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Selective episiotomy versus no episiotomy for severe perineal trauma: a systematic review with meta-analysis

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Abstract

Introduction and hypothesis

We hypothesized whether a non-episiotomy protocol or administration of selective episiotomy as an intrapartum intervention would modify the incidence of obstetric anal sphincter injuries (OASIS).

Methods

We registered this systematic review with the PROSPERO database (CRD42018111018). Prospective randomized controlled trials (RCTs) were included from databases until February 2019. The primary outcome was OASIS, and the secondary outcomes were any perineal trauma, duration of the second stage of labor, instrumental delivery, and post-partum hemorrhage. The risk of bias (Cochrane Handbook) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the RCTs.

Results

A total of 1,833 results (PubMed 650, SCOPUS 1,144, Cochrane Library 33, LILACS 6) were obtained. However, only 2 studies fulfilled the criteria for quantitative analysis and meta-analysis (n = 574). The non-episiotomy arm included two episiotomies (1.7% of deliveries), whereas the selective episiotomy included 33 episiotomies (21.4%). Performance of selective episiotomy demonstrated no difference compared with that of the non-episiotomy group with regard to OASIS (OR = 0.46 [0.15–1.39]; n = 543; I2 = 0%,p = 0.17), any perineal trauma (OR = 0.90 [0.61–1.33]; I2 = 0%, n = 546, p = 0.59), instrumental delivery (OR = 1.40 [0.80–2.45]; I2 = 0%, n = 545, p = 0.24), duration of the second stage of labor (MD = -3.71 [−21.56, 14.14]; I2 = 72%,n = 546, p = 0.68), perineal pain (MD = 0.59 [0.01–1.17]; I2 = 0%,p = 0.05), and post-partum hemorrhage (OR = 1.75 [0.87–3.54]; I2 = 0%,n = 546,p = 0.12). The evaluated studies displayed a low risk of bias in at least four of the seven categories analyzed. GRADE demonstrated a low certainty for severe perineal tears, postpartum hemorrhage, duration of the second stage of labor, and a moderate certainty for any perineal tear.

Conclusions

There was no significant difference between non-episiotomy and selective episiotomy regarding OASIS. No RCT was able to confirm a benefit of the non-performance of episiotomies in the non-episiotomy arm.

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References

  1. Sioutis D, Thakar R, Sultan AH. Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal. Ultrasound Obstet Gynecol. 2017;50(5):642–7.

    CAS  Google Scholar 

  2. Dietz HP, Pardey J, Murray H. Pelvic floor and anal sphincter trauma should be key performance indicators of maternity services. Int Urogynecol J. 2015;26(1):29–32.

    CAS  Google Scholar 

  3. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141–8.

    CAS  Google Scholar 

  4. 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.

    Google Scholar 

  5. Lund NS, Persson LK, Jango H, Gommesen D, Westergaard HB. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;207:193–9.

    Google Scholar 

  6. Gonzalez-Diaz E, Fernandez Fernandez C, Gonzalo Orden JM, Fernandez CA. Which characteristics of the episiotomy and perineum are associated with a lower risk of obstetric anal sphincter injury in instrumental deliveries. Eur J Obstet Gynecol Reprod Biol. 2019;233:127–33.

    Google Scholar 

  7. Lins VML, Katz L, Vasconcelos FBL, Coutinho I, Amorim MM. Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife, Brazil: a cohort study. J Matern Fetal Neonatal Med. 2019;32(18):3062–7.

    Google Scholar 

  8. Shmueli A, Gabbay Benziv R, Hiersch L, et al. Episiotomy—risk factors and outcomes. J Matern Fetal Neonatal Med. 2017;30(3):251–6.

    Google Scholar 

  9. McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG. 2015;122(5):672–9.

    CAS  Google Scholar 

  10. Panic N, Leoncini E, De Belvis G, Ricciardi W, Boccia S. Evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality of published systematic review and meta-analyses. PLoS One. 2013;8(12):e83138.

    Google Scholar 

  11. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.

    Google Scholar 

  12. Booth A, Moher D, Ghersi D, et al. The nuts and bolts of PROSPERO: an international prospective register of systematic reviews. Syst Rev. 2012;1(1):2.

    Google Scholar 

  13. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions, vol 4. Wiley, New York; 2011.

    Google Scholar 

  14. Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.

    Google Scholar 

  15. Sagi-Dain L, Bahous R, Caspin O, Kreinin-Bleicher I, Gonen R, Sagi S. No episiotomy versus selective lateral/mediolateral episiotomy (EPITRIAL): an interim analysis. Int Urogynecol J. 2018;29(3):415–23.

    Google Scholar 

  16. Amorim MM, Coutinho IC, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprod Health. 2017;14(1):55.

    Google Scholar 

  17. Gachon B, Fradet Menard C, Pierre F, Fritel X. Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury? Arch Gynecol Obstet. 2019;300(1):87–94.

    Google Scholar 

  18. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth. 2013;13:59.

    Google Scholar 

  19. LaCross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health. 2015;60(1):37–47.

    Google Scholar 

  20. Oliveira LS, Brito LG, Quintana SM, Duarte G, Marcolin AC. Perineal trauma after vaginal delivery in healthy pregnant women. Sao Paulo Med J. 2014;132(4):231–8.

    Google Scholar 

  21. Peppe MV, Stefanello J, Infante BF, Kobayashi MT, Baraldi CO, Brito LGO. Perineal trauma in a low-risk maternity with high prevalence of upright position during the second stage of labor. Rev Bras Ginecol Obstet. 2018;40(7):379–83.

    Google Scholar 

  22. Monteiro MVD, Pereira GMV, Aguiar RAP, Azevedo RL, Correia MD, Reis ZSN. Risk factors for severe obstetric perineal lacerations. Int Urogynecol J. 2016;27(1):61–7.

    Google Scholar 

  23. Evers EC, Blomquist JL, McDermott KC, Handa VL. Obstetrical anal sphincter laceration and anal incontinence 5–10 years after childbirth. Am J Obstet Gynecol. 2012;207(5):425.e1–6.

    Google Scholar 

  24. Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin no. 154: operative vaginal delivery. Obstet Gynecol. 2015;126(5):e56–65.

    Google Scholar 

  25. RCOG. Operative vaginal delivery. Green-top guideline 26. London: RCOG; 2011.

  26. Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep. 2015;64(1):1–65.

    Google Scholar 

  27. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol. 2009;200(5):573.e1–7.

    Google Scholar 

  28. Simic M, Cnattingius S, Petersson G, Sandstrom A, Stephansson O. Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study. BMC Pregnancy Childbirth. 2017;17(1):72.

    Google Scholar 

  29. Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG. 2013;120(12):1516–25.

    CAS  Google Scholar 

  30. Rouse DJ, Weiner SJ, Bloom SL, et al. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol. 2009;201(4):357.e1–7.

    Google Scholar 

  31. Gimovsky AC, Berghella V. Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines. Am J Obstet Gynecol. 2016;214(3):361.e1–6.

    Google Scholar 

  32. Sveinsdottir E, Gottfredsdottir H, Vernhardsdottir AS, Tryggvadottir GB, Geirsson RT. Effects of an intervention program for reducing severe perineal trauma during the second stage of labor. Birth. 2019;46(2):371–8.

    Google Scholar 

  33. ACOG. Practice bulletin: clinical management guidelines for obstetrician–Gynecologists number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039–47.

    Google Scholar 

  34. Tuncalp O, Souza JP, Gulmezoglu M. New WHO recommendations on prevention and treatment of postpartum hemorrhage. Int J Gynaecol Obstet. 2013;123(3):254–6.

    Google Scholar 

  35. World Health Organization. WHO recommendations for the prevention and treatment or postpartum haemorrhage: evidence base. Geneva: World Health Organization. 2012.

    Google Scholar 

  36. Dahlke JD, Mendez-Figueroa H, Maggio L, et al. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines. Am J Obstet Gynecol. 2015;213(1):76.e1–10.

    Google Scholar 

  37. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081.

    Google Scholar 

  38. De Jonge A, van Diem MT, Scheepers PL, van der Pal-de Bruin KM, Lagro-Janssen AL. Increased blood loss in upright birthing positions originates from perineal damage. BJOG. 2007;114(3):349–55.

    Google Scholar 

  39. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;5:CD002006.

    Google Scholar 

  40. Walker KF, Kibuka M, Thornton JG, Jones NW. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2018;11:CD008070.

    Google Scholar 

Download references

Funding

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) code 001.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitária, Campinas, 13148-254, Brazil

    Gláucia Miranda Varella Pereira, Cassia Raquel Teatin Juliato & Luiz Gustavo Oliveira Brito

  2. Centro de Referência em Saúde da Mulher (Mater-RP), Ribeirão Preto, Brazil

    Renato Sugahara Hosoume

  3. Department of Obstetrics and Gynecology, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil

    Marilene Vale de Castro Monteiro

Authors
  1. Gláucia Miranda Varella Pereira
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  2. Renato Sugahara Hosoume
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  3. Marilene Vale de Castro Monteiro
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  4. Cassia Raquel Teatin Juliato
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  5. Luiz Gustavo Oliveira Brito
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Contributions

G.M. Pereira: project development, data extraction/analysis, manuscript writing/editing; L.G. Brito: project development, data analysis, manuscript writing/editing; R.S. Hosoume: data extraction, manuscript writing/editing; M.V. Monteiro, C.R. Juliato: data analysis and manuscript editing.

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Correspondence to Luiz Gustavo Oliveira Brito.

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Pereira, G.M.V., Hosoume, R.S., de Castro Monteiro, M.V. et al. Selective episiotomy versus no episiotomy for severe perineal trauma: a systematic review with meta-analysis. Int Urogynecol J 31, 2291–2299 (2020). https://doi.org/10.1007/s00192-020-04308-2

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  • DOI: https://doi.org/10.1007/s00192-020-04308-2

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