Article

Is It Possible to Never Perform Episiotomy During Vaginal Delivery?

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Abstract

The beneficial effects of a restrictive policy of episiotomy for vaginal deliveries have been demonstrated. However, the ideal rate of episiotomy is not known and some studies describe rates less than 5%. The aim of this study was to describe the outcomes of a protocol of no episiotomy within a large project for humanization of childbirth care. A cohort study including 400 women who had vaginal deliveries in a school maternity in northeastern Brazil. During the second stage of labor, maneuvers such as directed pushing, fundal pressure, and Valsalva maneuver were avoided. A policy of no episiotomy was followed with strategies for perineal protection that included warm compresses and intrapartum perineal massage. The majority of births (85%) was assisted in the upright position (birthing chair or stool). There were 18 cases of forceps and six cases of vacuum extraction (6%). No episiotomy was carried out (0%), 56% of women had an intact perineum, 13% had first-degree perineal lacerations without suturing, 7% had first-degree perineal lacerations requiring suture, 8% had second-degree perineal lacerations without suture, and 16% had second-degree lacerations requiring suture. The overall suture rate was 23%. There were no third- or fourth-degree perineal lacerations. Women satisfied or very satisfied with the care corresponded to 96%. It is possible to reach a zero rate of episiotomy with a high frequency of intact perineum, reduced need for suturing, and no adverse outcomes such as severe perineal lacerations.

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... Ademais, sugerem que a realização da episiotomia já consiste em uma laceração de segundo grau e nem todas as mulheres terão lacerações e, quando as têm, são na maioria das vezes de primeiro grau. [10][11] No Brasil, por estímulo do Ministério da Saúde, objetivando melhorar a assistência ao parto e nascimento, em 2013, iniciaram-se os programas de residência em Enfermagem Obstétrica nas universidades federais, entre elas a Universidade Federal de Sergipe (UFS). Na residência de Enfermagem Obstétrica da UFS, o campo de prática é a maternidade estadual, caracterizada por ser referência para o alto risco para todo estado, além de Alagoas e Bahia. ...
... Esses estudos sugerem que a posição de litotomia é um preditor para realização de episiotomia, assim como a ocorrência de lacerações perineais. 10,[19][20] Todavia, não podemos afirmar categoricamente, tendo em vista que não foi avaliada esta associação. Adicionalmente, não foi possível descrever o grau de laceração, pois não havia registro nos prontuários, sendo esta uma fragilidade inerente a estudos que necessitam de informações constantes em registros dos pacientes. ...
... Ademais, no Vietnã, em um estudo realizado com 69 médicos obstetras e 79 parteiras, a episiotomia foi realizada por 76,8% dos obstetras e 82,8% das parteiras, os quais citaram como principal indicação prevenir lacerações de 3º e 4º graus 21 , no entanto estudiosos afirmam que a episiotomia já se constitui uma laceração de segundo grau, necessitando sempre de rafia e que não se justifica prevenir laceração espontânea realizando uma laceração. 10,22 Apesar de apenas três profissionais terem relatado a primiparidade como justificativa para realização de episiotomia, sendo esta a quarta causa referida pelos profissionais, observou-se que eles realizaram mais episiotomia nas primíparas, demonstrando que os profissionais a realizam por costume, e não com embasamento em evidências científicas, nem mesmo em suas próprias crenças. Diversos estudos comprovam que a primiparidade é uma condição que leva os profissionais a realizarem esta técnica, sem avaliar outros fatores relativos ao concepto e à parturiente. ...
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ABSTRACT Objective: to describe the frequency, indications, and factors associated with episiotomy. Method: this is a descriptive, cross-sectional, quantitative approach carried out in a maternity hospital with 372 puerperal women and 22 professionals involved in childbirth care. The collection instruments were a form for the puerperal and a questionnaire for professionals. Descriptive statistics, association tests and odds ratios were used. Results: the frequencies of episiotomy and perineal laceration in the current delivery were 107 (28.8%) and 133 (50.2%), respectively. There was a significant association between episiotomy and primiparity (OR = 2,513). There was no agreement between the indications cited by the professionals and the occurrence of episiotomy. Conclusion: the frequency of episiotomy was in agreement with the WHO recommendation, but its accomplishment was not related to the indications cited by the professionals. Primiparity was associated with episiotomy. There was no association between fetal outcome and episiotomy. Descriptors: Obstetric Nursing; Episiotomy; Natural Childbirth.
... Recently, some authors suggested that episiotomy should never be performed [1,9]. The question, however, has not yet been adequately evaluated in randomized clinical trials. ...
... This variable was later recoded as "any perineal pain" (scores of 1 to 10). Next, maternal satisfaction was evaluated and classified as very satisfied, satisfied, fairly satisfied, dissatisfied or very dissatisfied in accordance with the woman's selection from a range of faces in a faces scale [9]. ...
... In the present study-, no difference was found between the women randomized to the selective episiotomy group compared to those randomized to the nonepisiotomy group. The overall rate of episiotomy was very low (around 1.7%), similar in the two groups, and close to the low rates already described by other authors [9,12]. The episiotomy rate found in the present study is well below the maximum of 10% recommended by the WHO [3], and much lower than the overall episiotomy rate found in a Cochrane systematic review of around 28% in the group submitted to selective episiotomy [5]. ...
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Background Despite all the evidence corroborating the selective use of episiotomy and although routine use of the procedure is contraindicated, there are no evidences corroborating if episiotomy is necessary in any circumstance. The present clinical randomized trial was performed to compare maternal and perinatal outcomes in women submitted to a non-episiotomy protocol versus one of selective episiotomy. Methods An open-labelled, randomized clinical trial was carried out in a tertiary teaching hospital in Recife, Northeastern Brazil. Women in labor with a full-term live foetus, dilatation of 6 to 8 cm and cephalic presentation (vertex position) were included. Exclusion criteria consisted of bleeding disorders and an indication for a caesarean section. After signing the consent form, 241 women were randomized to a non-episiotomy protocol (the experimental group) or to a selective episiotomy group (the control group). No episiotomies were to be performed in the experimental group except under exceptional circumstances. In the control group, selective episiotomies were to be performed in accordance with the healthcare professionals’ clinical judgement. Maternal and perinatal outcomes were evaluated. Ratio Risk (RR) and the 95% confidence interval (95% CI) were calculated for our outcomes. ResultsThe analysis include 115 women assigned to a non-episiotomy protocol and 122 to selective episiotomy. There was no difference between the two groups with respect to maternal or perinatal outcomes. The episiotomy rate was similar (two cases in each group, about 1.7%), as was the duration of the second stage of labor, the frequency of perineal tears, severe perineal trauma, need for perineal suturing and blood loss at delivery. ConclusionsA non-episiotomy protocol appears to be safe for mother and child, and highlights the need to investigate whether there is, in fact, any indication for this procedure. Trial registrationThis trial was registered at ClinicalTrials.gov under reference number (NCT02178111).
... [10][11][12][13] Factors consistently associated with OASIS are instrumental delivery, prolonged second stage of labor, being primiparous, a fetus large for gestational age, and occipitoposterior position. [14][15][16][17][18] The lower incidence of OASIS in our study (0.43%) is likely a result of proactive labor management, timely episiotomy, avoidance of median episiotomy, and close observation by senior staff members in difficult cases. Manual assistance during the final part of the second stage of labor can significantly decrease in obstetric anal sphincter injuries. ...
... Reports conflict regarding episiotomy as a risk factor for OASIS. 11,14,15 However, randomized controlled trials have failed to demonstrate a significant reduction of OASIS in women who underwent an episiotomy compared with OASIS in women who did not. 16 A case-controlled study showed scared episiotomy with depth more than 16mm, length more than 17mm, incision more than 9mm lateral of mid-point and angle range 30-600 are significantly associated with less risk of OASIS. ...
Article
Objectives: To evaluate the rates of third- and fourth-degree tears and related predisposing factors for the tears in singleton vaginal deliveries. Methods: This was a retrospective study of third- and fourth-degree perineal tears in all women who underwent vaginal delivery in a tertiary hospital in Assir region between January 2014 and December 2019. There are approximately 5000 deliveries per year at the Abha Maternity and Children Hospital. The total number of deliveries during the study period was 31,788, of which 19,374 were delivered vaginally. Results: A total of 85 women (0.43% of all vaginal deliveries) had third-degree (n=81) or fourth-degree (n=4) perineal tears. The mean age of the women was 31 years (range: 16-46 years). Fifty-two of the 85 women (61%) were primiparous. Of the various obstetric parameters, episiotomy, occipitoposterior presentation, primigravida, multipara, and a previous episiotomy were found to be significant predisposing factors to third- and fourth-degree tears in our patients. Conclusion: The low incidence of obstetric anal sphincter injuries in this study is likely the result of proactive manual protection of the perineum, valid indications for episiotomy, and attendance of senior staff members at all difficult deliveries.
... 3 Recently some authors have questioned if there is any indication for episiotomy and whether if practiced selectively it can confer any benefit at all. 4 Indications such as a prolonged second stage, macrosomia, non-reassuring fetal heart rate, instrumental delivery, occiput posterior position, and shoulder dystocia have been questioned. 5 The incision substantially increases maternal blood loss, the average depth of posterior perineal injury, risk of anal sphincter damage, improper wound healing and increased amount of pain in the immediate postpartum period. 6,7 Episiotomy at the first vaginal birth significantly and independently increases the risk of repeated episiotomy and spontaneous tears in subsequent delivery. ...
... 19 There was no association between APGAR <7 supporting previous studies that found that episiotomy practice has failed to accomplish neonatal indications ascribed to it; hence the need for selective episiotomy practice as seen in a randomized control trial on selective episiotomy vs implementation of the non-episiotomy protocol in Brazil. 5 Assisted vaginal and breech delivery are known risk factors associated with episiotomy, in a metanalysis by Graham et al., 10 10,16,20 the few numbers for assisted vaginal birth and breech delivery seen in this study might have not given enough power to make and observable relationship. 181 of the 249 (72.7%) were attended to by the midwives of which 125(69.1%) has had episiotomies similar to the rate of episiotomies among supervised deliveries attended to by student trainees (67.6%) as shown in table 3. ...
Article
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Background; Episiotomy, an obstetric procedure introduced into practice without any clear scientific evidence showing its benefits, became almost a procedure performed on all parturient women. Recently, a liberal episiotomy has been discouraged and WHO recommends an episiotomy rate of about 10% or less. The procedure substantially increases the risk of anal sphincter damage, improper wound healing, hematoma, infections, and perineal pain. The study was aimed at investigating the prevalence and factors associated with episiotomy among primiparous parturients in Mulago National Referral. Methods: A cross-sectional study using a researcher administered questionnaires was conducted in Hospital Obstetrics and Gynecological Department in February and March 2018. Two hundred forty-nine participants were systematically recruited on the first postnatal day after meeting the inclusion criteria and the socio-demographic and obstetric characteristics were recorded. Logistic regression was used to determine the factors associated with the occurrences of episiotomy. Results: The prevalence of episiotomy was 73% (181/249) (CI 67-78). Mothers whose second stage of labor lasted between; 31-60 minutes were 3.6 times more likely to be made an episiotomy, (CI; 1.66-7.86, p=0.001), the odds further doubles if the second stage of labor was prolonged, lasting 60 minutes or greater OR=7.2 (CI; 1.46-35.64, p=0.015). Episiotomy was also found to be associated with gestational age above 37 weeks OR=1.8 (CI; 1.28-2.40 p<0.001). Conclusion: The prevalence of episiotomy among primiparous is high yet higher episiotomy rates are associated with increasing morbidities and lack of benefits. The factors associated with episiotomy practice were gestational age above 37 weeks and prolonged second stage Keywords: episiotomy, perineal tears, primiparity
... In 1983, Thacker and Banta gave a full account of the lack of scientific data supporting the use of episiotomy and the potential danger associated with the procedure [3]. Historical indications such as a prolonged second stage, macrosomia, non-reassuring fetal heart rate, instrumental delivery, occiput posterior position, and shoulder dystocia have been questioned [6]. ...
Chapter
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Episiotomy is one of the most commonly practiced obstetric procedures done to enlarge the diameter of the vulval outlet to facilitate the passage for the fetal head and prevent an uncontrolled tear of the perineal tissues in the second stage of labor. Historically, the procedure was indicated to prevent third- or fourth-degree perineal tears as well as for prolonged second stage, macrosomia, non-reassuring fetal heart rate, instrumental delivery, occiput posterior position, and shoulder dystocia. Routine episiotomy is now considered to be obstetrics violence, rates of not exceeding 10% have been recommended by World Health Organization (WHO). Despite this recommendation, episiotomy is still practiced routinely in many settings.
... In the study, the perineum integrity was observed in 56% of the cases, as well as 20% of first degree tear, and 24% of second degree tear. There was no description of third-and fourth-degrees tears [12]. Melo et al. are currently developing a comparative randomized clinical study about the selective episiotomy and non-performance of the episiotomy. ...
... The episiotomy rate in the present study was not low (13%); however, it shows that the use of episiotomy as a routine procedure is decreasing, since in the literature the rates of use of this procedure in nulliparous are much higher (94.2%) 28 . Therefore, we conclude that the maternity did not use episiotomy routinely but selectively, as recommended by the Ministry of Health 7 , because this procedure, when used, already causes second degree laceration 29 . In a previous study with 40 nulliparous submitted to routine or selective episiotomy, it was found that 80% of the selective group had intact perineum or suffered first degree laceration, thus evidencing that the use of selective episiotomy favors the reduction of perineal trauma 30 . ...
Article
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Introduction: Perineal trauma is an important complication for women after giving birth. Objective: To evaluate the prevalence of perineal trauma and its associated factors in nulliparous. Methods: A retrospective cohort study was carried out, through the analysis of the medical records of women with singleton pregnancy who achieved vaginal birth of a live infant, in 2017, in a maternity hospital. Data collection involved information about demographic, obstetric, and clinical data from nulliparous women, and infant birthweight. Univariate and multivariate logistic analyses were performed to verify the association of perineal trauma with the variables assessed, with significant variables remaining in the model (p<0.05), through a stepwise strategy. Results: A total of 326 medical records were analyzed. The percentage of perineal trauma was 60%. In the multivariate analysis, the use of oxytocin increased the chance of perineal trauma by 730%. In addition, the adoption of squatting position and hands and knees decreased the chances of perineal trauma by 81% and 97%, respectively, in comparison with those who adopted the lithotomy position, during the second stage labor. Conclusion: The rate of perineal laceration was high, but the severity was low. The use of oxytocin is associated with the presence of trauma and the squatting position and hands and knees, especially, have contributed to the protection of the perineum.
... Indications such as a prolonged second stage, macrosomia, non-reassuring fetal heart rate, instrumental delivery, occiput posterior position and shoulder dystocia have been questioned. 11 A systematic review of the effectiveness of episiotomy for prevention and management of shoulder dystocia found no evidence supporting the use of episiotomy. 12 The American College of Obstetricians and Gynaecologists recognises that there is an insufficient objective evidencebased criterion to define the indications for episiotomy and that restrictive use of episiotomy remains the best practice. ...
Article
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Background: Episiotomy is the incision given over the pudendum, i.e. on the external genitalia organ during the vaginal delivery. Aims and Objective: In this study it has been tried to evaluate the benefits and the risks of selective episiotomy over spontaneous lacerations. Materials and Methods: This is an institution based interventional longitudinal study carried out in the Department of Obstetrics & Gynaecology of College Of Medicine & JNM Hospital, Kalyani over a period of 18 months in 218 patients (109 in each group) fulfilling the inclusion criteria. The recruitment and allocation in episiotomy and non-episiotomy groups were random after proper consent from the participants. Results: The frequency of postpartum perineal pain was around 47% in no episiotomy group and around 60% in selective episiotomy group. There were no cases of dehiscence, haematoma or wound infection in either of the groups. Around 96.22% of the women in the non-episiotomy group were satisfied or very satisfied compared to 89.52% in the selective episiotomy group. Conclusion: An episiotomy rate of less than 1% found in no episiotomy group as compared to around 18% episiotomy rate in selective episiotomy group. However, they have almost same feto-maternal outcome which successfully establish the effectiveness of no episiotomy practice over the selective one.
... One of such evidence is a study conducted in the United States that shows a decline of episiotomy rate from 60.9% in 1979 to 24.5% in 2004 [21]. There is also a study that indicate the possibility of a zero percent episiotomy with a high frequency of intact perineum, reduced need for suturing, and no adverse outcomes such as severe perineal lacerations [22]. ...
Article
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Background: Episiotomy is a surgical incision of the perineum during delivery to enlarge the vaginal orifice. It is one of the most commonly performed obstetric intervention world widely. The magnitude of episiotomy varies from population to population. Limited information exists related to the practice of episiotomy in Ethiopia. This study aimed to assess the prevalence of episiotomy and its associated factors in University of Gondar Comprehensive Specialized Referral Hospital, Ethiopia. Methods: Institution based retrospective cross-sectional study was undertaken from March to June 2014 on 306 mothers who had a vaginal delivery in the Hospital. Systematic random sampling technique was employed to select study units. The data were collected using pretested cheek list. Proportion of patients who had episiotomy was calculated and the association between dependent and independent variables was checked using both binary and multiple logistic regression and Chi-square. Results: Prevalence of episiotomy in University of Gondar Comprehensive specialized Referral Hospital was 47.7% (n = 146). Majority (89.5%) of the delivery was spontaneous vaginal delivery while vacuum, forceps and destructive delivery were 4.6%, 4.6%, and 1.3% respectively. During pregnancy and delivery, 84% of mothers had no associated diseases while 8% had hypertensive disorder, 5% diabetes mellitus and 3% of them has other diseases. After multivariate analysis episiotomy was significantly associated with maternal age (15-24 years) (p = 0.041, AOR (CI 95%) 1.65 (1.02-2.66)), primiparity (p =0.010, AOR (CI 95%) 2.61 (1.54-4.44)), prolonged labor (p = 0.001, COR (CI 95%) 6.45 (2.89-14.38)), and weight of newborn (p = 0.044, COR (CI 95%) 2.48 (1.16, 5.31)). Conclusion: Prevalence of episiotomies in the institution was 47.7% and variables that remained associated significantly with episiotomy were maternal age, primiparity, prolonged labor, and newborn weight.
... One of such evidence is a study conducted in the United States that shows a decline of episiotomy rate from 60.9% in 1979 to 24.5% in 2004 [21]. There is also a study that indicate the possibility of a zero percent episiotomy with a high frequency of intact perineum, reduced need for suturing, and no adverse outcomes such as severe perineal lacerations [22]. ...
... Indeed, the "ideal" episiotomy rate remains to be established, since its actual indications 1 are unclear, and there are authors who defend the idea that the procedure should never be performed. 32 Although it has been shown that it is possible to achieve much lower episiotomy rates, 7,33 or even a 0% rate with no adverse outcomes, 33 we believe that a maximum rate of 20% would be more reasonable in the current context. Indeed, the practice of episiotomy appears to have become so commonplace that even among those obstetricians who stated that they never perform the procedure, 40% actually perform episiotomy in more than 20% of their deliveries. ...
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Objective To determine the prevalence of episiotomy and the factors associated with the knowledge, attitude and practice (KAP) of Brazilian obstetricians in relation to this procedure. Methods A KAP survey was conducted with obstetricians working in Brazil. An electronic form containing structured questions previously evaluated using the Delphi method was created in Google Docs and sent by e-mail. A multivariate logistic regression was performed to determine the principal factors associated with adequate KAP. For each dependent variable (knowledge, attitude and practice) coded as adequate (1 = yes; 0 = no), a multiple logistic regression model was developed. Binary codes (1 = yes and 0 = no) were assigned to every independent or predictor variables. Prevalence ratios (PRs) and their respective 95% confidence intervals (95%CIs) were calculated as measures of relative risk, at a significance level of 5%. Results Out of the 13 thousand physicians contacted, 1,163 replied, and 50 respondents were excluded. The mean episiotomy rate reported was of 42%. Knowledge was determined as adequate in 44.5% of the cases, attitude, in 10.9%, and practice, in 26.8% of the cases. Conclusion Most respondents had inadequate knowledge, attitudes and practices regarding episiotomy. Although some factors such as age, teaching, working in the public sector and attending congresses improved knowledge, attitude and practice, we must recognize that episiotomy rates remain well above what would be considered ideal. Adequate knowledge is more prevalent than adequate attitude or practice, indicating that improving knowledge is crucial but insufficient to change the outlook of episiotomies in Brazil.
... Reports on mediolateral episiotomy are inconclusive. Some authors report decrease in the incidence of third and fourth degree perineal injuries, whereas others found no connection between mediolateral episiotomy and OASIS 2,3,6,14,17,25,[27][28][29] . The rate of episiotomy varies from 3.7% in Denmark to 75.0% in Cyprus 6 . ...
Article
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In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.
... Qualitative data were categorized, described and interpreted considering the essential steps of Bardin's content analysis. 10 Speeches were coded with numbers according to the participant's inclusion sequence in the study, and six categories emerged in the results. ...
Article
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RESUMOObjetivo: identificar fatores associados à humanização da assistência durante o trabalho de parto, parto e nascimento. Método: estudo quanti-qualitativo, transversal, descritivo, realizado em uma maternidade pública. Foi utilizado formulário para a coleta de dados. Os dados foram analisados por meio de estatística simples e testes de associação e pela técnica de Análise de conteúdo. Resultados: participaram do estudo 373 puérperas com idade média de 26 anos, pardas, com baixa escolaridade e baixa renda. Houve associação significante entre a presença do acompanhante e liberdade para fazer perguntas; baixa escolaridade e menor informação; parto vaginal e desrespeito por parte dos profissionais; mulheres brancas e presença do acompanhante com maior satisfação. Quanto à percepção para melhoria da assistência, emergiram as categorias: ambiência, privacidade, informação, respeito, garantia do acompanhante e desejo pela cirurgia cesariana. Conclusão: a adequada estrutura física e dimensionamento de pessoal qualificado são necessários para garantir a assistência baseada em evidências, centrada na mulher, visando à garantia dos seus direitos. Descritores: Satisfação do Paciente; Assistência à Saúde; Humanização da Assistência; Maternidades; Parto; Enfermagem Obstétrica.ABSTRACT Objective: To identify factors associated with the humanization of care during labor, delivery and birth. Method: this is a quantitative, cross-sectional, descriptive study carried out in a public maternity hospital. A form for data collection was used. Data were analyzed using simple statistics and association tests and by the Content Analysis technique. Results: there were 373 postpartum women with a mean age of 26 years old, with low educational level and low income participating in the study. There was a significant association between the presence of the companion and the freedom to ask questions; low education level and less information; vaginal delivery and disrespect by the professionals; white women and presence of the companion with greater satisfaction. Concerning the perception for better care, the following categories emerged: ambience, privacy, information, respect, the right of a companion, and desire for cesarean surgery. Conclusion: Adequate physical structure and skilled staffing are needed to ensure evidence-based, women-centered assistance to ensure their rights. Descriptors: Patient Satisfaction; Delivery of Health Care; Humanization of assistance; Hospitals, Maternity; Parturition; Obstetric Nursing.RESUMEN Objetivo: identificar factores asociados a la humanización de la asistencia durante el trabajo de parto, parto y nacimiento. Método: estudio cuanti-cualitativo, transversal, descriptivo, realizado en una maternidad pública. Fue utilizado um formulario para la recolección de datos. Los datos fueron analizados por medio de estadística simple y tests de asociación y por la técnica de Análisis de contenido. Resultados: participaron del estudio 373 puérperas con edad media 26 años, pardas, con baja escolaridad y baja renta. Hubo asociación significante entre la presencia del acompañante y libertad para hacer preguntas; baja escolaridad y menor información; parto vaginal y falta de respeto por parte de los profesionales; mujeres blancas y presencia del acompañante con mayor satisfacción. Sobre la percepción para mejoría de la asistencia, surgieron las categorías: ambiente, privacidad, información, respeto, garantía del acompañante y deseo por la cirugía de cesária. Conclusión: la adecuada estructura física y dimensionamiento de personal calificado son necesarios para garantizar la asistencia basada en evidencias, centrada en la mujer, visando la garantía de sus derechos. Descriptores: Satisfacción del Paciente; Prestación de Atención de Salud; Humanización de la Atención; Maternidades; Parto; Enfermería Obstétrica.
... Se observa que si bien en las mujeres primíparas la realización o no de episiotomía es muy similar, sin embargo en las multíparas existe una tendencia a la no realización. Este resultado coincide con diversos estudios (16,37,38) , donde se observa que la primiparidad es uno de los principales factores de riesgo asociados a la episiotomía. La variable paridad nos lleva a preguntarnos que características son determinantes en una primípara para presentar mayor tasa de episiotomía y si dichas características justifican la diferencia de cifras con respecto a las mujeres multíparas. ...
Article
Objective: The conduction of episiotomy is a questioned practice given the strong scientific evidence on its adverse effects. The study objectives were to know the episiotomy rate and its adaptation to the recommendations of the Ministry of Health, Consumption and Social Welfare and assess the associated factors. Methods: It has been made a Observational, descriptive and transversal quantitative study, it was carried out in the university clinical hospital arrixaca. Data were collected from deliveries attended between January 1, 2016 and October 30, 2017, obtaining a sample of 10,630 women, registered in the SELENE computer program which is the clinical database of said hospital. To perform the data analysis, were used the SPSS statistical program and an Excel database. At the first level, it was carried out a descriptive analysis of the obstetric variables and, at a second level, the data were compared with the Ministry of Health indicators by means of a comparison of two proportions and the chi-square test. In order to estimate the Effect Size, the Cramer V was used for qualitative variables and the relative risk was calculated for each pair of qualitative variablesas a relative measure of the effect, to determine the strength of association between the variables. Results: The episiotomy rate was 36.5%. When the birth started spontaneously, the percentage was 35.5%, when it was induced 47.2% and stimulated rate was 42.3%. The rate in eutocic deliveries was 20.6% and in instrumented was 95.25%. In primiparas, the episiotomy was 49.64% and in multiparas the conduction was 15.55%. Was observed a tendency of second-degree tears (43.40%), followed by first-degree (35.61%) and third-degree (19.81%) with episiotomy. Conclusions: The episiotomy rate in our study exceeds current recommendations. The variables associated with the performance of the episiotomy are induced or stimulated delivery, instrumentation and primiparity. There is a significant relationship between the practice of episiotomy and the greater degree of tear.
... Episiotomies are referred to give more benefits as it forestall vaginal tears, ensure against incontinence, secure against prolapse and heals simpler than tears [2]. Regardless of all those evidence authenticating selective utilization of episiotomy and though routine utilization of that procedure is contraindicated, real indications for performing episiotomy in recent practice still needs to be clarified [3]. As per to the {American College of Obstetricians and Gynecologists} [4], in light of the existent proof, there are no specic circumstance in which episiotomy is fundamental, and the choice to play out an episiotomy ought to be founded on clinical considerations [4]. ...
... We use mediolateral episiotomy for every vacuum extraction for its known protective effect [15] [16]. However, there are some reports questioning the effects of episiotomy even in cases of instrumental delivery [17]. [18]. ...
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OBJECTIVES: Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman. MATERIAL AND METHODS: We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012. RESULTS: We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05). CONCLUSION: Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.
... These results were consistent with those of the Euro-peristat project, which described an increase in the rate of severe perineal tears for all vaginal deliveries between 2004 and 2010 in all European countries, except Germany and Norway [28]. This issue is still the subject of a controversial debate [7,9,20,[29][30][31][32]. Randomized trials showed no increase in severe perineal tears related to the restrictive use of episiotomy [3]. ...
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Background: Since the 2000s, selective episiotomy has been systematically recommended worldwide. In France, the recommended episiotomy rate in vaginal deliveries is less than 30%. The aims of this study were to describe the evolution of episiotomy rates between 2007 and 2014, especially for vaginal deliveries without instrumental assistance and to assess individual characteristics and birth environment factors associated with episiotomy. Methods: This population-based study included all hospital discharge abstracts for all deliveries in France from 2007 to 2014. The use of episiotomy in vaginal deliveries was identified by one code in the French Common Classification of Medical Procedures. The episiotomy rate per department and its evolution is described from 2007 to 2014. A mixed model was used to assess associations with episiotomy for non-operative vaginal deliveries and the risk factors related to the women's characteristics and the birth environment. Results: There were approximately 540,000 non-operative vaginal deliveries per year, in the study period. The national episiotomy rate for vaginal deliveries overall significantly decreased from 26.7% in 2007 to 19.9% in 2014. For non-operative deliveries, this rate fell from 21.1% to 14.1%. For the latter, the use of episiotomy was significantly associated with breech vaginal delivery (aOR = 1.27 [1.23-1.30]), epidural analgesia (aOR = 1.45 [1.43-1.47]), non-reassuring fetal heart rate (aOR = 1.47 [1.47-1.49]), and giving birth for the first time (aOR = 3.85 [3.84-4.00]). Conclusions: The episiotomy rate decreased throughout France, for vaginal deliveries overall and for non-operative vaginal deliveries. This decrease is probably due to proactive changes in practices to restrict the number of episiotomies, which should be performed only if beneficial to the mother and the infant.
... Therefore, a hospital policy of selective episiotomy might result in an increase in perineal tear but an overall reduction in rate of perineal suturing. The influence of maternal factors such as tight perineum, early bearing down, provider factors such as perineal support, flexion of head during delivery, good nursing care and perineal massage in late pregnancy for the prevention of perineal tears need to be evaluated further as some studies indicate protective role of perineal protection strategies 18,19 . ...
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Background & objectives: In developed countries, efforts have been made to restrict episiotomy practice. However, in developing countries the episiotomy rates continue to be high. This study was conducted to evaluate the pattern of episiotomy use and its immediate complications among women delivering at tertiary level public hospitals in India. Methods: Prospective data of all women undergoing vaginal delivery including instrumental delivery were collected daily from the labour room registers of the 18 tertiary care hospitals on a structured proforma. Weekly data from all sites were sent to a central unit for compilation and analysis. Odds ratio was used to compare the proportion of genital trauma among women with and without episiotomy both in nulliparous and multiparous women. Results: Among 1,20,243 vaginal deliveries, episiotomy was performed in 63.4 per cent (n=76,305) cases. Nulliparaous women were 8.8 times more likely to undergo episiotomy than multiparous women. The various genital tract injuries reported were first degree perineal tear (n=4805, 3.9%), second degree perineal tear (n=1082, 0.9%), third and fourth degree perineal tear (n=186, 0.2%), anterior vaginal trauma requiring suturing (n=490, 0.4%), extension of episiotomy/vaginal laceration/excessive bleeding from episiotomy or tear (n=177, 0.15%), vulval/vaginal haematoma (n=70, 0.06%) and cervical tear (n=108, 0.08%). The combined rate of third and fourth degree perineal tears was observed to be significantly lower (p<0.001) among nullipara who received episiotomy (0.13%) compared to those who delivered without episiotomy (0.62%). Interpretations & conclusions: Significantly lower rates of third or fourth degree perineal tear were seen among nulliparous women undergoing episiotomy. The risk and benefit of episiotomy and its complications need to be evaluated through randomized clinical trials in the Indian context.
... It is therefore not surprising that postpartum perineal pain is still a common complaint, even when there is seemingly satisfactory compliance with current routine maternity care guidelines for perineal repair [24]. Whether it is better to completely avoid episiotomy during childbirth has been considered [25,26]. ...
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Purpose: An important factor influencing the outcome of perineal repair is the repair technique. This study was done to determine if there is a difference in post perineal repair pain scores following the use of the standard multiple-knot technique (MKT) of perineal repair and a single-knot technique (SKT). Methods: We randomised 260 women who sustained a second-degree perineal tear at the University of Benin Teaching Hospital, Benin City, Nigeria and had perineal repair using either a SKT or a MKT between 1 July 2014 and 28 February 2015. Primary outcome measure was pain assessed with a numerical rating scale (0 = no pain, 10 = worst imaginable pain) on day two, day 10 and at 3 months. Secondary outcome measures were pain scores during basic activities of daily living, analgesia use, dyspareunia and patient satisfaction. Results: Mean pain scores were significantly lower in the SKT group on day two (2.8 versus 5.6; P < 0.001) and day 10 (1.8 versus 3.3; P < 0.001). Significantly fewer women in the SKT group reported pain on day two (90/126, 71.4 % versus 122/128, 95.3 %; Relative Risk [RR] 0.6, 95 % Confidence Interval [CI] 0.6-0.8; P < 0.001), and day 10 (69/126, 54.8 % versus 107/128, 83.6 %; RR 0.7, 95 % CI 0.5-0.7; P < 0.001)]. Women in the SKT group were more likely to be satisfied with outcome of repair at three months (RR 1.4, 95 % CI 1.2-1.5; P < 0.001). No difference in pain scores and dyspareunia at 3 months. Conclusions: SKT of perineal repair is associated with significantly less pain in the first 10 days postdelivery and a higher patient satisfaction rate at 3 months.
... Las tasas de episiotomía descendieron de forma notable: pasaron del 70% inicial a unos niveles inferiores al 16% al final del periodo de estudio 16,17 . Otro estudio desarrollado en Brasil concluyó que es posible llegar a un porcentaje de episiotomía cero con un alto porcentaje de perinés intactos sin aumentar los resultados adversos como laceraciones perineales graves, evitando dirigir los pujos, la presión del fondo uterino y la maniobra de Valsalva y estableciendo una política de no episiotomía mediante estrategias de protección perineal, como la realización de masajes y la aplicación de compresas calientes en la zona perineal 18 . ...
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Objective: The aim is to check the adaption of the obstetric clinical practise and the recommendations of the Strategy Normal Birth Care. Persons, material and methods: This has been a descriptive, transversal and analytical study of the obstetrical activity of 12,093 childbirths which took place between 2011 and 2012 in the Clinical University Hospital Virgen de la Arrixaca (Murcia). The studied variables were: parity, gestational age, onset of labor, use of epidural analgesia, use of oxytocin, stage position during fetal expulsion, newborn weight and type of delivery (eutocic, implemented or cesarean). Results: The clinical appropriateness of the recommendations of the Strategy Normal Birth Care presents a tendency to decrease in the following practises: perineal saving (13%), the use of enemas (7%) and the number of emergency caesareans (11.38%). Likewise, some practices have also had a tendency to increase: accompaniment of childbirth (88.7%), continuous monitoring (99%), intrapartum fluid intake (34.8%), the number of vaginal births after cesarean (93.1%) and the number of women with epidural (77%). There has not been any variation in the remaining studied variables (amniotomy and performing instrumental births). Conclusions: The recommendations of the Strategy are not followed entirely. Some points of improvement have been identified. It will be necessary to develop some reduction policies of procedure advised against by the Ministry, and to reinforce the interdisciplinary team training.
... In 2007 Sung et al. [52] estimated this cost as near 6,000 US$/year and per patient for a total health cost of 57,500,000 US $/year. Because of the insufficiency and variability of the available economic data it is impossible, at the moment, to estimate the possible savings resulting from a policy of no episiotomy [53] , a policy of planned minimal-risk episiotomy using an electrophysiological test [5] and a policy of routine episiotomy, but it seems that the second option is promising also from the point of view of economic and social cost. Like most interdisciplinary technologies, the minimally invasive method to estimate EAS innervation, and consequently plan the least risky episiotomy modality long before child delivery (in case it will be deemed necessary), is not easily accepted by busy clinicians and obstetricians. ...
Chapter
The external anal sphincter (EAS) and the puborectalis are the most important muscles providing fecal continence. Their innervation can be observed with intra-anal probes (no needles). Knowledge of the innervation pattern of the EAS allows proper planning of episiotomy and reduction of EAS denervation cases with likely reduction of subsequent incontinence.
... Las tasas de episiotomía descendieron de forma notable: pasaron del 70% inicial a unos niveles inferiores al 16% al final del periodo de estudio 16,17 . Otro estudio desarrollado en Brasil concluyó que es posible llegar a un porcentaje de episiotomía cero con un alto porcentaje de perinés intactos sin aumentar los resultados adversos como laceraciones perineales graves, evitando dirigir los pujos, la presión del fondo uterino y la maniobra de Valsalva y estableciendo una política de no episiotomía mediante estrategias de protección perineal, como la realización de masajes y la aplicación de compresas calientes en la zona perineal 18 . ...
... With a protocol of not conducting combined with episiotomy perineal protection strategies, Amorim et al. found an intact perineum rate around 60% and only 23% of pregnant women in need of sutures that have not undergone episiotomy [9,10]. However, this was a noncontrolled study with an isolated sample and the authors suggest the need for randomized clinical trials comparing a policy of not conducting episiotomy with the policy of selective episiotomy. ...
Article
An episiotomy rate of approximately 10% is recommended by the World Health Organization. However, there is no clinical evidence corroborating any indication of episiotomy, so it is not yet known whether it is in fact necessary in any context in modern obstetric practice. To compare maternal and perinatal outcomes in women undergoing a protocol of not conducting episiotomy compared with selective episiotomy. A randomized open clinical trial was conducted at Instituto de Medicina Integral Prof. Fernando Figueira, Brazil. Women in labor with term pregnancy with a live fetus in vertex cephalic presentation and maximum cervical dilation between 6 and 8 cm were included. Women with bleeding disorders of pregnancy and cesarean delivery indication were excluded. A total of 115 women were allocated for a protocol of not conducting episiotomy and 122 to a group in which episiotomy could be performed selectively. There was no difference between the two groups regarding maternal or perinatal outcomes. Episiotomy rate was similar (two cases in each group, 1.7% of total) as well as the duration of the second stage, frequency of perineal lacerations, and blood loss at delivery. A protocol of not conducting an episiotomy seems to be safe for mother and neonate and points to the need of investigating if there is in fact any indication of this procedure in current obstetrics practice. Further research should evaluate the need of episiotomies in the situations commonly described as indications, like a nonreassuring fetal heart rate, instrumental deliveries, macrosomia, shoulder dystocia, and prolonged second stage of labor.
... With a protocol of not conducting combined with episiotomy perineal protection strategies, Amorim et al. found an intact perineum rate around 60% and only 23% of pregnant women in need of sutures that have not undergone episiotomy [9,10]. However, this was a noncontrolled study with an isolated sample and the authors suggest the need for randomized clinical trials comparing a policy of not conducting episiotomy with the policy of selective episiotomy. ...
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World Health Organization (WHO) recommends that the episiotomy rate should be around 10%, which is already a reality in many European countries. Currently the use of episiotomy should be restricted and physicians are encouraged to use their clinical judgment to decide when the procedure is necessary. There is no clinical evidence corroborating any indication of episiotomy, so until the present moment it is not yet known whether episiotomy is indeed necessary in any context of obstetric practice. To compare maternal and perinatal outcomes in women undergoing a protocol of not performing episiotomy versus selective episiotomy. An open label randomized clinical trial will be conducted including laboring women with term pregnancy, maximum dilation of 8 cm, live fetus in cephalic vertex presentation. Women with bleeding disorders of pregnancy, indication for caesarean section and those without capacity to consent and without legal guardians will be excluded. Primary outcomes will be frequency of episiotomy, delivery duration, frequency of spontaneous lacerations and perineal trauma, frequency of instrumental delivery, postpartum blood loss, need for perineal suturing, number of sutures, Apgar scores at one and five minutes, need for neonatal resuscitation and pH in cord blood. As secondary outcomes frequency complications of perineal suturing, postpartum perineal pain, maternal satisfaction, neonatal morbidity and admission newborn in NICU will be assessed. Women will be invited to participate and those who agree will sign the consent form and will be then assigned to a protocol of not conducting episiotomy (experimental group) or to a group that episiotomy is performed selectively according to the judgment of the provider of care delivery (control Group). The present study was approved by IMIP’s Research Ethics Committee. Trial Registration Clinical Trials Register under the number and was registered in ClinicalTrials.gov under the number NCT02178111.
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Background: An episiotomy is a surgically planned incision on the posterior vaginal wall and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy. Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies. Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p<0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p<0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670). Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.
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Objetivo: avaliar o impacto de uma intervenção educativa sobre práticas obstétricas e desfechos perineais. Método: estudo longitudinal, segundo a metodologia de implementação de evidências científicas na prática clínica, realizado com enfermeiros e médicos, puérperas e prontuários em uma maternidade pública de referência no estado do Amapá. Resultado: após a intervenção educativa, mais profissionais recomendaram as posições lateral e verticais no período expulsivo do parto; mais puérperas relataram as práticas de puxo dirigido e manobra de Kristeller; menos prontuários indicaram a laceração espontânea e graus de lacerações maiores. Conclusão: a intervenção educativa proporcionou resultados melhores, mas não estatisticamente significativos.Descritores: Auditoria clínica, Períneo, Pesquisa translacional.IMPLEMENTATION OF SCIENTIFIC EVIDENCES IN NORMAL CHILDBIRTH CARE: LONGITUDINAL STUDYObjective: to evaluate the impact of an educational intervention on obstetric practices and perineal outcomes. Method: longitudinal study, according to the methodology of implementation of scientific evidence in clinical practice, performed with nurses and doctors, puerperas and medical records in a referred public maternity hospital in the state of Amapá. Result: after the educational intervention, more professionals recommended the lateral and vertical positions in the expulsive period of childbirth; More puerperas reported the practices of directed pull and maneuver of Kristeller; Less medical records indicated spontaneous laceration and higher degrees of lacerations. Conclusion: the educational intervention provided better results, but not statistically significant.Descriptors: Clinical audit, Perineum, Translational research.IMPLEMENTACIÓN DE LA EVIDENCIA CIENTÍFICA EN LA ATENCIÓN DE PARTO NORMAL: UN ESTUDIO LONGITUDINALObjetivo: Evaluar el impacto de una intervención educativa sobre las prácticas obstétricas y resultados perineales. Método: Estudio longitudinal, de acuerdo con la metodología de implementación de la evidencia científica en la práctica clínica, realizada con las enfermeras y los médicos, las madres y los registros en una referencia maternidad pública en el estado de Amapá. Resultado: Después de la intervención educativa, la mayoría de los profesionales recomiendan las posiciones laterales y verticales en la segunda etapa del parto; más madres reportaron las prácticas de extracción y maniobra dirigida Kristeller; a menos que los registros que se indican las laceraciones espontáneas y un mayor grado de laceraciones. Conclusión: La intervención educativa poca mejora de las prácticas y los resultados perineales.Descriptores: Auditoría clínica, Perineo, Investigación traslacional.
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Objective: to understand the episiotomy rate and its relationship with various clinical variables. Method: a descriptive, cross-sectional, analytic study of 12,093 births in a tertiary hospital. Variables: Parity, gestational age, start of labor, use of epidural analgesia, oxytocin usage, position during fetal explusion, weight of neonate, and completion of birth. The analysis was performed with SPSS 19.0. Results: the global percentage of episiotomies was 50%. The clinical variables that presented a significant association were primiparity (RR=2.98), gestational age >41 weeks (RR=1.2), augmented or induced labor (RR=1.33), epidural analgesia use (RR=1,95), oxytocin use (RR=1.58), lithotomy position during fetal expulsion (RR=6.4), and instrumentation (RR=1.84). Furthermore, maternal age ≥35 years (RR=0.85) and neonatal weight <2500 g (RR=0.8) were associated with a lower incidence of episiotomy. Conclusions: episiotomy is dependent on obstetric interventions performed during labor. If we wish to reduce the episiotomy rate, it will be necessary to bear in mind these risk factors when establishing policies for reducing this procedure.
Article
Objectives: To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. Methods: From December 2008 to October 2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1 ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. Results: A total of 761 patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR=7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR=3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR=2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. Conclusions: Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk.
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