Perineal audit: reasons for more than one thousand episiotomies

Czech version

Authors: Z. Rušavý ¹; V. Kališ ¹; J. Landsmanová ¹; L. Kašová ²; J. Karbanová ¹; K. Dolejšová ¹; T. Sýkora ¹; P. Nečesalová ¹; Z. Novotný ¹
Authors‘ workplace: Gynekologicko-porodnická klinika LF UK a FN, Plzeň, přednosta doc. MUDr. Z. Novotný, CSc. ¹; Katedra ošetřovatelství a porodní asistence Fakulty zdravotnických studií, Západočeská univerzita, Plzeň ²
Published in: Ceska Gynekol 2011; 76(5): 378-385

Overview

Aim:
To analyze reasons for episiotomy use in vaginal delivery among obstetricians and midwives. Consecutively, to indentify disputable indications for its use based on published research in order to facilitate the decrease in frequency of this operation, while preserving high quality of obstetrical care.

Methods:
Reasons for mediolateral episiotomy use were recorded by obstetricians and midwives after each vaginal delivery with episiotomy at the Ob&Gyn Department of the Charles University Hospital in Pilsen in the period of February 2006 – June 2007. The main reason and all reasons for episiotomy use were evaluated separately.

Results:
The reason for episiotomy use was recorded in 1069 cases (93%) out of a total of 1150 vaginal deliveries, in which mediolateral episiotomy was performed (42% of all vaginal deliveries). The most common group of main reasons for episiotomy use was a concern about postpartum pelvic floor functional impairment (624, 58% of episiotomies), especially a rigid, non-elastic perineum (401, 37%). Fetal distress (181, 17%) and abnormalities of the expulsive forces/uncooperative parturient (109, 10%) followed. When evaluating all (including secondary) reasons, the most common groups of reasons for episiotomy use were the effort of pelvic floor functionality preservation (871, 50%), abnormalities of the expulsive forces/uncooperative parturient (354, 20%) and fetal distress (253, 15%). When evaluating episiotomies performed by obstetricians and midwives separately, the concern about postpartum pelvic floor functionality prevailed in midwives (81% vs. 39% of episiotomies performed primarily for this reason). Conversely, the obstetricians performed episiotomy more frequently for fetal distress (28% vs. 4 %).

Conclusion:
In view of the fact that midwives attend only physiological deliveries in our department, the spectrum of reasons for episiotomy use among midwives is narrower and the concern about postpartum pelvic floor functionality dominates. Currently, the concern about postpartum pelvic floor functionality should not be considered a legitimate indication for episiotomy use. The fact that 624 (58%) episiotomies were performed for this reason represents a significant reserve for a decrease in the frequency of episiotomy use. The reduction should be possible primarily among midwives (81% of all main reasons for episiotomy use in the midwive group, i.e. 37% of all episiotomies performed). The analysis of reasons for episiotomy use is an important step in reduction of episiotomy rates while preserving or improving the standard of treatment provided.

Key words:
mediolateral episiotomy, indications, pelvic floor.

Sources

1. Alran, S., Sibony, O., Oury, JF., et al. Differences in management and results in term-delivery in nine European referral hospitals: descriptive study. Eur J Obstet Gynecol Reprod Biol, 2002, 103(1), p. 4-13.

2. Andrews, V., Sultan, AH., Thakar, R., Jones, PW. Occult anal sphincter injuries – myth or reality? BJOG, 2006, 113(2), p. 195‑200.

3. Bodner-Adler, B., Bodner, K., Kaider, A., et al. Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med, 2001, 46(8), p. 752-756.

4. Carroli, G., Mignini, L. Episiotomy for vaginal birth. Cochrane Database Syst Rev, 2009. Jan 21;(1): CD000081

5. Coats, PM., Chan, KK., Wilkins, M., Beard, RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol, 1980, 87(5), p. 408-412.

6. Dandolu, V., Chatwani, A., Harmanli, O., et al. Risk factors for obstetrical anal sphincter lacerations. Int Urogynecol J Pelvic Floor Dysfunct, 2005, 16(4), p. 304-307.

7. Dannecker, C., Hillemanns, P., Strauss, A., et al. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstet Gynecol Scand, 2004, 83(4), p. 364‑368.

8. 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.

9. 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), p. 104‑108.

10. 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.

11. de Oliveira, SM., Miquilini, EC. Freqüźncia e critérios para indicar a episiotomia. Rev Esc Enferm USP, 2005, 39(3), p. 288‑295.

12. de Tayrac, R., Panel, L., Masson, G., Mares, P. Épisiotomie et prévention des lésions pelvi-périnéales. J Gynecol Obstet Biol Reprod (Paris), 2006, Suppl. 1(35), p. 1S24-1S31.

13. DeLee, JB. The prophylactic forceps operation. Am J Obstet Gynecol, 1921, 34(1).

14. Dua, A., Whitworth, M., Dugdale, A., Hill, S. Perineal length: norms in gravid women in the first stage of labour. Int Urogynecol J Pelvic Floor Dysfunct, 2009, 20(11), p. 1361-1364.

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

16. Faruel-Fosse, H., Vendittelli, F. Peut-on réduire le taux des épisiotomies. J Gynecol Obstet Biol Reprod, 2006, Suppl. 1(35), p. 1S68-1S76.

17. Fitzpatrick, M., McQuillan, K., O’Herlihy, C. Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol, 2001, 98(6), p. 1027-1031.

18. Graham, ID., Carroli, G., Davies, C., Medves, JM. Episiotomy rates around the world: an update. Birth, 2005, 32(3), p. 219-223.

19. Grigoriadis, T., Athanasiou, S., Zisou, A., Antsaklis, A. Episiotomy and perineal repair practices among obstetricians in Greece. Int J Gynaecol Obstet, 2009, 106(1), p. 27-29.

20. Groom, KM., Paterson-Brown, S. Can we improve on diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol, 2002, 101(1), p. 19-21.

21. Gurewitsch, ED., Donithan, M., Stallings, SP., et al. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol, 2004, 191(3), p. 911-916.

22. Hartmann, K., Viswanathan, M., Palmieri, R., et al. Outcomes of routine episiotomy: a systematic review. JAMA, 2005, 293(17), p. 2141-2148.

23. Heres, MH., Pel, M., Elferink-Stinkens, PM., et al. The Dutch obstetric intervention study – variations in practice patterns. Int J Gynaecol Obstet, 1995, 50(2), p. 145-150.

24. Husic, A., Hammoud, MM. Indications for the use of episiotomy in Qatar. Int J Gynec Obstet, 2009, 104, p. 240–248.

25. Chang, SR., Chen, KH., Lin, HH., et al. Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study. Int J Nurs Stud, 2010, Epub ahead of print.

26. Kališ, V., Chaloupka, P., Turek, J., Rokyta, Z. Risk factors for 3rd and 4th degree perineal ruptures during delivery. Čes Gynek, 2005, 70(1), s. 30-36.

27. Kališ, V., Karbanová, J., Bukacová, Z., et al. Anal dilation during labor. Int J Gynaecol Obstet, 2010, 109(2), p. 136-139.

28. Kališ, V., Karbanová, J., Horák, M., et al. The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet, 2008, 103(1), p. 5-8.

29. Kališ, V., Štěpán, J. Jr., Horák, M., et al. Definitions of mediolateral episiotomy in Europe. Int J Gynaecol Obstet, 2008, 100(2), p. 188-189.

30. Karbanová, J., Štěpán, J. Jr., Kališ, V., et al. Mediolaterální epiziotomie a poranění análního sfinkteru. Čes Gynek, 2009, 74 (4), s. 247-251.

31. Klein, MC., Gauthier, RJ., Robbins, JM., et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol, 1994, 171(3), p. 591-598.

32. Klein, MC., Kaczorowski, J., Robbins, JM., et al. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ, 1995, 153(6), p. 769-779.

33. Kropp, N., Hartwell, T., Althabe, F. Episiotomy rates from eleven developing countries. Int J Gynec Obstet, 2005, 91, p. 157-159.

34. Laine, K., Pirhonen, T., Rolland, R., Pirhonen, J. Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol, 2008, 111(5), p. 1053-1057.

35. Larsson, PG., Platz-Christensen, JJ., Bergman, B., Wallstersson, G. Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynecol Obstet Invest, 1991, 31(4), p. 213-216.

36. 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), p. 1688-1694.

37. Pomeroy, RH. Shall we cut and reconstruct the perineum for every primipara? Am J Obstet Dis Women Child, 1918, 211(78).

38. Revicky, V., Nirmal, D., Mukhopadhyay, S., et al. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol, 2010, 150(2), p. 142-146.

39. Riethmuller, D., Courtois, L., Maillet, R. Pratique libérale versus restrictive de l’épisiotomie: existe-t-il des indications obstétricales spécifiques de l’épisiotomie? J Gynecol Obstet Biol Reprod, 2006, Suppl. 1 (35), p. 1S32-1S39.

40. Riethmuller, D., Khalife, H., Schaal, JP., et al. La grande extraction du siŹge sur 2e jumeau. A propos d’une série continue de 56 cas et revue de la littérature = Breech extraction of the second twin. J Gynecol Obstet Biol Reprod (Paris), 1996, 25(1), p. 94-98.

41. Rizk, DE., Thomas, L. Relationship between the length of the perineum and position of the anus and vaginal delivery in primigravidae. Int Urogynecol J Pelvic Floor Dysfunct, 2000, 11, p. 79-83.

42. 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.

43. Samarasekera, DN., Bekhit, MT., Preston, JP., Speakman, CTM. Risk factors for anal sphincter disruption during child birth. Langenbecks Arch Surg, 2009, 394, p. 535–538.

44. 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. 669-673.

45. Sheiner, E., Levy, A., Walfisch, A., et al. Third degree perineal tears in a university medical center where midline episiotomies are not performed. Arch Gynecol Obstet, 2005, 271(4), p. 307‑310.

46. Shiono, P., Klebanoff, MA., Carey, JC. Midline episiotomies: more harm than good? Obstet Gynecol, 1990, 75(5), p. 765-770.

47. STAKES, 2007. Knowledge for Welfare and Health. Statistics and Registers. National Research and Development Centre for Welfare and Health, Helsinki. [Online] http://www.stakes.fi /EN/tilastot/index.htm.

48. Sultan, AH., Kamm, MA., Hudson, CN., Bartram, CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ, 1994, 308, p. 887-891.

49. Sultan, AH., Stanton, SL. Preserving the pelvic floor and perineum during childbirth - elective caesarean section? Brit J Obstet Gynaecol, 1996, 103, p. 731-734.

50. Sze, EH., Ciarleglio, M., Hobbs, G. Risk factors associated with anal sphincter tear difference among midwife, private obstetrician, and resident deliveries. Int Urogynecol J Pelvic Floor Dysfunct, 2008, 19(8), p. 1141-1144.

51. van Dillen, J., Spaans, M., van Keijsteren, W., et al. A prospective multicenter audit of labor-room episiotomy and anal sphincter injury assessment in the Netherlands. Int J Gynaecol Obstet, 2010, 108(2), p. 97-100.

52. Weiner, Z., Ben-Shlomo, I., Beck-Fruchter, R., et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol, 2002, 105(1), p. 20‑24.

53. Youssef, R., Ramalingam, U., Macleod, M., Murphy, DJ. Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery. BJOG, 2005, 112(7), p. 941-945.