Risk factors for episiotomy during vaginal childbirth: A retrospective cohort study in Western China

Analysis of episiotomy incidence and risk factors in vaginal deliveries: a single-center

Introduction

Episiotomy is a surgical procedure involving the enlargement of the posterior vagina to facilitate the delivery of the baby. This study aims to further investigate the associated risk factors for episiotomy and the specific indications for its use in spontaneous labor.

Methodology

This institutional-based cross-sectional study was conducted among 349 vaginal births with a ratio of 1:4 from January 2020 to December 2020. We recruited study participants using consecutive sampling techniques. The sample size was calculated with a hypothesis test for two population proportions (one-sided test formula). Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.

Results

In our multivariate analysis, it was found that pregnant women who underwent instrumental delivery (P-value=.00; OR=25.63; 95% CI: 5.76-114.0) and those with fetal birth weight >3,000 grams (P-value=.00; OR=11.31; 95% CI: 3.96-32.32) had the highest risk of undergoing an episiotomy. Subsequently, the duration of the second stage of labor >30 minutes (P-value=.049; OR=16.34; 95% CI: 1.01-264.48) was associated with a slightly increased risk of episiotomy. Fetal head circumference >34 cm was not found to be risk of an increased risk of episiotomy in this study. However, pregnant women aged >30 years (P-value=.049; OR=0.306; 95% CI: 0.94-0.99) showed a reduced risk of episiotomy.

Conclusion

The prevalence of episiotomy practice in this study exceeds the recommended threshold set by the World Health Organization (WHO). Instrumental delivery, high birth weight, and prolonged second-stage labor emerged as significant factors influencing episiotomy practice. Hence, further interventions are warranted to mitigate the prevalence of episiotomy practice.

Prevalence of episiotomy and associated factors among women who gave birth at public health facilities in Jigjiga town, eastern Ethiopia: A cross-sectional study

INTRODUCTION

Maternal morbidity and mortality has remained a major public health concern worldwide. Basic emergency obstetric care is the primary intervention to prevent obstetric complications and maternal death. Episiotomy is one of the basic obstetrical procedures used to facilitate vaginal delivery, shorten the second stage of labor and prevent complications. However, there is a paucity of evidence on the prevalence and factors associated with episiotomy among women who gave birth in eastern Ethiopia.

OBJECTIVE

This study aimed to determine the prevalence of episiotomy and its associated factors among women who gave birth at public health facilities in Jigjiga town, eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among women who gave birth vaginally from May 1 to June 30, 2022. A total of 422 study participants were recruited using systematic random sampling. Data were collected using structured questionnaires through a face-to-face interview supported with standard observational checklist and reviewing medical records. A logistic regression analysis was carried out to examine the association between explanatory variables and episiotomy. An adjusted odds ratio (AOR) at a 95% confidence interval (CI) at a P-value <0.05 was used to declare significant association.

RESULTS

The prevalence of episiotomy among women was 52.6% (95% CI: 47.8%, 57.0%). Obstetric complications during current pregnancy (AOR:3.92, 95% CI: 1.59, 9.68), birth weight ≥4000 gm (AOR: 4.30, 95% CI: 1.53, 12.04), induction of labor (AOR: 3.10, 95% CI: 1.62, 5.93), meconium-stained amniotic fluid (AOR:2.10, 95% CI: 1.14, 3.88), duration of the second stage of labor ≥90 minutes (AOR:3.09, 95% CI: 1.53, 6.23), instrumental delivery (AOR: 2.69, 95%, CI: 1.39, 5.19), and female genital mutilation (AOR: 2.91, 95% CI: 1.83, 4.64) were factors significantly associated with episiotomy.

CONCLUSION

Slightly more than half of the women who gave birth at public health facilities in the study area underwent episiotomies. In addition to the common obstetric factors, having a female genital mutilation scar increased the risk of women's experiencing episiotomies. Therefore, intervention should be tailored to address the identified obstetric risk factors and avoid female genital mutilation in the community to reduce women's experiences of episiotomies in the future.

Perineal stress as a predictor of performing episiotomy in primiparous women: a prospective observational study

Background

Episiotomy is a surgical solution to relieve perineal stress, resulting in an easily repairable incision, in comparison to the risks of serious vaginal trauma during delivery. The midwife typically adopts such a clinical decision, on experience and subjective judgment. However, the association between perineal stress and episiotomy is poorly characterized. Our aim was to identify a threshold value for perineal stress leading to episiotomy, which eventually may be employed as a clinical tool for assessing whether an episiotomy is required or not.

Methods

In total, 245 nulliparous women were investigated for perineal stress during non-instrumental vaginal delivery in Ningbo Women & Children’s Hospital. During the second stage of labor, a flexible membrane stress sensor was placed between the fetal head and perineal wall above the anal fissure. Once the entire fetal head pressed against the sensor, real-time perineal stress was measured, and the peak value was recorded. Cases were divided into non-episiotomy group (n = 173) and episiotomy group (n = 72). The correlations between perineal stress and episiotomy was assessed through logistic regression with adjustment for maternal age, estimated birthweight, duration of second stage of labor, maternal body mass index, and presence of analgesia. Midwives were blinded to all stress measurement values. The predictive value of perineal stress on performing episiotomy was evaluated, together with the ideal cut-off perineal stress value for performing episiotomy. A ROC analysis was also performed.

Results

The episiotomy group had significantly higher levels of perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 N versus 118.37 ± 19.21 N, p < 0.01). The episiotomy group was linked to significantly higher perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 VS 118.37 ± 19.21 N, p < 0.01). ROC analysis between perineal stress and episiotomy revealed a high area under the curve (AUC 0.81, 95% CI 0.75–0.86) and a cut-off value for perineal stress of 124.49 N was identified for episiotomy decision.

Conclusion

The level of perineal stress was an independent predictor of performing episiotomy in nulliparous women during non-instrumental vaginal delivery. Perineal stress exceeding 124.49 N was identified as the cut-off prompting midwives to perform episiotomy.

Episiotomy for Medical Indications during Vaginal Birth-Retrospective Analysis of Risk Factors Determining the Performance of This Procedure

The WHO (World Health Organization) recommends that the percentage of perineal incisions should not exceed 10%, indicating that this is a good goal to achieve, despite the fact that it is still a frequently used medical intervention in Poland. The risk factors for perineal incision that have been analyzed so far in the literature allow, among others, to limit the frequency of performing this procedure. Are they still valid? Have there been new risk factors that we should take into account? We have conducted this study to find the risk factors for performing perineal incision that would reduce the frequency of this procedure. The aim of the study was to check whether the risk factors that were analyzed in the literature are still valid, to find new risk factors for perineal incisions and to compare them among Polish women. This was a single-center retrospective case-control study. The electronic patient records of Saint Sophia's Hospital in Warsaw, Poland, a tertiary hospital was used to create an anonymous retrospective database of all deliveries from 2015 to 2020. The study included the analysis of two groups, the study group of patients who had had an episiotomy, and the control group-patients without an episiotomy in cases where an episiotomy was indicated. A logistic regression model was developed to assess the risk factors for perineal laceration. Independent risk factors for episiotomy in labor include oxytocin use in the second stage of labor (OR (Odds Ratio) = 6.00; 95% CI (Confidence Interval): 4.76-7.58), the supply of oxytocin in the first and the second stage of labor (OR = 3.18; 95% CI: 2.90-3.49), oxytocin use in the first stage of labor (OR = 2.72; 95% CI: 2.52-3.51), state after cesarean section (OR = 2.97; 95% CI: 2.52-3.51), epidural anesthesia use (OR = 1.77; 95% CI: 1.62-1.93), male gender (OR = 1.10; 95% CI: 1.02-1.19), and prolonged second stage of labor (OR = 1.01; 95% CI: 1.01-1.01). A protective factor against the use of an episiotomy was delivery in the Birth Centre (OR = 0.43; 95% CI: 0.37-0.51) and mulitpara (OR = 0.31; 95% CI: 0.27-0.35). To reduce the frequency of an episiotomy, it is necessary consider the risk factors of performing this procedure in everyday practice, e.g., limiting the use of oxytocin or promoting alternative places of delivery.

Prevalence of episiotomy practice and factors associated with it in Ethiopia, systematic review and meta-analysis

An episiotomy is one of the most commonly performed obstetrics surgeries indicated in emergencies during the second stage of labor like fetal distress, dystocia, and tight perineum. As a result, this systematic review and meta-analysis aimed to assess the prevalence of episiotomy practice and associated factors in Ethiopia. Ten cross-sectional studies with a total population of 3718 were included in this study. The search was done using online databases like PubMed, HINARI, Web of Science, other gray, and online repositories of Universities. All the included papers were extracted and appraised using the standard extraction sheet format of JOANNA Briggs Institute. The Cochran Q-test and I² statistics test were used to test the heterogeneity of studies. To detect the publication bias of the included studies, a funnel plot and Egger's test were used. The pooled prevalence of episiotomy practice and the odds ratio with a 95% confidence interval were presented using forest plots. The overall pooled prevalence of episiotomy practice was 45.11% (95% CI; 37.04-53.18; I² = 96.3%). Prolonged second stage of labor (OR: 4.79, 95% CI: 3.03, 7.57), face presentation (OR: 4.26, 95% CI: 1.21, 15.07), birth weight > 4000 g (OR: 6.71, 95% CI: 3.14-14.33), instrumental delivery (OR: 4.26, 95% CI 2.95, 6.14), and primiparity (OR: 3.70, 95% CI: 1.90, 7.2) were factors associated with episiotomy practice. The overall prevalence of episiotomy practice was higher in Ethiopia compared to studies conducted in other countries. The prolonged second stage of labor, face presentation, birth weight > 4000 g, instrumental delivery, and primiparity of women were the factors associated with episiotomy practice. Therefore, efforts should be made to prevent routine episiotomy practice through creating awareness, adjusting national guidelines, affecting the World Health Organization episiotomy policy, and monitoring the activities of the health care facilities in executing the protocols.

Effectiveness of Olea Herbal Ointment on Episiotomy Wound Healing Among Primiparous Women: A Randomized Clinical Trial

Background: Episiotomy is a surgical incision in the perineal region to increase the vaginal diameter during delivery. Since the perineal region is not well visible to the mothers and there is a possibility of infection for the episiotomy wound by vaginal and rectal bacteria, such a cut is associated with infection and delay in wound healing. Objectives: This study aimed to detect the effect of Olea ointment on episiotomy wound healing among primiparous women. Methods: This randomized controlled clinical trial included 73 women referring to the Al-Zahra Education, Research, and Remedial Center in Rasht, Iran, during 2017 - 18. Women were randomly assigned into two groups: Intervention group (n = 39) and control group (n = 34). Episiotomy wound healing was assessed using the REEDA scale prior to the intervention, 2 and 24 hours following the first intervention, and 5 and 10 days after delivery. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, independent t-test, repeated-measure test, Friedman test, and chi-square. Results: The mean baseline scores of REEDA was 2.72 ± 0.46 in the Olea ointment group and 2.71 ± 0.46 in the control group; however, there was no statistically significant difference between the two groups. On the other hand, the episiotomy healing scores in the Olea ointment group were significantly lower than those of the control group at four intervals in the follow-up assessments: -0.34 (95% CI: -0.56 to -0.12) two hours after intervention, -0.63(95% CI: -0.89 to -0.37) 24 hours after intervention, -0.30 (95% CI: -0.48 to -0.12) on Day 5 postpartum, and -0.29 (95% CI: -0.46 to -0.13) on Day 10 postpartum. Conclusions: The present findings suggested that the Olea ointment facilitated wound healing of episiotomy; however, further studies are suggested to support these data.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

OBJECTIVE

Episiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards the practice of episiotomy among obstetricians and midwives in China's public hospitals and consider strategies to reduce its practice.

METHODS

A cross-sectional web survey using a self-administered questionnaire was conducted among obstetricians and midwives in 90 public hospitals in Henan Province, China.

RESULTS

900 (82.21%) participants completed the questionnaire. Average knowledge level (4.15, SD=1.10) on complications and overuse was identified among participants. Episiotomy was performed more frequently in secondary hospitals than in tertiary hospitals (p<0.05). Senior clinicians were more likely to perform episiotomy than younger ones (p<0.05). Almost half of the clinicians (42.11%) considered the current rate of episiotomy (45%) to be right or too low. The most common reason for performing episiotomy identified by obstetricians (83.94%) and midwives (79.69%) was to reduce third-degree or fourth-degree perineal laceration. Both obstetricians (80.29%) and midwives (82.57%) agreed that the most significant obstacle to reducing the rate of episiotomy was lack of training on reducing perineal tears.

CONCLUSION

In sum, episiotomy was driven by previous training, practitioners' experience and local norms rather than the latest medical evidence. Clinicians in secondary hospitals and senior clinicians are key training targets. It is urgent to improve current clinical policies and surgical procedure guidelines for obstetricians and midwives regarding episiotomy.

Episiotomy: an informed consent proposal

PURPOSE

Since every obstetric surgical procedure requires gaining informed consent from patient, we have set out to evaluate whether such requirement also applies to episiotomy.

MATERIAL AND METHODS

To that end, we have conducted a thorough search of relevant scientific literature on multidisciplinary databases (Scopus, PubMed, PubMed, Central, Research Gate, Google Scholar) and articles that were published from 1989 to March 2019. The search keys used were: "episiotomy," "informed consent," "complications," "malpractice."

RESULTS

The sources that we have ultimately drawn upon, whilst acknowledging the need for a targeted informed consent for episiotomy, do not deal with the specifics of what such consent should include, in terms of information provided and related aspects. Therefore, the authors have laid out an episiotomy-targeted consent form, drawing upon opinions and indications from scientific societies and institutions, in order to properly reflect and document the patient's acceptance or refusal of the procedure.

CONCLUSIONS

Valid consent documentation may well prove instrumental in staving off or reducing complications, malpractice and liability, and in order to safeguard health care operators from obstetric malpractice allegations.