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Once episiotomy, always episiotomy?

A Correction to this article was published on 06 May 2019

This article has been updated



To investigate the association between episiotomy and perineal damage in the subsequent delivery.

Study design

A retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991–2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders.


During the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n = 21,711) had subsequent delivery after episiotomy and 49.6% (n = 21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P < 0.001; OR 1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P < 0.001, and 0.2 vs. 0.1%; P = 0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery—the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR 6.7; 95% CI 6.2–7.3, P < 0.001). The results remained significant for term (adjusted OR 6.8; 95% CI 6.2–7.4, P < 0.001) as well as preterm deliveries (adjusted OR 4.5; 95% CI 3.3–6.3, P < 0.001) in two different models.


Episiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

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Change history

  • 06 May 2019

    The original article can be found online.


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Author information




AZ: data collection and manuscript writing. ES: manuscript editing. OB: data analysis. BEH: manuscript editing. TS: project development and manuscript editing.

Corresponding author

Correspondence to Tali Silberstein.

Ethics declarations

Conflict of interest

Author A Zilberman declares that she has no conflict of interest. Author E Sheiner declares that he has no conflict of interest. Author O Barret declares that she has no conflict of interest. Author BE Hamou declares that she has no conflict of interest. Author T Silberstein declares that she has no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Additional information

The original version of this article was revised due to a retrospective Open Access Cancellation.

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Zilberman, A., Sheiner, E., Barrett, O. et al. Once episiotomy, always episiotomy?. Arch Gynecol Obstet 298, 121–124 (2018).

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  • Episiotomy
  • Perineal tears
  • Perineal damage