Skip to main content
Log in

Episiotomy: the final cut?

  • Maternal-Fetal Medicine
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Objective

To investigate whether episiotomy prevents 3rd or 4th degree perineal tears in critical conditions such as shoulder dystocia, instrumental deliveries (vacuum or forceps), persistent occiput-posterior position, fetal macrosomia (>4,000 g), and non-reassuring fetal heart rate (NRFHR) patterns.

Methods

A retrospective study comparing 3rd and 4th degree perineal tears during vaginal deliveries with or without episiotomy, in selected critical conditions was performed. Multiple gestations, preterm deliveries (<37 weeks’ gestation) and cesarean deliveries were excluded from the analysis. Stratified analysis (using the Mantel–Haenszel technique) was used to obtain the weighted odds ratio (OR), while controlling for these variables.

Results

During the study period, there were 168,077 singleton vaginal deliveries. Of those, 188 (0.1 %) had 3rd or 4th degree perineal tears. Vaginal deliveries with episiotomy had statistically significant higher rates of 3rd or 4th degree perineal tears than those without episiotomy (0.2 vs. 0.1 %; P < 0.001). The association between episiotomy and severe perineal tears remained significant even in the critical conditions. Stratified analysis revealed that the adjusted ORs for 3rd or 4th degree perineal tears in these critical conditions (Macrosomia OR = 2.3; instrumental deliveries OR = 1.8; NRFHR patterns OR = 2.1; occipito-posterior position OR = 2.3; and shoulder dystocia OR = 2.3) were similar to the crude OR (OR = 2.3).

Conclusions

Mediolateral episiotomy is an independent risk factor for 3rd or 4th degree perineal tears, even in critical conditions such as shoulder dystocia, instrumental deliveries, occiput-posterior position, fetal macrosomia, and NRFHR. Prophylactic use of episiotomy in these conditions does not seem beneficial if performed to prevent 3rd or 4th degree perineal tears.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Weber AM, Meyn L (2002) Episiotomy use in the United States, 1979–1997. Obstet Gynecol 100:1177–1182

    Article  PubMed  Google Scholar 

  2. Frankman EA, Wang L, Bunker CH, Lowder JL (2009) Episiotomy in the United States: has anything changed? Am J Obstet Gynecol 200:573–573

    Article  PubMed  Google Scholar 

  3. Eason E, Labrecque M, Wells G, Feldman P (2000) Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 95:464–471

    Article  PubMed  CAS  Google Scholar 

  4. Bottoms S (1995) Delivery of the premature infant. Clin Obstet Gynecol 38:780–789

    Article  PubMed  CAS  Google Scholar 

  5. Carroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database Syst Rev (1). doi:10.1002/14651858.CD000081.pub2

  6. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN (2005) Outcomes of routine episiotomy: a systematic review. JAMA 293:2141–2148

    Article  PubMed  CAS  Google Scholar 

  7. Borghi J, Fox-Rushby J, Bergel E, Abalos E, Hutton G, Carroli G (2002) The cost-effectiveness of routine versus restrictive episiotomy in Argentina. Am J Obstet Gynecol 186:221–228

    Article  PubMed  Google Scholar 

  8. ACOG (2006) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71. Obstet Gynecol 107:957

    Google Scholar 

  9. Myers-Helfgott MG, Helfgott AW (1999) Routine use of episiotomy in modern obstetrics. Should it be performed? Obstet Gynecol Clin N Am 26:305–325

    Article  CAS  Google Scholar 

  10. Ramin SM, Gilstrap LC 3rd (1994) Episiotomy and early repair of dehiscence. Clin Obstet Gynecol 37:816–823

    Article  PubMed  CAS  Google Scholar 

  11. Nager CW, Helliwell JP (2001) Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 185:444–450

    Article  PubMed  CAS  Google Scholar 

  12. Jones KD (2000) Incidence and risk factors for third degree perineal tears. Int J Gynaecol Obstet 71:227–229

    Article  PubMed  CAS  Google Scholar 

  13. Hudelist G, Gelle’n J, Singer C, Ruecklinger E, Czerwenka K, Kandolf O et al (2005) Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy. Am J Obstet Gynecol 192:875–881

    Article  PubMed  Google Scholar 

  14. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap L III, Wenstrom KD (2005) At Williams obstetrics, 23rd edn. McGraw-Hill 401–405

  15. Ecker JL, Tan WM, Bansal RK, Bishop JT, Kilpatrick SJ (1997) Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population. Am J Obstet Gynecol 176(2):411–414

    Article  PubMed  CAS  Google Scholar 

  16. Sheiner E, Levy A, Walfisch A, Hallak M, Mazor M (2005) Third degree perineal tears in a university medical center where midline episiotomies are not performed. Arch Gynecol Obstet 271:307–310

    Article  PubMed  Google Scholar 

  17. Wooley RJ (1995) Benefits and risks of episiotomy: a review of the English literature since 1980. Obstet Gynecol Surv 50:806–820

    Article  Google Scholar 

  18. Combs CA, Robertson PA, Laros RK Jr (1990) Risk factor for third degree and fourth degree perineal tears in forceps and vacuum deliveries. Am J Obstet Gynecol 163:100–104

    PubMed  CAS  Google Scholar 

  19. Eskandar O, Shet D (2009) Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 29:119–122

    Article  PubMed  CAS  Google Scholar 

  20. Fitzgerald MP, Weber AM, Howden N, Cundiff GW (2007) Pelvic floor disorders network. Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol 109:29–34

    Article  PubMed  Google Scholar 

  21. Sheiner E, Levy A, Hershkovitz R, Hallak M, Hammel RD, Katz M et al (2006) Determining factors associated with shoulder dystocia: a population-based study. Eur J Obstet Gynecol Reprod Biol 126:11–15

    Article  PubMed  Google Scholar 

  22. Macleod M, Strachan B, Bahl R, Howarth L, Goyder K, Van de Venne M et al (2008) A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery. BJOG 115:1688–1694

    Article  PubMed  CAS  Google Scholar 

  23. Hastings-Tolsma M, Vincent D, Emeis C, Francisco T (2007) Getting through birth in one piece: protecting the perineum. MCN Am J Matern Child Nurs 32:158–164

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

None of the authors have any conflict of interest regarding this manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Naama Steiner.

Additional information

Presented in part at the 30th Annual Meeting of the Society of Maternal-Fetal Medicine, Chicago, IL, USA, February 1–6, 2010.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Steiner, N., Weintraub, A.Y., Wiznitzer, A. et al. Episiotomy: the final cut?. Arch Gynecol Obstet 286, 1369–1373 (2012). https://doi.org/10.1007/s00404-012-2460-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-012-2460-x

Keywords

Navigation