Impact of liberal use of mediolateral episiotomy on the incidence of obstetric anal sphincter tear

Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

The role of mediolateral episiotomy during vacuum-assisted vaginal delivery with soft cup devices

PURPOSE

This study evaluated whether episiotomy during vacuum-assisted delivery leads to fewer third- and fourth-degree tears.

METHODS

This was a retrospective cohort study of all nulliparas who underwent a singleton, soft cup, vacuum-assisted vaginal delivery in one institution, from January 2014 to August 2019. Failed vacuum deliveries were excluded. Based on power analysis calculation, a sample size of 500 women in each group was sufficient to detect an advantage of episiotomy, if present. Primary outcome was third- or fourth-degree perineal tear. Secondary outcomes were other maternal complications, and low neonatal cord pH and Apgar scores. Outcomes were compared between women with and without episiotomy.

RESULTS

During the study period, 2370 nulliparas had a vacuum-assisted vaginal delivery using soft vacuum cup and met the study inclusion criteria. Episiotomy was performed in 1868 (79%) women, and 502 (21%) delivered without episiotomy. Background characteristics were similar in both groups. There were no significant differences in the rates of third and fourth grade perineal lacerations between the two groups. Episiotomy was associated with higher rate of postpartum hemorrhage (p < 0.01) CONCLUSIONS: Using selective episiotomy for patients delivering vaginally with the assistance of soft cap vacuum does not increase third- or fourth-degree perineal tears.

ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery

Lacerations are common after vaginal birth. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes. Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth. The purpose of this document is to provide evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy.

Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery

Lacerations are common after vaginal birth. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes. Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth. The purpose of this document is to provide evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy.

Obstetric Anal Sphincter Injuries (OASIs) in Israel: A Review of the Incidence and Risk Factors

Obstetric anal sphincter injuries (OASIs) following vaginal deliveries are the main reason for subsequent development of anal incontinence in women. The diagnosis of such tears is crucial for treating and preventing such a grave sequela. The reported rate of OASIs in Israel was between 0.1% and 0.6%, out of all vaginal births, which is 10-fold lower than that reported in Europe and the United States. Structured hands-on training in repair of OASIs in seven medical centers in Israel significantly increased the detection rate of third-degree perineal tears. The implementation of such programs is crucial for increasing awareness and detection rates of OASIs following vaginal deliveries.

Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study

OBJECTIVE

To compare the incidence of obstetric anal sphincter injuries (OASIS) in two time periods, before and after implementing a training programme for improved perineal support aimed at reducing the incidence of obstetric anal sphincter injuries. The secondary aim was to study incidence of obstetric anal sphincter injuries in subgroups defined by risk factors for OASIS.

DESIGN

Population-based cohort study.

SETTING

University hospital setting in Oslo, Norway.

PARTICIPANTS

Two cohorts of all delivering women in the largest hospital in Norway during two time periods (2003-2005 and 2008-2010) were studied. After excluding caesarean sections and preterm deliveries (< week 32), the study population consisted of 31 709 deliveries, among which 907 women were identified with obstetric anal sphincter injury.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidence of OASIS in two time periods. Maternal, obstetrical and foetal risk factors for OASIS were collected from the hospital obstetric database. Univariate analyses and multivariate logistic regression analyses, presenting adjusted ODs for OASIS, were performed.

RESULTS

The OASIS incidence was significantly reduced by 50%, from 4% (591/14787) in the first time period to 1.9% (316/16 922) in the second. This reduction could not be explained by changes in population characteristics or OASIS risk factors during the study years. The reduction of incidence of OASIS between the two study periods was consistent across subgroups of women; regardless of parity, delivery method and infant birth weight.

CONCLUSIONS

A marked reduction in the incidence of OASIS was observed in all studied subgroups of women after implementing the training programme for perineal protection. Further, this reduction could not be explained by the differences in patient characteristics across the study period. These findings indicate that the training programme with improved perineal protection markedly reduced the risk of OASIS.