267	Analysis of electronic medical charts of 19 hospitals in 7 years	The rate of third- and fourth-degree lacerations was of 5.8% in primiparous, and of 0.6% in multiparous women; 78% were midline episiotomies. The episiotomy was a risk factor both in nulliparous (OR; 2.4; CI: 2.1–2.7) and multiparous women (OR: 4.4; CI: 3.3–5.8)
Aukee et al¹⁰10 Aukee P, Sundström H, Kairaluoma MV. The role of mediolateral episiotomy during labour: analysis of risk factors for obstetric anal sphincter tears. Acta Obstet Gynecol Scand 2006;85(7):856-860	9,178	Retrospective analysis of 9,178 births in Finland	The rate of third- and fourth-degree lacerations was of 1.0%, and the episiotomy was a protective factor (OR: 0.37; CI: 0.20–0.70)
Moini et al¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242	283	Patients randomized for selective or routine episiotomy in Iran	The routine episiotomy group presented a higher rate of third- and fourth-degree lacerations: 13.14% versus 2.05%
Eskandar and Shet¹²12 Eskandar O, Shet D. Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 2009;29(2):119-122	3,038	Review of records of 3,038 vaginal births that occurred in a 2-year period in England	The rate of third and fourth-degree lacerations was of 1.58%, and the medio-lateral episiotomy showed a non-significant trend to protection: OR: 0.35; CI: 0.08–1.4
Räisänen et al¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7	303,758	Assessment of Finnish medical records	The rate of serious perineal lacerations ranged from 0.2% in multiparous women to up to 2.3% in primiparous women. The episiotomy was a protective factor in primiparous women (OR: 0.77; CI: 0.69–0.86), and a risk factor in multiparous women (OR: 1.61; CI: 1.14–2.29)
Fritel et al¹⁹19 Fritel X, Schaal JP, Fauconnier A, Bertrand V, Levet C, Pigné A. Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG 2008;115(2): 247-252	627	Comparison between patients attending two French hospitals. The first with a policy of selective, and the second, routine episiotomy	With no differences in urinary incontinence four years after delivery. Fecal incontinence higher in the routine episiotomy group
Murphy et al²⁰20 Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG 2008;115(13):1695-1702, discussion 1702-1703	317	Routine versus selective episiotomy in patients with operative deliveries	With no differences in serious lacerations, fecal or urinary incontinence six weeks postpartum
Macleod et al²¹21 Macleod M, Strachan B, Bahl R, et al. A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery. BJOG 2008;115(13):1688-1694	1,360	Routine versus selective episiotomy in patients with operative deliveries	With no differences in serious lacerations or shoulder dystocia. Episiotomy associated with increase in infections and neonatal trauma
de Leeuw et al²²22 de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG 2008;115(1):104-108	21,254	Patients with operative deliveries in Holland	The medio-lateral episiotomy strongly protected against third- and fourth-degree lacerations in patients submitted to vacuum extractor (OR: 0.11; CI: 0.09–0.13) and forceps (OR: 0.08; CI: 0.07–0.11)
Islam et al²³23 Islam A, Hanif A, Ehsan A, Arif S, Niazi SK, Niazi AK. Morbidity from episiotomy. J Pak Med Assoc 2013;63(6):696-701	200	A randomized study comparing routine and selective episiotomy (abstract only)	Most common serious lacerations in the routine episiotomy group
Sulaiman et al²⁴24 Sulaiman AS, Ahmad S, Ismail NA, Rahman RA, Jamil MA, Mohd Dali AZ. A randomized control trial evaluating the prevalence of obstetrical anal sphincter injuries in primigravida in routine versus selective mediolateral episiotomy. Saudi Med J 2013 ; 34(8):819-823	171	Patients randomized for selective or routine episiotomy in Malaysia (abstract only)	Serious lacerations were more common in the routine episiotomy group (3.7%) than in the selective episiotomy group (1.1%)
Hauck et al²⁵25 Hauck YL, Lewis L, Nathan EA, White C, Doherty DA. Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study. Women Birth 2015;28(1): 16-20	10,408	Retrospective analysis of medical records in an Australian hospital (abstract only)	The rate of serious perineal laceration was of 3%. The episiotomy was a protective factor in primiparous women (OR: 0.54; CI: 0.39–0.74), and a risk factor in multiparous women (OR: 2.01; CI: 1.18–3.45)

Risk Factor	Number of studies	Lesser OR or RR	Higher OR or RR
Maternal age > 35 years	2⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146 ⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635	1.6 (1.2–2.0)	2.84 (1.69–4.76)
Primiparity	5¹⁰10 Aukee P, Sundström H, Kairaluoma MV. The role of mediolateral episiotomy during labour: analysis of risk factors for obstetric anal sphincter tears. Acta Obstet Gynecol Scand 2006;85(7):856-860 ¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242 ¹²12 Eskandar O, Shet D. Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 2009;29(2):119-122 ¹³13 Stedenfeldt M, Øian P, Gissler M, Blix E, Pirhonen J. Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme. BJOG 2014;121(1):83-91 ¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272 ¹⁵15 Dahlen HG, Ryan M, Homer CS, Cooke M. An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth. Midwifery 2007;23(2):196-203	3.2 (2.5–4.1)	8.34 (3.98–17.48)
Gestational age ≥ 42 weeks	1¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242	3.62 (1.28–10.21)	−
Weight ≥ 3,500 g	1⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635	3.8(2.5–5.9)	−
Weight ≥ 4,000 g	5⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146 ⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹⁰10 Aukee P, Sundström H, Kairaluoma MV. The role of mediolateral episiotomy during labour: analysis of risk factors for obstetric anal sphincter tears. Acta Obstet Gynecol Scand 2006;85(7):856-860 ¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272 ¹⁵15 Dahlen HG, Ryan M, Homer CS, Cooke M. An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth. Midwifery 2007;23(2):196-203 ¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7	2.12 (1.64–2.72)	12.92 (2.77–60.11)
Weight ≥ 4,500 g	3⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242 ¹⁷17 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014 ; 210(1):59.e1-59.e6	4.42 (2.68–7.27)	10.5 (5.4–20.6)
Duration of the second stage ≥ 60 minutes	2⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272 ¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7	1.32 (1.18–1.47)	1.52 (1.11–2.10)
Duration of the second stage ≥ 90 minutes	1¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242	2.95 (1.39–6.27)	−
Duration of the second stage ≥ 120 minutes	1⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7	1.42 (1.11–1.82)	1.7 (1.5–2.0)
Duration of the second stage ≥ 180 minutes	1⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635	2.0 (1.7–2.4)	−
Vacuum extractor	8⁵5 Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourthdegree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120(12):1516-1525 ⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146 ⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹⁰10 Aukee P, Sundström H, Kairaluoma MV. The role of mediolateral episiotomy during labour: analysis of risk factors for obstetric anal sphincter tears. Acta Obstet Gynecol Scand 2006;85(7):856-860 ¹¹11 Moini A, Yari RE, Eslami B. Episiotomy and third- and fourthdegree perineal tears in primiparous Iranian women. Int J Gynaecol Obstet 2009;104(3):241-242 ¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7 ¹⁷17 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014 ; 210(1):59.e1-59.e6 ¹⁸18 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Risk factors of recurrent anal sphincter ruptures: a population-based cohort study. BJOG 2012;119(13):1640-1647	1.68 (1.50–1.87)	5.22(2.69–10.13)
Forceps	6⁵5 Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourthdegree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120(12):1516-1525 ⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146 ⁹9 Landy HJ, Laughon SK, Bailit JL, et al; Consortium on Safe Labor. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627-635 ¹³13 Stedenfeldt M, Øian P, Gissler M, Blix E, Pirhonen J. Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme. BJOG 2014;121(1):83-91 ¹⁶16 Räisänen S, Selander T, Cartwright R, et al. The association of episiotomy with obstetric anal sphincter injury-a population based matched cohort study. PLoS ONE 2014;9(9):1-7 ¹⁷17 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014 ; 210(1):59.e1-59.e6	1.95 (1.39–2.75)	6.3(5.57–7.64)
Lithotomy position	1¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272	2.02 (1.58–2.59)	−
Squatting position	1¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272	2.05 (1.09–3.82)	−
Variety of OP presentation	2¹²12 Eskandar O, Shet D. Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 2009;29(2):119-122 ¹⁸18 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Risk factors of recurrent anal sphincter ruptures: a population-based cohort study. BJOG 2012;119(13):1640-1647	1.34 (1.22–1.46)	69.8 (14–84)
Head circumference > 35 cm	1¹⁴14 Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114(10):1266-1272	1.57 (1.23–1.99)	−
Shoulder dystocia	4⁵5 Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourthdegree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120(12):1516-1525 ⁸8 Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142-146 ¹⁷17 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014 ; 210(1):59.e1-59.e6 ¹⁸18 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Risk factors of recurrent anal sphincter ruptures: a population-based cohort study. BJOG 2012;119(13):1640-1647	1.33(1.16–1.53)	1.98(1.11–3.54)

Federação Brasileira das Sociedades de Ginecologia e Obstetrícia Av. Brigadeiro Luís Antônio, 3421, sala 903 - Jardim Paulista, 01401-001 São Paulo SP - Brasil, Tel. (55 11) 5573-4919 - Rio de Janeiro - RJ - Brazil
E-mail: editorial.office@febrasgo.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Address for correspondence Mário Days Corrêa Junior, MD, Departmento de Ginecologia e Obstetrícia, Faculdade de Medicina, UFMG, Av. Prof. Alfredo Balena, 190, sala 217, Santa Efigênia, 30130- 100 - Belo Horizonte, MG, Brazil (e-mail: mariodcorrea@ufmg.br).