Episiotomy and its complications: A cross sectional study in Episiotomy and its complications: A cross sectional study in secondary care hospital secondary care hospital

Episiotomy is a commonly performed procedure at the time of vaginal delivery to prevent perineal lacerations. A study was conducted to evaluate the complications of episiotomy. A sample size of 235 patients was taken. The complications were divided in two groups depending on the time of occurrence after delivery. Out of 235 patients, immediate complications were reported in 10(4.3%) patients. These included perineal tears, postpartum haemorrhage, extended episiotomy, perineal pain, inability to pass urine or stool and vaginal haematoma. Early complications including wound infection, gaping wound and resuturing of wound were reported in 21(8.9%) patients. On multivariate analysis, it was seen that age (19-29 years) was significantly associated with complications. Mediolateral episiotomy is a safe obstetrical surgical procedure in order to prevent third and fourth degree perineal tears and is not associated with increased incidence of complications.


Introduction
Episiotomy is one of the most commonly performed obstetrical procedure 1 to prevent deep perineal lacerations and anal sphincter trauma. 2 In spite of the fact, scientific evidence does not support its routine practice. Variables that increase the need of episiotomy are primiparity, induction of labour, term pregnancy, instrumental delivery, maternal age < 35 years, neonatal weight, epidural analgesia, and lithotomy position. 3 Complication of episiotomy include bleeding, perineal pain, suture dehiscence, perineal bruising, perineal oedema, vaginal haematoma, anal sphincter damage and dyspareunia which affects the quality of life of the parturient. 4 The delay in perineal wound healing also leads to bad anatomical outcomes which subsequently may lead to dysparunea. 5 We conducted this study to observe the immediate and early complications of episiotomy in our secondary care hospital.

Patients and Results
It was a cross sectional study conducted at Aga Khan Hospital for women, Karimabad from March 2017 till Aug 2017 after taking approval from Ethical Review Committee of Aga Khan University. A sample size of 235 patients was calculated by WHO sample size calculator version 2.0 6 by keeping 18.8% incidence of lacerations in patients delivered vaginally with episiotomy, 95% CI and 5% margin of error. Sampling technique was non probability convenience sampling. Patients delivered vaginally with episiotomy were included in the study. Data was collected on pre structured performa. The complications were divided in two groups depending on the time of occurrence after delivery-immediate and early. Immediate complications occurred within 24 hours of delivery while early complications occurred between 24 hours to two weeks postnatally. Data collected was analyzed in SPSS version 19.   Episiotomy has been reportedly associated with third and fourth degree perineal tears, more common with midline episiotomy. But in our study no third or fourth degree tear was seen may be because all the episiotomies were mediolateral.
Pain after episiotomy is a common complaint and is usually controlled with oral analgesics. Our patients received Diclofenac Sodium for one week postpartum. Those patients who still had pain in their first followup visit received pain killer for one more week.
Urinary retention is a known complication after normal and particularly after instrumental deliveries. If not managed timely may result in urinary tract infections, prolonged voiding difficulties, rarely renal failure and life threatening emergencies. 7,8 In our study urinary retention was seen in one patient who had instrumental delivery. Urinary tract infection was seen in 3 patients that were managed with oral antibiotics.
Incidence of episiotomy wound infection varies in different countries and institutes and has significant physical, psychological and social implication. An audit conducted in Lancashire Teaching Hospital England reported the incidence of 8% after normal deliveries and 48% after instrumental deliveries. 9 Another study by Johnson A reported it to be 11%. 10 Wound infection in our study was seen in 0.04% of cases. This could be due to effective infection control practices and use of empirical antibiotics.

Conclusion
Mediolateral episiotomy is not associated with increased incidence of complications and can be a safe obstetrical surgical procedure in order to prevent third and fourth degree perineal tears.