Mediolateral episiotomy and anal sphincter trauma

Czech version

Authors: J. Karbanová ¹; J. Štěpán jr. ¹; V. Kališ ¹; J. Landsmanová ¹; B. Bednářová ¹; Z. Bukačová ²; M. Horák ³; L. Lobovský ³; J. Křen ³; M. Králíčková ¹; Z. Rokyta ¹
Authors‘ workplace: Gynekologicko-porodnická klinika LF UK a FN, Plzeň, přednosta doc. MUDr. Z. Rokyta, CSc. ¹; Gynekologicko-porodnické oddělení, Klatovská nemocnice, Klatovy ²; Katedra mechaniky, Západočeská univerzita, Plzeň ³
Published in: Ceska Gynekol 2009; 74(4): 247-251
Category: Original Article

Overview

Objective:
A summary of recent knowledge of the correlation between mediolateral episiotomy and anal sphincter injury.

Design:
Review.

Setting:
Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen.

Conclusions:
The methodology of most studies is not well managed. Four problematical points were identified: definition of the mediolateral episiotomy, practical execution of the mediolateral episiotomy, diagnostics of perineal trauma and classification of the perineal trauma.

Mediolateral episiotomy is often deficiently defined. Definitions differ depending on individual textbooks or departments. The majority of studies gives no definition and no description of the practical execution of an episiotomy or describes it inadequately. To the current knowledge there is no international consensual definition, which is used universally.

Until 2003, there was no study evaluating adequate implementation of the mediolateral episiotomy. It appears that most of executed mediolateral episiotomies are not truly mediolateral. The angle of inclination between 40-60 degrees was suggested. According to the latest study, the lower limit of the mediolateral episiotomy definition (40 degrees) appears to be insufficient.

At the present time, the correlation between mediolateral episiotomy and perineal trauma cannot be precisely evaluated. Before analyzing the benefits and risks of mediolateral episiotomy, an international consensus must be found, that would establish an exact definition of mediolateral episiotomy.

Key words:
mediolateral episiotomy, third-degree tear, anal incontinence, pelvic floor, perineal trauma, delivery.

Sources

1. http://www.answers.com/episiotomy&r=67

2. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Obstet Gynecol, 2006, 107, 4, p. 957-962.

3. Argentine Episiotomy Trial Collaborative Group. Routine vs. selective episiotomy: a randomized trial. Lancet, 1993, 342, p. 1517-1578.

4. CollŹge National des Gynécologues et Obstétriciens Franćais. L`ÉPISIOTOMIE. Recommandations pour la Practique Clinique. [Episiotomy: recommendations of the CNGOF for clinical practice (December 2005)] Gynecol Obstet Fertil, 2006, 34, 3, p. 275-279.

5. Obstetric procedures. In Obstetrics by Ten Teachers. London: Arnold, 1995, p. 285-303.

6. Williams Obstetrics. 21st ed., McGraw-Hill Companies, Inc. 2001.

7. Allen, RE., Hosker, GL., Smith, ARB., Warrell, DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol, 1990, 97, p. 770-779.

8. Andrews, V., Thakar, R., Sultan, AH., Jones, PW. Are mediolateral episiotomies actually mediolateral? BJOG 2005, 112, 8, p. 1156-1158. Erratum in: BJOG 2005, 112, 10, p. 1459.

9. Andrews, V., Thakar, R., Sultan, AH. Episiotomy technique between midwives and doctors – time for reappraisal? ICS 2004, Paris, France, Abstract No. 0277, non-discussion poster, category Pregnancy.

10. Andrews, V., Sultan, AH., Thakar, R., Jones, PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth, 2006, 33, 2, p. 117-122.

11. Aukee, P., Sundstrom, 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, p. 856-860.

12. Beischer, NA., MacKay, EV. Episiotomy. In: Obstetrics and The Newborn. London: Bailliere Tindall, 1986.

13. Carroli, G., Belizan, J. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2000, 2, p. CD000081.

14. Čech, E., Hájek, Z., Maršál, K., et al. Porodnictví. Praha: Grada Publishing, 1999, p. 382-383.

15. de Leeuw, JW., Struijk, PC., Vierhout, ME., Wallenburg, HC. Risk factors for third degree perineal ruptures during delivery. BJOG, 2001, 108, 4, p.383-387.

16. Dannecker, C., Hillemanns, P., Strauss, A., et al. Episiotomy and perineal tears presumed to be imminent: the influence on the urethral pressure profile, analmanometric and other pelvic floor findings—follow-up study of a randomized controlled trial. Acta Obstet Gynecol Scand, 2005, 84, 1, p. 65-71.

17. Doležal, A. Technika porodnických operací. Praha: Grada Publishing, 1998, p. 28.

18. Dudenhausen, JW., Pschyrembel, W. Praktische Geburtshilfe mit geburtshilflichen Operationen. 19. überarb. Auflage 2001, de Gruyter, 2001.

19. Eogan, M., Daly, L., O’Connell, P., O’Herlihy, C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG, 2006, 113, 2, p. 190-194.

20. Everhardt, E. Postpartum anal sphincter tear approach: more than only continuity repair of the external anal sphincter. Workshop 6: „Anal sphincter repair.“ 31st Annual Meeting of the IUGA, 6-9 September 2006, Athens, Greece.

21. Kalis, V., Karbanova, J., Horak, M., et al. The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet, 2008, 103, 1, p. 5-8.

22. Kalis, V., Stepan, J Jr., Horak, M., et al. Definitions of mediolateral episiotomy in Europe. Int J Gynaecol Obstet, 2008, 100, 2, p. 188-189.

23. Myles, MF. Myles’ Textbook for Midwives. London: Churchill Livingstone, 1979, p. 218.

24. Poen, AC., Felt-Bersma, RJ., Dekker, GA., et al. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol, 1997, 104, 5, p. 563-566.

25. O’Brien, WF., Cefalo, RC. Labour and delivery. In: Gabbe, SG., Niebyl, NJ., eds. Obstetrics: normal and problem pregnancies. New York: Churchill Livingstone, 1991, p. 427-455.

26. Rockner, G., Jonasson, A., Olund, A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand, 1991, 70, 1, p. 51-54.

27. Sartore, A., De Seta, F., Maso, G., et al. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol, 2004, 103, 4, p. 669-63.

28. Sultan, AH., Kamm, MA., Hudson, CN., et al. Anal sphincter disruption during vaginal delivery. N Engl J Med, 1993, p. 329, p. 1905-1911.

29. Sultan, AH., Thakar, R. Educational Course 12. Hands-on course on repair of 3rd/4th degree tears. 37th Annual Meeting of ICS, August, 2007, Rotterdam, Netherlands.

30. Štěpán, J Jr., Králíčková, M., Ulmanová, E., Rokyta, Z. Jak přesné je provedení mediolaterální epiziotomie. .....??

31. Tincello, DG., Williams, A., Fowler, GE., et al. Differences in episiotomy technique between midwives and doctors. BJOG, 2003, 110, 12, p. 1041-1044.

32. Woodman, PJ., Graney, DO. Anatomy and physiology of the female perineal body with relevance to the obstetrical injury and repair. Clin Anat, 2002, 15, 5, p. 321-334.

33. Zwinger, A. et al. Porodnictví. Praha: Galén, 2004.