Episiotomy: Difference between revisions
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Revision as of 11:26, 31 May 2022
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Description[edit | edit source]
An episiotomy is the most common obstetric surgical procedure performed in the second stage of labor. [1]It is done to reduce the incidence of severe perineal tears (third and fourth-degree) during labor. A controlled incision is made in the perineum to enlarge the vaginal orifice, thereby facilitating a difficult delivery resulting in an easily repairable incision compared to an uncontrolled vaginal trauma. [2]
Episiotomy was first introduced in the 18th century for preventive measures. The rate increased gradually in the first half of the 20th century worldwide. During that time, there was also an increasing trend for hospital births and for physicians to become involved in the normal uncomplicated birth process.[3] According to reports, episiotomy rates in the year 1977 in the United States varied from 9.8% for home births to 91% for primipara deliveries in selected hospitals, and the data from British maternity units in 1984 indicated rates varying from 14% to 96% for primiparas and 16% to 71% for multiparas.[4]Although episiotomy had become one of the most commonly performed surgical procedures, there was no solid scientific evidence of its effectiveness [3]. A review (Lede 1996) [5] suggested that the routine use of episiotomy gave few benefits; rather, it involved a greater need for surgical perineal repair, thereby involving higher costs of medical care and more maternal discomfort. Furthermore, the routine use resulted to poor muscle tone, fecal and /or urinary incontinence and poorer sexual function[5].A meta-analysis comparing routine episiotomy with restrictive episiotomy suggests that the restrictive episiotomy was associated with lesser posterior perineal trauma, lesser need for suturing, and fewer complications related to healing.[3]The World Health Organization (WHO) and other professional societies recommends restrictive over routine episiotomy since 1990s. The prevalence of episiotomy varies worldwide. Though the rate of episiotomy has been declining in developed countries, it still remains high in less industrialized and developing countries..[6]
Types of Episiotomy[edit | edit source]
Episiotomy is classified into following types[2]:
- Midline
- Mediolateral
- Lateral
- the modified-median,
- J-shaped,
- anterior, and radical
Midline versus mediolateral[edit | edit source]
Mediolateral episiotomy was preferred in Britain and most European countries, whereas midline episiotomy was done most frequently in North America.[4]There is a debate regarding which method is best for episiotomy. Research states mediolateral episiotomy lowers the risk of third-degree tear. Midline compared to medio-lateral episiotomy resulted in more deep perineal tears. [7]
Indication[edit | edit source]
Episiotomy is suggested to be administered during difficult vaginal deliveries to control and avoid potentially perineal lacerations at the time of delivery.
It is done in conditions such as:
- complicated vaginal deliveries (breech, shoulder dystocia, forceps, vacuum),[8]
- incision-related scars in the genital area[8],
- poorly healed or 4th degree tears, and fetal distress,[8]
- when there is poor perineal tissue elasticity, that perineal tear seems unavoidable,[9]
- or short perineal length, research based on the traditional views is of the opinion that the Asian women have shorter perineal length than Caucasians, putting them at increased risk of tears,[9]
There are varying beliefs about the benefits of this procedure.
Benefits thought for the mother are:[10][3]
- reduction in the likelihood of third degree perineal tears,
- the preservation of the muscle relaxation of the pelvic floor and perineum leading to improved sexual function,
- reduced risk of fecal and urinary incontinence,
- ease of repair and better healing than laceration because it is a straight and clean incision
Benefits for the baby:
It is also suggested that episiotomy increases the APGAR score of the baby, reduces the prolonged second stage and may also reduce the possibility of fetal shoulder dystocia. In some cases, rigid perineum could lead to fetal asphyxia, cranial trauma, cerebral hemorrhage, and mental retardation.[10][3]
Complication[edit | edit source]
- bleeding
- infection
- prolonged wound healing,
- dyspareunia,
- pelvic floor dysfunction
- urinary fistulas, and
- inappropriate wound scarring
According to a study evaluating early complications after delivery with episiotomy in Vietnamese women, pain in sitting position (30.4%) was the most prominent trouble, and pelvic disorders such as urinary incontinence (11.4%), urinary retention (10.8%), or flatus incontinence (8.9%), were also observed in a remarkable number of participants and sexual dysfunction ( 40.7% )was seen with trouble occurring commonly in the domains of desire (68.9%) and pain (58.5%).[11]
Contraindications[edit | edit source]
Clinical Significance[edit | edit source]
Different opinions exists about the applicability of episiotomy. Traditional views suggest that routine episiotomy reduces the pressure of the fetal head on the pelvic floor tissues and prevents third-degree or fourth-degree perineal laceration. It is easy to suture because an open wound is smoother than a spontaneous wound[9]. However, there are published reports that claim that episiotomy had no such benefits and large studies stress that routine implementation of episiotomy should be abandoned[12] According to American College of Obstetricians and Gynecologists (ACOG) guidelines “the best available data do not support the liberal or routine use of episiotomy.[13] As a matter of fact, an episiotomy is essentially a type of birth injury. It does not reduce the incidence of severe perineal lacerations. Instead, research suggests that it increases the risk of complications, including perineal tears, perineal pain (compared with no laceration), puerperal infection, postpartum hemorrhage, and later dyspareunia. Therefore, the clinician must ensure that the benefits of the procedure outweigh the risks during the decision-making process. It is seen that many obstetricians have begun to limit the use of episiotomy in recent years.[10][12][2] WHO does not recommend routine or liberal use of episiotomy for women undergoing spontaneous vaginal birth
References[edit | edit source]
- ↑ Langrová P, Vrublová Y. Relationship between episiotomy and prevalence of urinary incontinence in women 2-5 years after childbirth. small. 2014;90:98.
- ↑ 2.0 2.1 2.2 2.3 Barjon K, Mahdy H. Episiotomy. InStatPearls [Internet] 2021 Jul 31. StatPearls Publishing.
- ↑ 3.0 3.1 3.2 3.3 3.4 Carroli G. Mignini l. Episiotomy for vaginal birth (Cochrane Review). The Cochrane Collaboration and published in The Cochrane Library. 2009.
- ↑ 4.0 4.1 Ruderman J, Carroli JC, Reid AJ, Murray MA. Episiotomy: Differences in practice between family physicians and obstetricians. Canadian Family Physician. 1992 Nov;38:2583.
- ↑ 5.0 5.1 Lede RL, Belizán JM, Carroli G. Is routine use of episiotomy justified?. American journal of obstetrics and gynecology. 1996 May 1;174(5):1399-402.
- ↑ Woretaw E, Teshome M, Alene M. Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia. Reproductive Health. 2021 Dec;18(1):1-1.
- ↑ Sooklim R, Thinkhamrop J, Lumbiganon P, Prasertcharoensuk W, Pattamadilok J, Seekorn K, Chongsomchai C, Pitak P, Chansamak S. The outcomes of midline versus medio-lateral episiotomy. Reproductive Health. 2007 Dec;4(1):1-5.
- ↑ 8.0 8.1 8.2 Kartal B, Kızılırmak A, Calpbinici P, Demir G. Retrospective analysis of episiotomy prevalence. Journal of the Turkish German Gynecological Association. 2017 Dec;18(4):190.
- ↑ 9.0 9.1 9.2 Yang J, Bai H. Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China. BMJ open. 2021 Apr 1;11(4):e043596.
- ↑ 10.0 10.1 10.2 Izuka EO, Dim CC, Chigbu CO, Obiora-Izuka CE. Prevalence and predictors of episiotomy among women at first birth in Enugu, south east Nigeria. Annals of medical and health sciences research. 2014;4(6):928-32.
- ↑ 11.0 11.1 Huy NV. Pelvic floor and sexual dysfunction after vaginal birth with episiotomy in vietnamese women. Sexual medicine. 2019 Dec 1;7(4):514-21.
- ↑ 12.0 12.1 Živković K, Živković N, Župić T, Hodžić D, Mandić V, Orešković S. Effect of delivery and episiotomy on the emergence of urinary incontinence in women: review of literature. Acta Clinica Croatica. 2016 Dec 11;55(4).
- ↑ M Amorim M, Coutinho IC, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial-Reproductive Health-Vol. 14-ISBN: 1742-4755-p. 55.
