Episiotomy in the United States: has anything changed? REPLY

Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
American journal of obstetrics and gynecology (Impact Factor: 4.7). 03/2009; 200(5):573.e1-7. DOI: 10.1016/j.ajog.2008.11.022
Source: PubMed

ABSTRACT The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice.
The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy.
The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004.
Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

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Available from: Elizabeth A Frankman, Oct 08, 2014
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    • "It is, however, of note that there might have been differences in registration and diagnosing OASR. In the USA, frequencies of 3.5% for vaginal deliveries and 15.3% for assisted deliveries have been reported (Frankman, et al, 2009). In Finland, the frequency of OASR has increased from 0.2% in 1997 to 1.0% in 2009. "
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    ABSTRACT: ABSTRACT Obstetric anal sphincter rupture (OASR) is a well-known complication of vaginal delivery; it can have serious implications for women’s health since it results in anal incontinence in 20-60% of those affected. The incidence of OASR varies widely; in 2008 it was reported at a level of 0.9% in Finland but 2.6-5.6% in the other Nordic countries. The purpose of this study was to identify the risk factors for OASR, and to describe trends in the incidence of OASR and episiotomy between 1997 and 2007 in Finland. A population-based inventory of 514,741 women with singleton vaginal deliveries, including all presentations and assisted deliveries, recorded in the Finnish Medical Birth Register was analyzed. For the years 1997-2003, the information on OASR was taken from the Hospital Discharge Register (HDR). Primiparous (=first vaginal delivery) (n=2,315) and multiparous (n=534) women with OASR were compared in terms of possible risk factors to primiparous (n=215,463) and multiparous (n=296,429) women without OASR, respectively, using stepwise logistic regression analysis. The risk factors for OASR included forceps delivery, a prolonged active second stage of birth, delivery of an infant weighing more than 4,000 grams, and vacuum assistance. Lateral episiotomy was associated with a 17% lower risk of OASR among primiparous women in spontaneous vaginal deliveries; however this approach was inefficient since more than 900 primiparous women must be exposed to an episiotomy to prevent a single OASR. In vacuum assisted deliveries among primiparous women the equivalent number was 66, which is clinically more acceptable. Correspondingly, among the multiparous women, episiotomy was associated with a doubling of the risk of OASR. Furthermore, pain management was associated with 13-52% lower risk of OASR among both groups of women except epidural analgesia among the multiparous women that increased the risk 1.5-fold. In Finland, the incidence of OASR has increased, from 0.2% in 1997 to 0.9% in 2007. The likelihood of OASR increased 3.28-fold among primiparous and 2.83-fold among multiparous women during the study period, 1997– 2007. Changes in population characteristics and in the use of interventions were small, and consequently did not cause the increased OASR rate. The only exception was vacuum assisted deliveries, which explained about 9% of the rising OASR risk, in line with the increased use of this technique. The results of this study suggest that time factors were of minor importance to the increasing rate of OASR, because the risk of it was shown to be 11% lower during the night than daytime and 15% lower in July (the most popular holiday month) than other months. In fact, ca. 3- to 8-fold inter-hospital differences in OASR risks in primiparous and multiparous women, respectively, were of greater importance. Hospitals with high rates of OASR for primiparous women also had high rates for multiparous women, implying that treatment differences might have played a crucial role in the variations or that there were differences in registration routines or in diagnosing OASR. The results suggest that episiotomy provided protection from OASR in the first vaginal birth, but was a risk factor in multiparous women. Among the multiparous women, episiotomy was performed prophylactically more often in those who were at a high risk of OASR than in low risk women, consequently there might have been confounding by indication. The results indicate the value of selective use of lateral episiotomy, and its routine use might be advisable in vacuum assisted deliveries for primiparous women. Inter-hospital differences suggest that, between the hospitals, there may be an important healthcare quality issue or differences in recording or diagnosing OASR. National Library of Medicine Classification: WQ415; WQ330; WP170 Medical Subject Headings (MeSH): Delivery, Obstetric; Obstetric Labor Complications; Anal Canal +injuries; Rupture +epidemiology; Episiotomy; Registries
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