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Does birthweight have a role in the effect of episiotomy on anal sphincter injury?

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

Abstract

Purpose

Most professional guidelines advise against routine episiotomy during vaginal delivery, although mounting evidence supports its protective role regarding obstetric anal sphincter injury (OASI). We aimed to study the effect of lateral and mediolateral episiotomies on the rate of OASI in relation to birthweight among nulliparous women undergoing vaginal delivery.

Methods

A historical cohort study was conducted of all nulliparous women who delivered vaginally at term between 2011 and 2019 at a tertiary university hospital. Women were allocated into two groups: (1) with OASI and (2) without OASI. Episiotomy performance and birthweight groups were analyzed.

Results

Overall, 22,250 deliveries were analyzed for inclusion: 18,533 (83.3%) spontaneous vaginal deliveries (SVD), 3222 (14.5%) vacuum-assisted deliveries (VAD) and 495 (2.2%) forceps deliveries. Total episiotomy and OASI rate was 48.2% and 1.7%, respectively. Episiotomy rate was lower in the OASI group as compared to the no OASI group (158 (41.3%) vs. 10,568 (48.3%), OR 0.75, 0.61–0.92, p = 0.006). Median birthweight was higher for OASI group neonates (3355 vs. 3160, p < 0.001). In SVDs, episiotomy decreased the rate of OASI in neonatal birthweight groups of 3000–3499, 3500–3999 and > 4000 g (OR 0.56, 0.38–0.82, p = 0.003; 0.66, 0.45–0.99, p = 0.04 and 0.24, 0.07–0.78, p = 0.01, respectively). In VADs, episiotomy decreased the rate of OASI in the neonatal weight groups of 2500–2999 and 3000–3499 g (OR 0.36, 0.14–0.89, p = 0.02 and OR 0.38, 0.19–0.75, p = 0.004, respectively).

Conclusions

Lateral and mediolateral episiotomies are independent modifiable predictors of OASI, protective against OASI in SVDs when neonates weigh > 3000 g and 2500–3499 g in VADs.

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References

  1. Ginath S, Mizrachi Y, Bar J, Condrea A, Kovo M (2017) Obstetric anal sphincter injuries (OASIs) in Israel: a review of the incidence and risk factors. Rambam Maimonides Med J 8(2):e0018

    PubMed Central  Google Scholar 

  2. Lund NS, Persson LK, Jangö H, Gommesen D, Westergaard HB (2016) 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 207:193–199

    PubMed  Google Scholar 

  3. Bulletins-Obstetrics CoP (2018) ACOG practice bulletin no. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol 132(3):e87–e102

    Google Scholar 

  4. Pergialiotis V, Vlachos D, Protopapas A, Pappa K, Vlachos G (2014) Risk factors for severe perineal lacerations during childbirth. Int J Gynaecol Obstet 125(1):6–14

    PubMed  Google Scholar 

  5. Kudish B, Sokol RJ, Kruger M (2008) Trends in major modifiable risk factors for severe perineal trauma, 1996–2006. Int J Gynaecol Obstet 102(2):165–170

    PubMed  PubMed Central  Google Scholar 

  6. Baghestan E, Irgens LM, Børdahl PE, Rasmussen S (2010) Trends in risk factors for obstetric anal sphincter injuries in Norway. Obstet Gynecol 116(1):25–34

    PubMed  Google Scholar 

  7. Nordenstam J, Altman D, Brismar S, Zetterström J (2009) Natural progression of anal incontinence after childbirth. Int Urogynecol J Pelvic Floor Dysfunct 20(9):1029–1035

    PubMed  Google Scholar 

  8. Kalis V, Laine K, de Leeuw JW, Ismail KM, Tincello DG (2012) Classification of episiotomy: towards a standardisation of terminology. BJOG 119(5):522–526

    CAS  PubMed  Google Scholar 

  9. Zilberman A, Sheiner E, Barrett O, Hamou B, Silberstein T (2018) Once episiotomy, always episiotomy? Arch Gynecol Obstet 298(1):121–124

    PubMed  PubMed Central  Google Scholar 

  10. Bulletins-Obstetrics CoP (2015) ACOG practice bulletin no. 154: operative vaginal delivery. Obstet Gynecol 126(5):e56–e65

    Google Scholar 

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

    PubMed  Google Scholar 

  12. Deane RP (2019) Operative vaginal delivery and pelvic floor complications. Best Pract Res Clin Obstet Gynaecol 56:81–92

    PubMed  Google Scholar 

  13. WHO (2018) World Health Organization recommendations: intrapartum care for a positive childbirth experience, Geneva

  14. Sultan AH, Thakar R, Ismail KM, Kalis V, Laine K, Räisänen SH et al (2019) The role of mediolateral episiotomy during operative vaginal delivery. Eur J Obstet Gynecol Reprod Biol 240:192–196

    CAS  PubMed  Google Scholar 

  15. 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(4):307–310

    PubMed  Google Scholar 

  16. Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E (2012) Episiotomy: the final cut? Arch Gynecol Obstet 286(6):1369–1373

    PubMed  Google Scholar 

  17. Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T (2018) Obstetric anal sphincter injuries at vaginal delivery: a review of recently published national guidelines. Obstet Gynecol Surv 73(12):695–702

    PubMed  Google Scholar 

  18. Muraca GM, Liu S, Sabr Y, Lisonkova S, Skoll A, Brant R et al (2019) Episiotomy use among vaginal deliveries and the association with anal sphincter injury: a population-based retrospective cohort study. CMAJ 191(42):E1149–E1158

    PubMed  PubMed Central  Google Scholar 

  19. Gynecologists ACoOa (2013) ACOG committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol 121(1):210–212

    Google Scholar 

  20. Carpenter MW, Coustan DR (1982) Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 144(7):768–773

    CAS  PubMed  Google Scholar 

  21. Bulletins-Obstetrics ACoOaGCoP (2003) ACOG practice bulletin number 49, December 2003: dystocia and augmentation of labor. Obstet Gynecol 102(6):1445–1454

    Google Scholar 

  22. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN (2005) Outcomes of routine episiotomy: a systematic review. JAMA 293(17):2141–2148

    CAS  PubMed  Google Scholar 

  23. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E, Guaschino S (2004) The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 103(4):669–673

    PubMed  Google Scholar 

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

    PubMed  Google Scholar 

  25. Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B (2008) A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG 115(13):1695–1702 (discussion 702-3)

    CAS  PubMed  Google Scholar 

  26. Sagi-Dain L, Sagi S (2015) Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta-analysis. BJOG 122(8):1073–1081

    CAS  Google Scholar 

  27. van Bavel J, Hukkelhoven CWPM, de Vries C, Papatsonis DNM, de Vogel J, Roovers JWR et al (2018) The effectiveness of mediolateral episiotomy in preventing obstetric anal sphincter injuries during operative vaginal delivery: a ten-year analysis of a national registry. Int Urogynecol J 29(3):407–413

    PubMed  Google Scholar 

  28. Bodner-Adler B, Kimberger O, Käfer A, Husslein P, Bodner K (2018) Management of the perineum during delivery with the Kiwi Omnicup: effects of mediolateral episiotomy on anal sphincter tears in nulliparous women. Gynecol Obstet Invest 83(2):171–178

    PubMed  Google Scholar 

  29. Boujenah J, Tigaizin A, Fermaut M, Murtada R, Benbara A, Benchimol M et al (2019) Is episiotomy worthwile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women? Eur J Obstet Gynecol Reprod Biol 232:60–64

    CAS  PubMed  Google Scholar 

  30. Marschalek ML, Worda C, Kuessel L, Koelbl H, Oberaigner W, Leitner H et al (2018) Risk and protective factors for obstetric anal sphincter injuries: a retrospective nationwide study. Birth 45(4):409–415

    PubMed  PubMed Central  Google Scholar 

  31. Levin G, Elami-Suzin M, Elchalal U, Ezra Y, Mankuta D, Lewkowicz A et al (2019) Subsequent pregnancy outcomes after failed vacuum-assisted delivery. Obstet Gynecol 134(6):1245–1251

    PubMed  Google Scholar 

  32. Muraca GM, Lisonkova S, Skoll A, Brant R, Cundiff GW, Sabr Y et al (2018) Ecological association between operative vaginal delivery and obstetric and birth trauma. CMAJ 190(24):E734–E741

    PubMed  PubMed Central  Google Scholar 

  33. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM (1999) Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 341(23):1709–1714

    CAS  PubMed  Google Scholar 

  34. Levin G, Dior U, Shushan A, Gilad R, Benshushan A, Rottenstreich A (2019) Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1–4 change in HCG. Reprod Biomed Online 39(1):149–154

    CAS  PubMed  Google Scholar 

  35. Laufe LE (1992) Assisted vaginal delivery: obstetric forceps and vacuum extraction techniques. McGraw-Hill, New York

    Google Scholar 

  36. Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD (2015) Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstet Gynecol 125(4):927–937

    PubMed  Google Scholar 

  37. Richter HE, Brumfield CG, Cliver SP, Burgio KL, Neely CL, Varner RE (2002) Risk factors associated with anal sphincter tear: a comparison of primiparous patients, vaginal births after cesarean deliveries, and patients with previous vaginal delivery. Am J Obstet Gynecol 187(5):1194–1198

    PubMed  Google Scholar 

  38. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ (2010) Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 150(2):142–146

    PubMed  Google Scholar 

  39. Gerdin E, Sverrisdottir G, Badi A, Carlsson B, Graf W (2007) The role of maternal age and episiotomy in the risk of anal sphincter tears during childbirth. Aust N Z J Obstet Gynaecol 47(4):286–290

    PubMed  Google Scholar 

  40. Loewenberg-Weisband Y, Grisaru-Granovsky S, Ioscovich A, Samueloff A, Calderon-Margalit R (2014) Epidural analgesia and severe perineal tears: a literature review and large cohort study. J Matern Fetal Neonatal Med 27(18):1864–1869

    CAS  Google Scholar 

  41. Edqvist M, Hildingsson I, Mollberg M, Lundgren I, Lindgren H (2017) Midwives’ management during the second stage of labor in relation to second-degree tears—an experimental study. Birth 44(1):86–94

    PubMed  Google Scholar 

  42. Ramm O, Woo VG, Hung YY, Chen HC, Ritterman Weintraub ML (2018) Risk factors for the development of obstetric anal sphincter injuries in modern obstetric practice. Obstet Gynecol 131(2):290–296

    Google Scholar 

  43. Stephansson O, Sandström A, Petersson G, Wikström AK, Cnattingius S (2016) Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period. BJOG 123(4):608–616

    CAS  PubMed  Google Scholar 

  44. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A (2014) Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 210(1):59.e1–6

    Google Scholar 

  45. Gurol-Urganci I, Cromwell DA, Edozien LC, Mahmood TA, Adams EJ, Richmond DH et al (2013) Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 120(12):1516–1525

    CAS  PubMed  Google Scholar 

  46. Bergendahl S, Ankarcrona V, Leijonhufvud Å, Hesselman S, Karlström S, Kopp Kallner H et al (2019) Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial. BMJ Open 9(3):e025050

    PubMed  PubMed Central  Google Scholar 

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Funding

This research received no external funding.

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Author notes

  1. Gabriel Levin and Amihai Rottenstreich have contributed equally.

Authors and Affiliations

  1. The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

    Gabriel Levin & Amihai Rottenstreich

  2. The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel

    Tal Cahan, Hadas Ilan, Daniel Shai, Abraham Tsur & Raanan Meyer

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  1. Gabriel Levin
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Contributions

GL—project development, analysis and interpretation of data, manuscript writing, approval of the version to be published. AR—project development, manuscript writing, approval of the version to be published. TC—data collection or management, revision of the manuscript, approval of the version to be published. HI—data collection or management, revision of the manuscript, approval of the version to be published. DS—data collection or management, revision of the manuscript, approval of the version to be published. AT—project development, revision of the manuscript, approval of the version to be published. RM—project development, analysis and interpretation of data, manuscript writing, approval of the version to be published.

Corresponding author

Correspondence to Raanan Meyer.

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This article does not contain any studies with human participants or animals performed by any of the authors. The study protocol was approved by the institutional review board of the Sheba Medical Center, 6345-19-SMC, 26/11/2019.

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Levin, G., Rottenstreich, A., Cahan, T. et al. Does birthweight have a role in the effect of episiotomy on anal sphincter injury?. Arch Gynecol Obstet 301, 171–177 (2020). https://doi.org/10.1007/s00404-020-05444-2

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  • DOI: https://doi.org/10.1007/s00404-020-05444-2

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