Episcissors-60™ and obstetrics anal sphincter injury: a systematic review and meta-analysis

  • Olga Divakova
  • Aethele Khunda
  • Paul A. Ballard
Original Article


Introduction and hypothesis

The National Health Service (NHS) in England has chosen the Episcissors-60™ as one of the products included in the NHS Innovation Accelerator programme. However, the evidence for its effectiveness is scanty. We therefore set out to systematically review the literature to compare risk of obstetric anal sphincter injury (OASI) in women who had undergone episiotomy with Episcissors-60™ versus those who had an episiotomy with other scissors.


Electronic search was performed on the Healthcare Databases Advanced Search (HDAS) platform using the MEDLINE, EMBASE and CINHAL search engines up to September 2018. The search words used were ‘Episcissors-60’ or ‘episcissors 60.’ Studies were included if patients who had episiotomies with Episcissors-60™ were compared with parallel or historic patients who had episiotomy with other scissors. The only restriction used was “human” studies.


Of the initial 21 citations, 4 studies had enough information to be included in the meta-analysis. The number of study participants ranged from 63 to 4314. When comparing 797 patients who had episiotomies with Episcissors-60™ to 1122 patients who had episiotomies with other scissors, there was a significant reduction in OASI: risk difference = −0.04 (95% CI = −0.07 to −0.01; p = 0.005, I2 = 41%). The number needed to treat was 25 (95% CI = 14–100). This was not associated with an increase in episiotomy rate.


We reported the first systematic review on the effect of Episcissors-60™ on OASI rate. Although the studies are few, and of small size and low quality, the results are promising in terms of possible reduction in OASI.


Episcissors-60 Episiotomy Obstetric anal sphincter injury 



The authors thank Mr. Ashish Pradhan and Dr. Ajay Bini for sharing their data with us.

Compliance with ethical standards

Conflicts of interest

Olga Divakova: None.

Aethele Khunda: Educational travel grant from Medronic plc.

Paul Ballard: None.


  1. 1.
    Meyer I, Richter HE. Impact of fecal incontinence and its treatment on quality of life in women. Women's Health (Lond Engl). 2015;11(2):225–38.CrossRefGoogle Scholar
  2. 2.
    Signorello L, Harlow B, Chekos A, Repke J. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol. 2001;184:881–90.CrossRefPubMedGoogle Scholar
  3. 3.
    Macarthur AJ, Macarthur C. Incidence, severity and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol. 2004;191(4):1199–204.CrossRefPubMedGoogle Scholar
  4. 4.
    Keighley MR, Perston Y, Bradshaw E, Hayes J, Keighley DM, Webb S. The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following obstetric anal sphincter injury: use of a word picture to identify a hidden syndrome. BMC Pregnancy Childbirth. 2016;16(1):275.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Budd J, Hartigan E, Link A, Purrmann G, Ridge T, Sutton L, Larkin M. No laughing matter stress incontinence and the environment. Women’s Environmental Network. 2004. Accessed 06 Sept 2018.
  6. 6.
    NMPA Project Team. National maternity and perinatal audit: clinical report 2017. RCOG London; 2018.Google Scholar
  7. 7.
    Clesse C, Lighezzolo-Alnot J, De Lavergne S, Hamlin S, Scheffler M. Statistical trends of episiotomy around the world: comparative systematic review of changing practices. Health Care Women Int. 2018;39(6):644–62.CrossRefPubMedGoogle Scholar
  8. 8.
    Friedman A, Ananth C, Prendergast E, D’Alton M, Wright J. Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstet Gynecol. 2015;125(4):927–37.CrossRefPubMedGoogle Scholar
  9. 9.
  10. 10.
    Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis. Int Urogynecol J. 2016;27(10):1459–67.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Royal College of Obstetricians and Gynaecologists. Third- and fourth-degree perineal tears, management (Green-top Guideline No. 29), London: RCOG; 2015.Google Scholar
  12. 12.
    Rahman N, Vinayakarao L, Pathak S, Minden D, Melson L, Vitue E, et al. Evaluation of training programme uptake in an attempt to reduce obstetric anal sphincter injuries: the SUPPORT programme. Int Urogynecol J. 2017a;28:403–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Freeman RM, Hollands HJ, Barron LF, Kappor DS. Cutting a mediolateral episiotomy at the correct angle: evaluation of a new device, the Episcissors-60™. Medical Devices: Evidence and Research. 2014;7:23–8.Google Scholar
  14. 14.
    van Roon Y, Kirwin C, Rahman N, Vinayakarao L, Melson L, Kester N, et al. Comparison of obstetric anal sphincter injuries in nulliparous women before and after introduction of the EPISCISSORS-60™® at two hospitals in the United Kingdom. Int J Women's Health. 2015;7:949–55.CrossRefGoogle Scholar
  15. 15.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65–94.CrossRefPubMedGoogle Scholar
  16. 16.
    Sawant G, Kumar D. Randomized trial comparing episiotomies with Braun-Stadler episiotomy scissors and Episcissors-60™®. Medical Devices: Evidence and Research. 2015;8:251–4.CrossRefGoogle Scholar
  17. 17.
    Lou YY, Thakar R, Sultan AH, Ajay B. Does Episcissors-60™ reduce the incidence of obstetric anal sphincter injuries (OASIS)? BJOG. 2016;123:51.Google Scholar
  18. 18.
    Mohiudin H, Ali S, Pisal PN, Villar R. Implementation of the RCOG guidelines for prevention of obstetric anal sphincter injuries (OASIS) at two London hospitals: a time series analysis. Eur J Obstet Gynecol Reprod Biol. 2018;224:89–92.CrossRefPubMedGoogle Scholar
  19. 19.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Rahman N, Pradhan A, Van Roon Y, Kirwin C, Vinayakarao L, Melson L, et al. Introduction of Episcissors-60TM in response to rising OASIS: combined results from two district general hospitals in England. Int Urogynecol J Pelvic Floor Dysfunct. 2016a;27(7):1109–10.Google Scholar
  21. 21.
    Rahman N, Pradhan A, van Roon Y, Kirwin C, Vinayakarao L, Melson L, Kester N, Pathak S. Combined results from two district general hospitals in England. Selected Abstracts from the Annual Research Meeting of the British Society of Urogynaecology 2015. Int Urogynecol J Pelvic Floor Dysfunct. 2016b;27(7.Google Scholar
  22. 22.
    van Roon Y, Kirwin C, Rahman N, Vinayakarao L, Melson L, Kester N, et al. Comparison of Obstetric anal sphincter injuries (OASIS) in nulliparous women before and after introduction of the EPISCISSORS-60TM® at two Hospitals in the United Kingdom. Kongress Deutsche Gesellschaft fur Pranatal- und Geburtsmedizin. Geburtshilfe und Frauenheilkunde. 2016;76(5).Google Scholar
  23. 23.
    Rahman N, Pradhan A, Vinayakarao L, Minden D, Melson L, Pathak S, et al. Evaluation of training programme uptake in an attempt to reduce obstetric anal sphincter injuries: the SUPPORT programme. Int Urogynecol J. 2017b;28(3):403–7.CrossRefPubMedGoogle Scholar
  24. 24.
    van Roon Y, Percival R, Pathak S, Pradhan A, Vinayakarao L, Melson L. Comparative study of episiotomy angles achieved by cutting with straight Mayo scissors and the EPISCISSORS-60™ in a birth simulation model. Int Urogynecol J. 2017;28(7):1063–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Patel RP, Ubale SM. Evaluation of the angled Episcissors-60TM episiotomy scissors in spontaneous vaginal deliveries. Medical Devices: Evidence and Research. 2014;7(1):253–6.CrossRefGoogle Scholar
  26. 26.
    Patel RP, Ubale SM. Prospective series of 53 episiotomies performed with the angled EPISCISSORS-60™©. BJOG. 2015;122:204.Google Scholar
  27. 27.
    Kumar D, Sawant G. Prospective comparative study comparing episiotomy suture angles with Braun-Stadtler episiotomy scissors and EPISCISSORS-60™. BJOG. 2015;122:214–5.Google Scholar
  28. 28.
    Reeves BC, Deeks J, Higgins JPT, Wells GA. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 Including non-randomized studies. In: Higgins JPT, Green S, editors, (updated March 2011) The Cochrane Collaboration. Chapter 13. 2011.Google Scholar
  29. 29.
    Landsberger Henry A. Hawthorne revisited: management and the worker: its critics, and development in human relations in industry. New York: Cornell University; 1958.Google Scholar
  30. 30.
    National Institute for Health and Care Excellence (NICE). Clinical guidance [CG190], Intrapartum care for healthy women and babies. Last updated: February 2017.Google Scholar

Copyright information

© The International Urogynecological Association 2019

Authors and Affiliations

  1. 1.James Cook University HospitalSouth Tees NHS TrustMiddlesbroughUK
  2. 2.LondonUK

Personalised recommendations