Abstract
Background:
This observational study aimed to describe the rates and indicators for practice of episiotomy during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above).
Methods:
The study was conducted at Mother and Child Hospital, Buraidah from October- December 2013 as a descriptive cross sectional study.
Results:
Overall rate of Episiotomy was 51.20%. Amongst the Primigravidas all went through episiotomies however in G2 and above only 7 patients (4.69%) delivered with episiotomy. Proportions tests revealed that there were significant differences between gravidity groups on two indications of episiotomy (vaginal breech p <0.001 and previous history of perineal tear p < 0.001). G2 and above had episiotomy for breech delivery (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.0%). And G2 and above participants experienced episiotomy for previous perineal tear (2 of 7 = 28.5% as compared to none in PG No other significant differences were found on indications of episiotomy.
Conclusion:
Episiotomy is a very common obstetric intervention (51.20%). The PG experience episiotomy significantly more often than G2 and above women. Efforts should be made to reduce its rates. This can be done by reviewing the indications and rates at repeated intervals and setting guidelines for these indications.
Keywords: Episiotomy, Primigravida, labour, Saudi Arabia
1. INTRODUCTION
Episiotomy is a commonly used obstetric intervention (1). It’s defined as a surgical incision in the perineum to enlarge the introitus during the second stage of labour (2). It can be median or mediolateral and was introduced as a prophylactic measure to prevent perineal tears (2).
The procedure was routinely performed on all Primigravidas with the background that a clean surgical incision is better to heal as compared to irregular perineal tears and that routine episiotomy will reduce the incidence of perineal tears (3).
However literature review indicates that episiotomy is not free from complications of increased blood loss, infection rate and even increased incidence of third and fourth degree perineal tears (4, 5, 6).
After several years of practicing routine episiotomy to all Primigravidas, Countries like United Kingdom have recommended that routine episiotomy should not be performed in all Primigravidas (7). In accordance with Argentine episiotomy trial episiotomy rates for Primigravida should not exceed 40% and for multigravidas above 30% (8). Literature is sparse about the rates of episiotomies from Saudi Arabia. This study tries to describe the rates and indicators for practice of episiotomy during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above).
2. PATIENTS AND METHODS
It was a descriptive cross sectional study conducted over a period of 3 months from September - November 2013. A self-structured pro form was used to collect data.
The study was conducted at Mother Child Hospital, Buraidah which is a major tertiary care facility in the region with annual delivery rate of 10,000. Seventy percent of them deliver normally however 30% undergo cesarean section.
All women undergoing normal vaginal delivery between 37-40 weeks of gestation were included in the study and episiotomy was considered as an obstetrical intervention. Sample size of 291 women had a 95% confidence level and a confidence interval of 5. The study aimed to find out the rates of episiotomy in the study population, along with their indications. The intervention rates were compared between Primigravidas and Gravida two or above. Data was kept anonymous for privacy.
3. STATISTICAL ANALYSIS
The Statistical Package for the Social Sciences (SPSS) 22 was used to conduct proportion z-tests to determine if any significant differences existed between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above) as regards indications of episiotomy. That is, for each intervention, several indicators were examined to determine if the frequency of occurrence was different between gravidity groups. P values less than 0.05 was considered as significant.
4. RESULTS
Most of the participants 132 (45.36%) were above 35 years of age, Seventy six (26.02%) had no formal education and 142 (48.7% were Primigravidas (Table 1).
Table 1.
Demographic and obstetric characteristics of the study population
Indications of Episiotomy
Proportion z-tests were used to determine if differences existed between gravidity groups (PG and G2 and above) in terms of indications of episiotomy. The indications of episiotomy included forceps delivery, concerns with FHR, ventouse delivery, vaginal breech, face to pubes, previous history (H/O) of perineal tear, maternal exhaustion, rigid perineum, good size baby, and no specific reason. Since this analysis examines indications of episiotomy, participants that reported not receiving an episiotomy were removed from the study. Thus, there were a total of 142 PG participants and 7 G2 and above participants that reported receiving an episiotomy.
As displayed in Table 2, the most frequent indication of episiotomy was rigid perineum for PG participants (n = 24) and the most frequent indication for G2 and above participants was previous H/O perineal tear (n = 2). The lowest frequencies of indication of episiotomy for PG were vaginal breech (n = 0), previous H/O perineal tear (n = 0) and pubes to face (n = 7). See Table 2 for details of the cross tabulation of gravidity groups and indications of episiotomy.
Table 2.
Cross Tabulation of Gravidity Groups and Indications of Episiotomy
Results from the proportions tests revealed that there were significant differences between gravidity groups on two indications of episiotomy (vaginal breech p < .001 and previous H/O perineal tear p < .001). That is, G2 and above participants experienced vaginal breech (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.00%). And, G2 and above participants experienced a previous H/O perineal tear (2 of 7 = 28.57%) more often than PG participants. No other significant differences were found on indications of episiotomy. A summary of the proportions z-tests is displayed in Table 3.
Table 3.
Summary of Proportion z-Tests on Indications of ARM by Gravidity Groups
5. DISCUSSION
Overall rate of Episiotomy was 51.20%. Amongst the Primigravidas all went through episiotomies however amongst G2 and above only 7 patients (4.69%) delivered with episiotomy. The reported rates for episiotomies are variable from different parts of the world. Argentine collaborative trial has reported 83% rates, Kaufman from USA reported 50% and Rockner from Sweden reported 30% rates of episiotomy (8, 9, 10). France has managed to reduce the episiotomy rates from 55.7% to 13.3% from 2004 to 2009 without significantly increasing the perineal trauma (11). England by setting the policy of avoiding routine episiotomies has managed to reduce the rates to 20% (12). Episiotomy is not totally free from complications like perineal pain, wound dehiscence and increased bleeding (13). Routine episiotomy to all women to avoid third and fourth degree perineal tears has been a practice in many developing countries (13). World Health Organization (WHO) has clear guidelines stating that liberal use of episiotomy has failed to reduce the rates of perineal tears (14).
The indications in PG and G2 and above were similar except for two indications of episiotomy (Vaginal breech p <0.001 and previous H/O perineal tear p < 0.001). That is, G2 experienced episiotomy for breech delivery (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.0%). And G2 and above participants experienced episiotomy for previous perineal tear (2 of 7 = 28.5%) more often than PG participants. This indication cannot be compared between two groups as Primigravidas do not have previous obstetric history thus perineal tears does not exist in this group. Babies with occipito-posterior position deliver as face to pubes and increase the risk of perineal injury and instrumental delivery because second stage of labour is prolonged. So it’s justified to recommend episiotomy in this case (15). However there was no significant difference between two studied groups as regard this indication. Maternal exhaustion is said to occur when the mother fails to push after more than 2 hours of efforts. It has been observed that mothers are asked to push down for a long period of time from early second stage and this leads to maternal exhaustion (16). This practice also needs re-evaluation and training of concerned staff. Mothers should not be forced for this action until late in second stage when she has a desire of bearing down, this can also reduce the rates for episiotomy for this indication. Significant efforts are thus required to reduce the rates of episiotomy especially in Primigravidas.
Acknowledgement
Author is grateful to the MCH staff and administration for their support.
Footnotes
CONFLICT OF INTEREST: NONE DECLARED.
REFERENCES
- 1.Webb DA, Culhane J. Hospital variation in episiotomy use and the risk of perineal trauma during childbirth. Birth. 2002 Jun;29(2):132–136. doi: 10.1046/j.1523-536x.2002.00173.x. [DOI] [PubMed] [Google Scholar]
- 2.Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv. 1983 Jun;38(6):322–338. [PubMed] [Google Scholar]
- 3.Lewis TLT, Chamberlain GVP. 15th edn. London: Edward Arnold; 1990. P. Obstetrics by ten teachers. [Google Scholar]
- 4.Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynaecol Surv. 1983;38:322–338. [PubMed] [Google Scholar]
- 5.Larsson PG, Platz-Christensen JJ, Bergman B, Wallstersson G. Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynaecol Obstet Invest. 1991;31:213–216. doi: 10.1159/000293161. [DOI] [PubMed] [Google Scholar]
- 6.Larsson PG, Platz-Christensen JJ, Bergman B, Wallstersson G. Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynaecol Obstet Invest. 1991;31:213–216. doi: 10.1159/000293161. [DOI] [PubMed] [Google Scholar]
- 7.Pernoll ML, Benson RC. 6th edn. Norwalk, CT: Appleton & Lange; 1987. Current obstetric and gynecologic diagnosis and treatment. [Google Scholar]
- 8.Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: a randomised controlled trial. Lancet. 1993;ii:1517–1518. [PubMed] [Google Scholar]
- 9.Kaufman SC. Episiotomy. To cut or not to cut? Online J Curr Clin Trials Doc. 1992:16. [PubMed] [Google Scholar]
- 10.Rockner G, Olund A. The use of episiotomy in primiparas in Sweden. A descriptive study with particular focus on two hospitals. Ada Obstet Gynaecol Scand. 1991;70:325–330. doi: 10.3109/00016349109007881. [DOI] [PubMed] [Google Scholar]
- 11.Reinbold D, Eboue C, Morello R, Lamendour N, Herlicoviez M, Dreyfus M. From the impact of French guidelines to reduce episiotomy's rate. J Gynecol Obstet Biol Reprod (Paris) 2012 Feb;41(1):62–68. doi: 10.1016/j.jgyn.2011.08.006. [DOI] [PubMed] [Google Scholar]
- 12.London: Department of Health; 1997. Department of Health, NHS maternity statistics, England 1989-90 to 1994-5. [Google Scholar]
- 13.Maduma-Butshe A, Dyall A, Garner P. Routine episiotomy in developing countries. Time to change a harmful practice. BMJ. 1998 Apr 18;316(7139):1179–1180. doi: 10.1136/bmj.316.7139.1179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Thompson A. Geneva: World Health Organisation; 1997. Safe Motherhood Newsletter; p. 12. Episiotomies should not be routine. [Google Scholar]
- 15.Martino V, Iliceto N, Simeoni U. Occipito-posterior fetal head position, maternal and neonatal outcome. Minerva Ginecol. 2007 Aug;59(4):459–464. [PubMed] [Google Scholar]
- 16.O’Rourke K. Maternal Exhaustion as an Obstetric Complication: Implications of TBA Training. Int Q Community Health Educ. 1994 Jan 1;15(4):395–404. doi: 10.2190/T9FR-PX0P-W52X-XQ6E. [DOI] [PubMed] [Google Scholar]