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The practice of episiotomy in a university teaching hospital in Nigeria: How satisfactory?

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Background: Episiotomy is essentially a surgical procedure but it is often relegated to the least experienced member of the obstetric team with possible untoward consequences to the mother. Aim: This study set out to appraise how episiotomy was practiced in the University of Calabar Teaching Hospital during the period of the study. Materials and Methods: It was a cross sectional exploratory study which assessed episiotomy and episiorrhaphy procedures among parturients in the centre. Results: Thirty two percent of the 275 parturients studied did not know what episiotomy means. The majority (61.5%) of the parturients were not counseled on the need for episiotomy before the procedure was performed on them. The mean delivery-repair interval for episiotomy among parturients in the study population was 17.9 + 5.66 minutes. Most (75.6%) of the episiotomies were performed by midwives. A significant proportion (45.8%) of the parturients had episiotomy performed on them without prior administration of local anaesthesia. The majority (52.7%) of the episiotomies were repaired by house officers. Common complications among women in the study population were perineal discomfort, perineal pain and difficulty in breastfeeding. Conclusion: The practice of episiotomy in the studied University Teaching Hospital during the period of the study did not meet all necessary requirements of a surgical procedure. Senior members of the obstetric team should supervise the practice in order to ensure the maintenance of standard.
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International Journal of Medicine and Biomedical Research
www.ijmbr.com
© Michael Joanna Publications
Original Article
Int J Med Biomed Res 2012;1(1):68-72
68
The practice of episiotomy in a university teaching hospital in
Nigeria: How satisfactory?
Inyang-Etoh E.C*, Umoiyoho A.J
Department of Obstetrics and Gynaecology, University of Uyo, Uyo, Akwa Ibom state, Nigeria.
*Corresponding Author: emmacol2000@yahoo.com
INTRODUCTION
Episiotomy is the commonest surgical procedure in
obstetric practice only second to the cutting of the
umbilical cord at delivery. The practice of
episiotomy has undergone a number of reviews
starting from the 1920s when routine episiotomy
was advocated to the 1980s when restrictive use of
episiotomy became the recommended practice.[1]
The incidence of episiotomy ranges from 20.0% to
62.5% worldwide with a wide inter-centre
variation.[2,3] In Nigeria, the incidence of episiotomy
ranges from 20.8% to 54.9%.[4,5] The following
benefits were traditionally ascribed to routine
episiotomy: reduction of severe perineal laceration,
reduction of fetal trauma, reduction of urinary stress
incontinence and improved wound healing.[1]
Thacker and Banta[1] in 1993 however, found that
most of these acclaimed benefits lacked scientific
basis. They discovered in their study that
episiotomy was associated with more pain,
excessive bleeding, wound hematoma, wound
infection and wound breakdown.[2,6] Thacker and
Banta therefore advocated restrictive use of
episiotomy. Their findings were later corroborated
by other workers who confirmed the need for
restrictive use of episiotomy.[2,6]
ABSTRACT
Background: Episiotomy is essentially a surgical procedure but it is often relegated
to the least experienced member of the obstetric team with possible untoward
consequences to the mother. Aim: This study set out to appraise how episiotomy
was practiced in the University of Calabar Teaching Hospital during the period of the
study. Materials and Methods: It was a cross sectional exploratory study which
assessed episiotomy and episiorrhaphy procedures among parturients in the centre.
Results: Thirty two percent of the 275 parturients studied did not know what
episiotomy means. The majority (61.5%) of the parturients were not counseled on
the need for episiotomy before the procedure was performed on them. The mean
delivery-repair interval for episiotomy among parturients in the study population was
17.9 + 5.66 minutes. Most (75.6%) of the episiotomies were performed by midwives.
A significant proportion (45.8%) of the parturients had episiotomy performed on
them without prior administration of local anaesthesia. The majority (52.7%) of the
episiotomies were repaired by house officers. Common complications among
women in the study population were perineal discomfort, perineal pain and difficulty
in breastfeeding. Conclusion: The practice of episiotomy in the studied University
Teaching Hospital during the period of the study did not meet all necessary
requirements of a surgical procedure. Senior members of the obstetric team should
supervise the practice in order to ensure the maintenance of standard.
Key words: Episiotomy, episiorrhaphy, surgical procedure, practice, counseling
Inyang-Etoh and Umoiyoho. The practice of episiotomy
Int J Med Biomed Res 2012;1(1):68-72
69
This evidence has led to a decline in the incidence
of episiotomy in many maternity centers around the
world.[5,7] Nonetheless, episiotomy which is
essentially a surgical procedure is generally
associated with complications, some of which
include pain, hemorrhage, local anesthetic toxicity,
wound infection and wound breakdown.[8,9] The
occurrence of these complications may be
influenced by the skill and experience of the
attending physician. Episiotomy also interferes with
the mothers comfort during the postpartum period.
The fear of episiotomy by women in our
environment has also been adduced as one of the
reasons why some women receive antenatal care in
hospitals but elect to deliver in unlicensed maternity
homes where episiotomies are never performed
and intrapartum care may be inadequate.[8,10]
Published literature on episiotomy as it is practiced
in maternity units around the world are generally
sparse; however, anecdotal evidence suggests that
in most maternity centers, the repair of episiotomy
is often relegated to the inexperienced house officer
with attendant adverse consequences to the
mother. This study seeks to appraise how
episiotomy was practiced in the University of
Calabar Teaching Hospital. It is envisaged that the
findings of this study would help us bring to the fore
the need for review of our practice and/or reinforce
our current practice as regards episiotomy.
MATERIALS AND METHODS
Study design and study area
This was a cross-sectional exploratory study that
was conducted at the maternity annex of the
University Calabar Teaching Hospital over a twelve
month period to appraise how episiotomy was
performed and repaired in the center. The
University of Calabar Teaching Hospital is located
in Calabar, the state capital of Cross River State,
which is located in the south-south geopolitical zone
of Nigeria. The University of Calabar Teaching
Hospital is the only tertiary health facility that
provides specialist maternity care to women in the
state and its environ. Calabar has an estimated
population of 328,876 people, 50% of which are
women. (Final Report of the Nigerian national
population census- 2006)
Recruitment and data collection
Following approval from the ethical committee of
the hospital, all the parturients who had episiotomy
and gave their informed consent to participate in the
study were recruited into the study. The
questionnaires which were partly pre-coded and
partly open-ended were pretested and administered
to each parturient within 24 hours postpartum to
assess how episiotomy was performed and
repaired. Additional information on the parturients
demographics were abstracted from the delivery
notes and attending personnel were also
interviewed on counseling of the parturients before
the procedure, the use of local anaesthesia, the
interval between delivery and repair of the
episiotomy and the problems encountered in the
course of repair of the episiotomy.
Statistical analysis
The data obtained were presented as numericals,
simple proportions, and percentages. Mathematical
calculations were done using conventional
statistical formulas and the results were presented
in tabular form. Descriptive and inferential principles
were used to draw conclusions from the study.
RESULTS
During the 12 months period of the study, 1306
women were delivered vaginally in the maternity
annex of the University of Calabar Teaching
Hospital out of which 275 had episiotomy performed
on them. This gave an incidence of episiotomy of
21.0% during the period of the study. Out of the 275
parturients, 260 (94.5%) were booked, 10 (3.6%)
were unbooked and 5 (1.8%) of the parturients
were referred from other health facilities.
Table 1 shows the knowledge status of parturients
in the study population. The majority (61.0%) of the
parturients had knowledge of what episiotomy
means when they were interviewed while eighty-
eight (32.0%) of the parturients did not know what
episiotomy means. Nineteen women were not sure
whether they knew what episiotomy means or not.
Table 1: Knowledge about episiotomy before
labour
Knowledge status
No of parturients (%)
Had knowledge
168(61.0)
Had no knowledge
88(32.0)
Cannot remember
19(7.0)
Total
275(100.0)
The distribution of women according to their
counseling status is shown in table 2. The majority
(61.5%) of the women who had episiotomy
performed on them were not counseled about the
procedure. Only 97 (35.2%) of the parturients were
Inyang-Etoh and Umoiyoho. The practice of episiotomy
Int J Med Biomed Res 2012;1(1):68-72
70
duly counseled before the episiotomy were
performed on them.
Table 2: Counseling before episiotomy was
performed
Counseling status
Counseled
Cannot remember
Cannot remember
Total
Table 3 shows the interval from delivery to repair of
the episiotomy in the study population. A total of
169 (61.4%) women had their episiotomy repaired
within 15 minutes after delivery. The episiotomies of
forty-nine (17.8%) of the women were repaired
between 15 and 30 minutes after delivery. The rest
(20.8%) had their repair delayed longer that
30minutes. Two of the parturients were delayed for
about 2 hours because of lack of sterile instruments
for the repair . The mean delivery-repair interval
was 17.9 + 5.66minutes.
Table 3: Interval from delivery to repair of the
episiotomy
Interval (min)
No. of parturients (%)
0 15
169(61.4)
15 30
49(17.8)
30 45
36(13.2)
45 60
13(4.7)
>60
8(2.9)
Total
275 (100.0)
The designation of staff that performed the
episiotomy on parturients in the study population is
shown in table 4. Only seventeen (6.1%) of the
women had their episiotomy performed by either a
consultant or senior Registrar. A vast majority
(75.6%) of the episiotomies were performed by
midwives.
Table 5 shows the proportion of women whom local
anesthesia were administered before episiotomy.
As many as one hundred and twenty-six (45.8%) of
the women were not on local anesthesia before
episiotomy were performed on them. The ranks of
the doctors who repaired the episiotomy among
women in the study population are shown in table 6.
One hundred and forty-five (52.7%) women had
their episiotomy repaired by House officers whereas
only 9.9% of women had theirs repaired by either a
Senior Registrar or a Consultant.
Table 4: Designation of the staff who performed
the episiotomy
Designation
No of parturients (%)
Consultant
8(2.9)
Senior Registrar
9(3.2)
Registrar
50(18.3)
Midwife
208(75.6)
Total
275(100.0)
Table 5: Administration of local anaesthesia
before episiotomy
Local anaesthesia
status
No of parturients (%)
Administered
149(54.2)
Not administered
126(45.8)
Total
275(100.0)
Table 6: Rank of the Doctors who repaired the
episiotomy
Rank
No of parturients (%)
Consultant
12(4.4)
Senior Registrar
15(5.5)
Registrar
103(37.4)
House officer
145(52.7)
Total
275(100.0)
Table 7 shows the different complications that
occurred among women in the study population.
The commonest complication was perineal
discomfort, which occurred in 81(29.5%) of the
women. The least complication was perineal
bleeding which occurred in only 4.7% of the
women.
Table 7: Complications resulting from
episiotomy
Complications
No of parturients (%)
Perineal discomfort
81(29.5)
Perineal pain
69(25.1)
Difficulty with
breastfeeding
49(17.8)
Difficulty with
walking
40(14.5)
Perineal bleeding
13(4.7)
Inyang-Etoh and Umoiyoho. The practice of episiotomy
Int J Med Biomed Res 2012;1(1):68-72
71
DISCUSSION
The review of clinical and surgical practices in every
clinical unit is desirable so that aberrant practices
could be detected and efforts made to correct them
in the overall interest of the patients whom we
serve. The prevalence of episiotomy among women
in the center during the period of the study was
21.0%. This was at the lower limit of the estimated
range from Nigerian centers which revealed a rate
of 20.8% 54.9%.[4,5] Although relatively low by
Nigerian standard, this prevalence still fell short of
the recommended episiotomy rate of less than 15%
advocated by restrictive episiotomy activists.[6] A
comparable episiotomy rate of 24.8% was also
obtained at Jos, Nigeria.[5] This result however
contrasted with relatively high episiotomy rates of
54.9%, 40.4% and 46.6% obtained at other
Nigerian centers namely: Lagos, Enugu and Benin
respectively.[4,11,12] Although, the reason for this
disparity in episiotomy rates among centers has not
been adduced, restrictive use of episiotomy is said
to be a goal that is achievable in every maternity
unit.
Merely 61% of the parturients in the study
population knew what episiotomy means at the time
they were admitted in labor. The proportion of the
women that knew what episiotomy means was
modest considering the fact that most (94.5%) of
the parturients had booked and received antenatal
care in the center. Antenatal clinic in the centre
provides an avenue where health-talks are given to
attending women on episiotomy and other
procedures that may be needed in the course of
pregnancy and delivery. This rather surprising
finding unfolds some defects in our antenatal care
in the centre.
Only ninety-seven (35.2%) parturients were
counseled on the need for episiotomy before the
procedure was performed on them. This finding was
disturbing because this type of practice does not
recognize the fact that episiotomy is essentially a
surgical procedure. Informed consent is required
prior to any clinical or surgical procedure and this
requirement should be met before any such
procedure is performed.[13]
Only 61.4% of the parturients had their episiotomy
repaired within 15minutes from delivery in the study
population. It seems reasonable for episiotomies to
be repaired immediately; however, a short interval
may be needed to get the patient ready and this
should ideally not exceed fifteen minutes. Any
further delay may be unreasonable as the risk of
bleeding, wound contamination and infection
increases as the delivery-repair interval is
prolonged. Surprisingly, up to 38.6% of the
episiotomies were not repaired within 15minutes
interval in the center. Interestingly, a study in Zaria
revealed a mean deliveryrepair interval of
60.5minutes due largely to inadequate episiotomy-
repair packs in the centre; this contrasted with the
significantly shorter delivery-repair interval of
17.9minutes obtained in our study.[8]
A vast majority (75.6%) of the episiotomies were
performed by midwives. This was not surprising
because most vaginal deliveries in the center are
conducted by midwives except when there is an
identified risk factor warranting the attention of the
doctor. Only 6.1% of the parturients had their
episiotomy performed by a consultant or senior
registrar. This finding is a reflection of the practice
in our centre where senior members of the obstetric
team are only sparingly invited to conduct high risk
deliveries.
About 54.2% of the parturients had local
anaesthesia administered before episiotomy was
performed on them. A study in a Teaching Hospital
in Ethiopia revealed a much lower rate of 28.1% of
local anesthesia use among parturients who had
episiotomy in their study.[14] This practice, which is
not recommended can be traced back to the 1970s
when vaginal delivery was regarded as a natural
process requiring no interference. Anecdotal
evidence holds that midwives were then
indoctrinated to cut at the peak of uterine
contractions when pain is maximal with the hope
that the ischemic pain of uterine contractions would
mask the pain of the episiotomy. This practice of
performing episiotomy without anesthesia is cruel
and should be abandoned in all maternity units.
Episiotomy which is essentially a surgical procedure
requires adherence to basic surgical principles and
so, adequate anesthesia must precede the
procedure.[15] The correction of this aberrant
practice calls for training and retraining of nurses on
modern midwifery practices.
The majority (52.7%) of the episiotomies were
repaired by house officers. This finding has
confirmed the suspicion that episiotomy is often
relegated to house officers. This practice must be
checked if satisfactory results are to be expected
from the management of episiotomy. Nonetheless,
House Officers can repair episiotomy satisfactorily if
they are adequately trained. Such training should
follow the principle of initial observation, assisting,
repairing under direct supervision and repairing
Inyang-Etoh and Umoiyoho. The practice of episiotomy
Int J Med Biomed Res 2012;1(1):68-72
72
under indirect supervision before he or she is
allowed to repair unsupervised.
The commonest (29.5%) complication of episiotomy
among mothers in the study population was
perineal discomfort. This was not surprising as most
patients who had surgical procedures would
complain of some discomfort at the site of the
operation. However, perineal pain occurred in
25.1% of mothers either because of inadequacy of
anesthesia, failure of postoperative analgesia or
inappropriate surgical technique. Such
determinants may be influenced by the skill and
experience of the surgeon.
In conclusion, the practice of episiotomy in the
studied University Teaching Hospital during the
period of the study did not meet the minimal
requirements of a surgical procedure. Senior
members of the obstetric team should supervise the
practice to ensure standard. The provision of pre-
packed episiotomy-repair packs would go a long
way in the reduction of delivery-repair interval.
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1. Thacker B and Banta HD. Benefits and risk of
episiotomy: An interpretative review of the English
literature (1860-1980) Obstet Gynaecol 1983;38:322-328.
2. Goldberg J, Holtz D, Hyslop T, Tolosa JE. Has
the use of routine episiotomy decreased? Examination of
episiotomy rates from 1983 to 2000. Obstet Gynaecol
2002;3:395-400.
3. Meyn L, Weber AM. Episiotomy use in the
United States 1979-1997. Obstet Gynaecol 2002;4:49.53.
4. Ola ER, Bello O, Abudu OO, Anorlu RI.
Episiotomies in Nigeria: Should their use be restricted?
Niger Postgrad Med J 2002;99:13-16.
5. Mutihir JT, Ujah IOA. Episiotomies in the Jos
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6. Hartmann K, Viswanathan M, Palmieri R.
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7. Graham ID and Graham DF. Episiotomy counts:
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8. Sule ST, Shittu SO. Puerperial complication of
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9. Liu TY. and Fairweather DVI. Episiotomy and
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ward manual. 2nd Edition Great Britain. Butterworth-
Heimann Ltd. 1991. Pp 47-51.
10. Rasheed I, Khan AA. A multifactorial study of
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11. Onah HE and Akani CI. Rates and predictors of
episiotomy in Nigerian women. Trop J Obstet Gynaecol
2004;21:44-45.
12. Otoido VO, Ogbonmwan SM and Okonofua FE.
Episiotomy in Nigeria. Int J Gynaecol Obstet 2000;68:13-
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15. Myerscough PR. Episiotomy: maternal injuries.
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doi: http://dx.doi.org/10.14194/ijmbr.1111
How to cite this article: Inyang-Etoh
E.C, Umoiyoho A.J. The practice of
episiotomy in a university teaching
hospital in Nigeria: How satisfactory? Int
J Med Biomed Res 2012;1(1):68-72
Conflict of Interest: None declared
... [7][8][9][10] It also stated episiotomy as a risk factor of spontaneous perineal tear, subsequent pelvic floor dysfunction, urinary and fecal incontinence, sexual dysfunction, and fetal head injury, medical resident and individual professional judgment was decreased in order to accelerate the second stage of labor. 11,12,24,32 In the 1920s a number of reviews were started and then routine episiotomy was advocated. 13 However, when the first clear clinical studies were released, the long-held assumptions that postoperative pain is less and that recovery improved with an episiotomy compared to a tear seemed to be wrong. ...
... Whereas the finding is in line with the study done in Burikinafaso (37%) 37 and in Nigeria (45%). 11 The possible explanation for this consistency might be similar distribution of qualified personnel in adherence to the recommendation of selective use of episiotomy. ...
Article
Full-text available
Background: Episiotomy is the surgical enlargement of the vaginal orifice during the last part of the second stage of labor or childbirth by an incision to the perineum. The World Health Organization advises the use of episiotomy on a restricted and selective basis. Indeed, the rate of episiotomy in developed countries is decreasing, but in developing countries, including Ethiopia, it still remains high. Therefore, this study tried to assess the proportion and factors associated with episiotomy among women who gave birth at Felege Hiwot Referral Hospital, Bahir Dar City, North West Ethiopia, 2017. Methods: An institution-based cross-sectional study was conducted among 411 mothers from February to April 2017. Data were collected through face-to-face interviews and supported by observation using standard checklist with systematic random sampling technique. Data was entered by Epi Info and analyzed by SPSS version 23. The association between variables was analyzed using bivariable and multivariable logistic regression model. P-value <0.05 at 95% CI was considered to be statistically significant. Results: The proportion of episiotomy was 41.1% with 95% CI (36.5%, 46.2%). Multivariable logistic regression showed that primiparity (AOR=6.026, 95% CI (3.542,10.253)), prolonged second stage of labor (AOR=4.612, 95% CI (2.247,9.465)), instrument delivery (AOR =3.933, 95% CI (1.526,10.141)), using oxytocin (AOR=2.608, 95% CI (1.431,4.751)), medical resident attendant (AOR =3.225, 95% CI (1.409,7.382)) and birth weight ≥4000 grams (AOR=5.127,95% Cl (1.106,23.772)) were significantly associated with episiotomy practice. Conclusion: The proportion of episiotomy was high. Parity, using oxytocin, second-stage labor duration, instrument delivery, birth weight, and delivery attendant were statistically significant factors for episiotomy practice. Therefore, as per our findings, we suggest awareness creation, and the setting and use of new national guidelines, the practice of routine episiotomy should be abandoned, and selective and restrictive use of episiotomy is highly advised.
... It also minimizes postpartum pelvic floor dysfunction by reducing anal sphincter damage, reduces the amount of blood lost during delivery, and protects against neonatal trauma [4,5]. Empirical evidence has episiotomy as the commonest surgical procedure in obstetrics only second to cutting of the umbilical cord [6,7]. ...
... Abubakar and Suleiman that majority (94.5% and 87.6% respectively) of the women had heard of episiotomy [7,17] but disagrees with the findings of Inyang-Eto and Umoiyoho in Nigeria that a significant portion (32%) of participants did not know what episiotomy means [6]. ...
Article
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Objectives: To determine the knowledge, attitude and acceptance of episiotomy among first-time and multiparous parturient women. Methods: It was a cross-sectional descriptive study conducted in four selected hospitals in Enugu, Nigeria. Parturient women were recruited for the study using stratified sampling method. A well-structured validated questionnaire was the instrument of data collection. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 23 computer program. All correlation tests were two-tailed with values of P<0.05 considered significant. Results: Two hundred and twenty two parturients were analyzed. Majority 180 (81.1%) had a prior knowledge of episiotomy, while 42 (18.9%) had not heard of episiotomy. The proportion of women with prior knowledge of episiotomy was significantly higher in multiparous women than in first time parturients (p<0.05). Of the 180 women that had heard of episiotomy, majority 108 (60.0%) indicated doctors/midwives, 57 (31.7%) indicated neighbours/friends, 52 (28.9%) indicated mother/grandmother, while 20 (11.1%), 6 (3.3%) and 3 (3.3%) indicated books (magazines and journal), media and internet respectively as their sources of information. More multiparous parturients heard of episiotomy from doctors/midwives than the first-time-parturients (P>0.05). On attitude, multiparous parturients were more negatively disposed to episiotomy than the first-time counterparts. Of the 180 women that had heard of episiotomy, majority of them 140 (77.8%) would not like to have episiotomy during their childbirth majorly because of the pain and discomfort associated with it. Out of the 140 (77.8%) who would not like to have episiotomy during their labor, 46 (32.9%) preferred skillful guarding of the perineum and 42 (30.0%) preferred antenatal perineal massage and exercises. Conclusion: Majority of the respondents got the information about episiotomy from unreliable sources; mostly their family and friends instead of professionals in the field leading to significantly wrong perceptions and negative attitude towards episiotomy among respondents.
... [7][8][9][10] It also stated episiotomy as a risk factor of spontaneous perineal tear, subsequent pelvic floor dysfunction, urinary and fecal incontinence, sexual dysfunction, and fetal head injury, medical resident and individual professional judgment was decreased in order to accelerate the second stage of labor. 11,12,24,32 In the 1920s a number of reviews were started and then routine episiotomy was advocated. 13 However, when the first clear clinical studies were released, the long-held assumptions that postoperative pain is less and that recovery improved with an episiotomy compared to a tear seemed to be wrong. ...
... Whereas the finding is in line with the study done in Burikinafaso (37%) 37 and in Nigeria (45%). 11 The possible explanation for this consistency might be similar distribution of qualified personnel in adherence to the recommendation of selective use of episiotomy. ...
Article
Full-text available
Background: Episiotomy is the surgical enlargement of the vaginal orifice during the last part of the second stage of labor or childbirth by an incision to the perineum. The World Health Organization advises the use of episiotomy on a restricted and selective basis. Indeed, the rate of episiotomy in developed countries is decreasing, but in developing countries, including Ethiopia, it still remains high. Therefore, this study tried to assess the proportion and factors associated with episiotomy among women who gave birth at Felege Hiwot Referral Hospital, Bahir Dar City, North West Ethiopia, 2017. Methods: An institution-based cross-sectional study was conducted among 411 mothers from February to April 2017. Data were collected through face-to-face interviews and supported by observation using standard checklist with systematic random sampling technique. Data was entered by Epi Info and analyzed by SPSS version 23. The association between variables was analyzed using bivariable and multivariable logistic regression model. P-value <0.05 at 95% CI was considered to be statistically significant. Results: The proportion of episiotomy was 41.1% with 95% CI (36.5%, 46.2%). Multivariable logistic regression showed that primiparity (AOR=6.026, 95% CI (3.542,10.253)), prolonged second stage of labor (AOR=4.612, 95% CI (2.247,9.465)), instrument delivery (AOR =3.933, 95% CI (1.526,10.141)), using oxytocin (AOR=2.608, 95% CI (1.431,4.751)), medical resident attendant (AOR =3.225, 95% CI (1.409,7.382)) and birth weight ≥4000 grams (AOR=5.127,95% Cl (1.106,23.772)) were significantly associated with episiotomy practice. Conclusion: The proportion of episiotomy was high. Parity, using oxytocin, second-stage labor duration, instrument delivery, birth weight, and delivery attendant were statistically significant factors for episiotomy practice. Therefore, as per our findings, we suggest awareness creation, and the setting and use of new national guidelines, the practice of routine episiotomy should be abandoned, and selective and restrictive use of episiotomy is highly advised.
... Prevention of perineal trauma is most time not possible [1], but when it occurs there can be short-term and longterm complications such as fear of becoming pregnant [2][3][4]. Perineal discomfort, perineal pain, difficulty with breastfeeding, difficulty with walking, perineal bleeding [5] and episiotomy breakdown [6]. ...
... Routine use of episiotomy originally began by Pomeroy in 1918 and this routine practice was accepted and taught in obstetrics services till 1970s, when the first consistent clinical trials questioning the value of episiotomy were published [8]. Since then many studies, reviews and metanalyses have evidenced that there is no scientific basis for maintaining the routine practice of episiotomy. ...
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Background Episiotomy is a surgical incision of the perineum to hasten the delivery. There is a scarce of information related to episiotomy practice, and its associated factors, in developing countries, including Ethiopia. Thus, this study was aimed to determine the level of episiotomy practice and to identify its determinants at public health facilities of Metema district, northwest, Ethiopia. Methods Institutional-based cross sectional study was conducted among 410 delivered mothers from March 1 to April 30, 2020. We recruited study participants using systematic random sampling technique. Data were entered to Epi data version 3.1 and exported to STATA version 14 for statistical analysis. Stepwise backward elimination was applied for variable selection and model fitness was checked using Hosmer and Lemshows statistics test. Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables. Results In this study, the magnitude of episiotomy practice was found 44.15% (95% CI 39.32–48.97). Vaginal instrumental delivery (AOR 3.04, 95% CI 1.36–6.78), perineal tear (AOR 3.56, 95% CI 1.68–7.55), age between 25 and 35 (AOR 0.11, 95% CI 0.05–0.25), birth spacing less than 2 years (AOR 4.76, 95% CI 2.31–9.83) and use of oxytocin (AOR 2.73, 95% CI 1.19–6.25) were factors significantly associated with episiotomy practice. Conclusions Magnitude of episiotomy practice in this study is higher than the recommended value of World Health Organization (WHO). Instrumental delivery, age, oxytocin, birth spacing and perineal tear were significant factors for episiotomy practice. Thus, specific interventions should be designed to reduce the rate of episiotomy practice. Plain English summary The routine use of episiotomy practice is not recommended by WHO. A study that compares routine episiotomy with restrictive episiotomy suggests that the latter is associated with less posterior perineal trauma, less need for suturing, and fewer complications related to healing. In addition, though, the rate of episiotomy has been declined in developed countries, still it remains high in less industrialized countries. The data for this study were taken at public health facilities of Metema district, northwest, Ethiopia. We included a total of 410 delivered mothers. The magnitude of episiotomy practice was found 44%. This result was higher than the recommended value of WHO. The WHO recommends an episiotomy rate of 10% for all normal deliveries. The result of this study showed that episiotomy practice is common among mothers whose age group are 18–24. In addition, mothers whose labor were assisted by instrumental vaginal delivery are more likely to have episiotomy as compared to those delivered by normal vaginal delivery. Laboring mothers who had used oxytocin were about three times more likely to be exposed for episiotomy than laboring mothers who did not use oxytocin drug. Moreover, episiotomy practice was nearly five times more likely among mothers who had birth spacing of 2 years and less as compared to mothers who had birth spacing of more than 2 years.
... [7][8][9] In nearby Calabar, a metropolitan city like Port Harcourt also in south-southern Nigeria, a recent study showed a comparatively low episiotomy rate of 20.1% among all women that had a vaginal delivery. 10 In other parts of Nigeria, a study from Zaria reported a rate of 35.6% following all vaginal deliveries and 88.5% in primigravidae; in Enugu, the rate was 40.4% for all parities and 76.2% in primigravidae. 2,11 It has been known that perineal tears were observed in women that had not undergone episiotomy, which suggest episiotomy prevents unwanted tear. ...
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Background: Despite many years of it being practiced, episiotomy has remained a controversial operation. The rate is on the decline in developed countries but remains high in developing countries. This study seeks to determine the prevalence of episiotomy and perineal tear, and to assess the associated factors, at the Rivers state university teaching hospital (RSUTH). Methods: A retrospective study over a two-year period, from 01 January 2018 to 31 December 2019, was carried out. All women who had singleton spontaneous vaginal deliveries (SVD) with episiotomy or perineal tear at the RSUTH with complete records were included, those with twin delivery and incomplete data were excluded. Data was retrieved from the birth registers and case notes using a proforma. Information on maternal age, parity, gestational age (GA), type of injury, birth weight, head circumference and Apgar scores were extracted. Data were analyzed using statistical package for the social sciences (SPSS) version 20. Results: There were 2150 vaginal deliveries, with 440 (20.5%) receiving episiotomy, while 21 (1.0%) had perineal tear. The mean age±standard deviation (SD) was 29.52±4.97 years, median parity was 1, and mean GA±SD was 37.35±1.71 weeks. The mean birth weight±SD was 3.33±0.52 kg and mean head circumference±SD was 34.76±1.90 cm. There was significant association between maternal parity and fetal birth weight with the occurrence of episiotomy and perineal tears. Conclusions: The rate of episiotomy and perineal tear was higher than recommended, with an increasing trend. The lower the parity and the higher the fetal birth weight, the likelihood to receive an episiotomy. More efforts are needed to reduce the rate. Keywords: Episiotomy, Perineal tear, Prevalence, Predictors, Tertiary hospital
... Vietnamese-born women in Australia (29.9%) [27]; Nigeria (21%) [30]; Brazil 29.1% [22]; Iran 41.5% [31]; Kano, Nigeria 41.4% [32]; Nepal 22% [33]; East African women in Australia 30% [34]; Eastern Nigeria 45% [23]; Mizan Aman 30.6% [17]; Addis Ababa 40.2% [16]; Shire 41.4% [20]; and Jimma 25% [15]. This difference might be due to the difference in time of the studies conducted, study settings of the study participants, and characteristics of the study population. ...
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Background: Episiotomy is the most common obstetric procedure, performed when the clinical circumstances place the patient at a high risk of high-degree laceration. However, episiotomy should be done with judicious indication to lower perineal laceration with fewer complications. Despite its adverse effects, the magnitude of episiotomy is increasing due to different factors. Therefore, this study is aimed at determining the recent magnitude of episiotomy and at identifying associated factors among women who gave delivery in Arba Minch General Hospital, Southern Ethiopia. Methods: An institution-based cross-sectional study was conducted from December 15, 2018, to January 30, 2019. A systematic random sampling technique was used to select study participants. A semistructured questionnaire was used to collect data. This was supplemented with a review of the labor and delivery records. Binary and multivariable logistic regression analyses were performed to identify factors associated with the magnitude of episiotomy. P value ≤ 0.05 was used to determine the level of statistically significant variables. Results: The magnitude of episiotomy was found to be 272 (68.0%) with 95%CI = 64.0-72.5. Women who attended secondary education [AOR = 10.24, 95%CI = 2.81-37.34], women who attended college and above [AOR = 4.61, 95%CI = 1.27-16.71], birth weight ≥ 3000 g [AOR = 4.84, 95%CI = 2.66-8.82], primipara [AOR = 4.13, 95%CI = 2.40-7.12], being housewife occupants [AOR = 3.43, 95%CI = 1.20-9.98], married women [AOR = 2.86, 95%CI = 1.40-5.84], and body mass index < 25 kg/m2 [AOR = 2.85, 95%CI = 1.50-5.44] were independent variables found to have significant association with episiotomy. Conclusion: The magnitude of episiotomy was 68.0% which is higher than the recommended practice by WHO (10%). The study participants' occupational status, marital status, educational status, parity, birth weight, and BMI were significantly associated with the magnitude of episiotomy in the study area. Therefore, to reduce the rate of episiotomy, it is better to have periodic training for birth attendants regarding the indication of episiotomy.
... The rate of episiotomy among the postnatal mothers in Nigeria is around 35.6% and in PrimiGravida mothers the rate was around 88.5% and in Enugu, the rate of episiotomy was around 40.4% for women including Primi Para and in multipara. Nigeria is showing the lower rate of episiotomy wound among the postnatal mothers [9][10][11]. ...
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Introduction: Globally, approximately 140 million births occur every year. In India the incidence of Institutional normal vaginal deliveries 61.5% with 58.4% of normal vaginal delivery with episiotomy. Maternal mortality Worldwide nearly 6 Lakh mothers between the age of 15-49 years die every year due to complication arising from pregnancy and childbirth.Kegel exercises are the most popular method of reinforcing pelvic floor muscles. They were first described in 1948 by the American gynecologist Arnold Kegel. The squeeze and hold vaginal exercises known as Kegel’s were specifically designed to target pelvic floor strengthening which damage due to vaginal delivery. Material and Methods: A Pre-experimental one group Pre-test post-test research design was adopted to conduct the study. Target population was B.Sc. Nursing 3rd year students. A purposive sampling technique was utilized for selecting a sample of 60 B.Sc. Nursing 3rd year students. Section A: - Deals with the socio-demographic variables such as Age, Residence, types of family, period of exposure in Clinical area, Previous knowledge about Kegel exercise and Source of knowledge. Section B: - Deals with self-structured knowledge questionnaire to assess the knowledge regardingKegel exercise on episiotomy pain and wound healing among B.Sc. Nursing 3rd year students. Result: Analysis of pre-test and post-test knowledge score using frequency, percentage and total score indicates that out of 60 B.Sc. Nursing 3rd year students in pre-test majority 3.33% (02) were in good, 63.33% (38) were in averageand 33.33% (20) sample were in need to improve on knowledge regardingKegel exercise on episiotomy pain and wound healingand in post-test majority 76.66% (46) sample were in good, 23.33% (14) were average and 0% (0) were in need to improve.which proves the effectiveness of the video assisted teaching programme.Chi-square analysis shows significant association between knowledge and previous knowledge of subjects, source of information of subjects. Conclusion: A study that conducted the use of video assisted teaching programmeregardingKegel exercise on episiotomy pain and wound healingwas effective in increase knowledge among B.Sc. Nursing 3rd year students.
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Background Around 70% of women who give birth vaginally experience perineal injury during childbirth, which may happen spontaneously or as a result of the incision made to facilitate childbirth. There are very few studies on the perceptions of episiotomy recipients about these services. Therefore, investigating these women's perception is crucial for providing appropriate care. Methods This qualitative study examined 20 women from hospitals and health centres who had undergone episiotomy using in-depth semi-structured interviews. Data were analysed using conventional content analysis and the accuracy and rigour of the data were assessed using the Lincoln and Guba criteria. Results The ‘change in perception and behaviour’ theme encompassed one category of negative experiences and views about episiotomy and a second category covering positive views. Conclusions Women's perceptions of episiotomy contained both positive and negative views. Since healthcare systems should support mothers' physical and mental health, it is recommended that health policymakers devise plans to boost factors that lead to positive views and eliminate those contributing to negative experiences and views.
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Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use. To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality. Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function--pain with intercourse was more common among women with episiotomy. Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.
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To establish the epidemiological variables associated with episiotomies and their puerperal complications at Ahmadu Bello University Teaching Hospital Zaria, in order to institute appropriate management including preventive measures. A prospective cohort study. Ahmadu cello University Teaching Hospital, Zaria, Nigeria. A cohort of all consecutive patients that underwent vaginal deliveries during a 12-week period were followed up for six weeks in order to determine the distribution and determinants of episiotomy and its complications. The episiotomy rate was 35.6% of all vaginal deliveries. Episiotomies were significantly associated with primigravidity being performed in 88.5% of all primigravidae. The mean delivery-repair interval was 60.5 minutes. The most common puerperal complication of episiotomies was perineal pain that lasted an average of 5.5 days. Other complications included asymmetry (32.9%), infection (23.7%), partial dehiscence (14.5%), skin tags (7.9%), haemorrhage (5.3%) and extension of the incision (1.3%). The complications were not significantly associated with any potential risk factor. In view of the very high episiotomy rate among primigravidae, it is recommended that the episiotomy rate among primigravidae be reduced by re-acquainting accoucheurs with the indications for episiotomy. Attention needs to be given to adequate pain relief for all women who have had an episiotomy and the delivery-repair interval in this unit should be reduced by provision of materials for episiotomy repair in the delivery suite.
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The benefits and risks of episiotomy in labor and delivery as recorded in the English language literature in over 350 books and articles published since 1860 are reviewed and analyzed. Episiotomy is performed in over 60 per cent of all deliveries in the United States and in a much higher per cent of primigravidas. Yet, there is no clearly defined evidence for its efficacy, particularly for routine use. In addition, although poorly studied, there is evidence that postpartum pain and discomfort are accentuated after episiotomy, and serious complications, including maternal death, can be associated with the procedure. Therefore, carefully designed controlled trials of benefit and risk should be carried out on the use of episiotomy.
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The purpose of this study was to produce a minimum estimate of the prevalence of episiotomy use in Canada, and to investigate the trend in its use between 1981/1982 and 1993/1994. A retrospective population case series study was conducted using hospital discharge abstracts. Outcome measures were the count of episiotomies performed during a 12-month period and the episiotomy rate per 100 vaginal births. For more than a decade, official statistics have significantly underreported episiotomy use by as much as 50 percent. In 1993/1994 at least 37.7 percent of women giving birth vaginally in Canada are known to have received an episiotomy. Between 1981/1982 and 1993/1994 its prevalence declined 29.1 percent, with the greatest decline occurring during the 1990s. This decline did not result from changes in parity in the population. The decrease in episiotomy use during this 13-year period is more than twice that found in the United States (a decline of only 13.6%). The reporting of official statistics on obstetric procedures in Canada should be modified to include all known cases of episiotomy. The observed downward trend in the rate of this procedure is encouraging, and is in the direction of evidence-based recommendations advocating its restrictive use.
Article
To determine if practice patterns have been altered by the large body of literature strongly advocating the selective use of episiotomy. An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 to 2000 was completed. Univariate and multivariable models were computed using logistic regression models. Overall episiotomy rates in 34,048 vaginal births showed a significant reduction from 69.6% in 1983 to 19.4% in 2000. Significantly decreased risk of episiotomy was seen based upon year of childbirth (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86, 0.87), black race (OR 0.29, 95% CI 0.28, 0.31), and spontaneous vaginal delivery (OR 0.40, 95% CI 0.36, 0.45). Increased association with episiotomy was seen in forceps deliveries (OR 4.04, 95% CI 3.46, 4.72), and with third- or fourth-degree lacerations (OR 4.87, 95% CI 4.38, 5.41). In deliveries with known insurance status, having Medicaid insurance was also associated with a decreased episiotomy risk (OR 0.59, 95% CI 0.54, 0.64). There was a statistically significant reduction in the overall episiotomy rate between 1983 and 2000. White women consistently underwent episiotomy more frequently than black women even when controlling for age, parity, insurance status, and operative vaginal delivery.
Article
Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. The incidence of episiotomy and perineal tears and also the indications for episiotomy were therefore investigated in 1007 singleton deliveries between January 1, 1997 and December 31, 1997 at the Lagos University Teaching Hospital. The incidence of episiotomy was 54.9% of all deliveries. Episiotomy was more frequently performed in primipara (90.4%). Perineal tears occurred in only 18.8% of all deliveries, with majority in the multipara (93.6%). Most of the team were of first degree (98.4%). No third degree tear was recorded. The commonest indication for episiotomy was that of protecting the perineum from possible tears (80.7%). All the episiotomies were mediolateral. Episiotomy rate was higher among deliveries conducted by doctors. Performance of episiotomy had a positive correlation with increasing foetal weight. No major complication or maternal death attributable to episiotomy was recorded. The results of our study suggest that the use of episiotomy can be restricted to specified indications like instrumental and big babies delivery. It is also useful for the prevention of maternal morbidity through perineal laceration. Randomized control trials will however be necessary to clarify the controversies relating to restrictive episiotomy.
Article
To describe episiotomy usage at vaginal delivery in the United States from 1979-1997. We used the National Hospital Discharge Survey, a federal database of a national sample of inpatient hospitals. Data from 1979 to 1997 were analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnoses and procedures. Rates per 1000 women were calculated using the 1990 census population for women aged 15-44 years. We calculated the number of episiotomies per 100 vaginal deliveries. Rates and percentages were compared using the score test for linear trend. The number of episiotomies ranged from a high of 2,015,000 in 1981 to a low of 1,128,000 in 1997. The age-adjusted annual rate for episiotomy with vaginal deliveries varied from 32.7 in 1979 to 18.7 in 1997 per 1000 women aged 15-44 years. The percentage of episiotomy with vaginal deliveries ranged from 65.3% in 1979 to 38.6% in 1997 (P <.001). Episiotomy with operative deliveries decreased over time (87.0% to 70.8%, P <.001), as did episiotomy with spontaneous deliveries (60.1% to 32.8%, P <.001). Women undergoing episiotomy were slightly younger (mean +/- standard deviation, 25.7 +/- 5.5 years) than women without episiotomy (26.2 +/- 5.7 years, P <.001). Black women (39%) were less likely to receive episiotomy than white women (60%, P <.001). More women with private insurance (62%) had episiotomy performed than women with government insurance (43%, P <.001). Although episiotomy use has decreased over time, the most recent rate of 39 per 100 vaginal deliveries remains higher than evidence-based recommendations for optimal patient care.
Article
To assess the rate of Episiotomy in vaginal birth in Tikur Anbessa teaching Hospital and the associated factors that influences the use of episiotomy in the unit. A cross-sectional study was conducted in the delivery unit of the Tikur Anbessa Hospital from May to September 2000. Data on mothers who delivered in the study period was collected using structured questionnaire. Variables on use of episiotomy, parity, fetal presentation, duration of labor, mode of delivery, Apgar scores at first and fifth minutes, indications for episiotomy and the practice of analgesia & anesthesia in the management of Episiotomy were collected Medical charts and the labor ward logbook were reviewed for collecting the data. A total of 917 deliveries were attended during the study period among which 672 mothers (83.1%) delivered vaginally. Among the vaginal deliveries, 270 (40.2%) mothers had episiotomy. Of these 203 (75.2%) mothers were primigravidae. Nulliparity (77.7% vs 21.3%), the duration of the second stage of labor more 90 minutes (76% vs. 13.8%) and instrumental delivery (86.2% vs. 13.8%) has been shown to be significantly associated to having episiotomy, while the birth weight and Apgar scores didn't show significant differences. Local anesthesia was used only in 71 (28.1%) cases among the 253 on whom information regarding the use of local anesthesia was retrieved. The rate of episiotomy is significantly higher than the recommended practice for many centers. Measures should be taken to lower the rate of episiotomy rate that include preparation of guidelines and protocols according to the standard and training and nurses, midwives and doctors on the selective use of episiotomy. The current practice of perineal repair without analgesia/anesthesia should be revised and making labor and delivery less painful needs to be advocated.