In women with spontaneous vaginal delivery, repair of perineal tears might be easier compared to episiotomy

INTRODUCTION AND HYPOTHESIS

To examine a common assumption that suturing of episiotomy, a straight performer-controlled incision, might be easier compared to repair of unpredictable spontaneous perineal tears.

METHODS

Data for this study were collected prospectively, as part of a randomized controlled trial examining the outcomes of episiotomy avoidance. Suturing characteristics were compared between vaginal deliveries with episiotomy vs. spontaneous perineal tears. Primary outcomes included the duration of the repair, number of suture packs used for the repair, and subjective rating of suturing difficulty (rated from 1 to 5 by practitioner performing the suturing).

RESULTS

Of 525 vaginal deliveries, episiotomy was performed in 165 (31.4%) of the cases, 59 of which (35.8%) were accompanied by additional vaginal tears. Spontaneous vaginal tears without episiotomy were noted in 272 deliveries (51.8%). Compared to spontaneous perineal tears, episiotomy performance was associated with an adverse effect on all three suturing characteristics in the overall cohort and in subgroup of non-operative deliveries. When comparing episiotomy only to second-degree tear suturing, in the subgroup of non-operative vaginal deliveries a higher rate of suturing duration < 10 min was noted in favor of spontaneous tears. However, in sub-analysis of vacuum-assisted deliveries, a benefit was noted in favor of the episiotomy-only group in terms of fewer suture packs and lower subjective difficulty.

CONCLUSIONS

In women with non-operative vaginal delivery, suturing of spontaneous perineal tears was easier and shorter compared to episiotomy repair. This might be related to the unpredictable nature of perineal tears, which might be shorter and shallower compared to the standard episiotomy incision.

Is it time to abandon episiotomy use? A randomized controlled trial (EPITRIAL)

INTRODUCTION AND HYPOTHESIS

The objective of this trial was to evaluate whether avoidance of episiotomy can decrease the risk of advanced perineal tears.

METHODS

In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into "avoidance of episiotomy" (the study group in which episiotomy was allowed only in cases of fetal distress) or "standard care." The primary outcome was the incidence of advanced (3rd- and 4th-degree) perineal tears.

RESULTS

The participants were randomized into "standard care" (n = 337) vs. "no episiotomy" (n = 339) groups, not differing in any demographic or obstetric characteristics. Episiotomy rates were significantly lower in the study group (19.6%) compared with the standard care group (29.8%, p = 0.004). Five (1.5%) advanced tears were diagnosed in the study group vs. ten = 3.0% in the controls, yielding an odds ratio of 0.50 (95% CI 0.17-1.50) in favor of the "no episiotomy" group (p = 0.296). No differences were noted in any secondary outcomes. By per protocol analysis (omitting cases in which episiotomy was performed for indications other than fetal distress in the study group), a trend to decreased risk of advanced tears in the study group was noted (p = 0.0956). By per protocol analyses, no severe tears were noted in the 53 vacuum deliveries in the study group vs. 4/65 (6.2%) tears in the controls (p = 0.126).

CONCLUSIONS

Since decreased use of episiotomy was not associated with higher rates of severe tears or any other adverse outcomes, we believe this procedure can be avoided in spontaneous as well as vacuum-assisted deliveries. Trial registration no. NCT02356237.