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Meta-Analysis
. 2009 Jan 21:(1):CD000081.
doi: 10.1002/14651858.CD000081.pub2.

Episiotomy for vaginal birth

Guillermo Carroli  1 , Luciano Mignini
Affiliations
Meta-Analysis

Episiotomy for vaginal birth

Guillermo Carroli et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear.

Objectives: The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth.

Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008).

Selection criteria: Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy.

Data collection and analysis: The two review authors independently assessed trial quality and extracted the data.

Main results: We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison.

Authors' conclusions: Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

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References

References to studies included in this review

    1. Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: a randomised controlled trial. Lancet. 1993;42:1517–8. - PubMed
    1. Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. 2004;83(4):364–8. - PubMed
    2. Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: the influence on the urethral pressure profile, analmanometric and other pelvic floor findings - follow up study of a randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. 2005;84:65–71. - PubMed
    1. Eltorkey MM, Al Nuaim MA, Kurdi AM, Sabagh TO, Clarke F. Episiotomy, elective or selective: a report of a random allocation trial. Journal of Obstetrics and Gynaecology. 1994;14:317–20.
    1. Harrison RF, Brennan M, North PM, Reed JV, Wickham EA. Is routine episiotomy necessary? BMJ. 1984;288:1971–5. - PMC - PubMed
    1. House MJ, Cario G, Jones MH. Episiotomy and the perineum: a random controlled trial. Journal of Obstetrics and Gynaecology. 1986;7:107–10.

References to studies excluded from this review

    1. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. British Journal of Obstetrics and Gynaecology. 1980;87:408–12. - PubMed
    1. Detlefsen GU, Vinther S, Larsen P, Schroeder E. Median and mediolateral episiotomy [Median og mediolateral episiotomi] Ugeskrift for Laeger. 1980;142(47):3114–6. - PubMed
    1. Dong LQ, Li HL, Song ZL. Clinical study and application of the improved episiotomy incision and anesthesia method in the vaginal deliveries. Journal of Qilu Nursing. 2004;10(1):1–3.
    1. Henriksen T, Beck KM, Hedegaard M, Secher NJ. Episiotomy and perineal lesions in spontaneous vaginal deliveries. British Journal of Obstetrics and Gynaecology. 1992;99:950–4. - PubMed
    2. Henriksen TB, Bek KM, Hedegaard M, Secher NJ. Episiotomy and perineal lesions in spontaneous vaginal delivery [Episiotomi og perineale laesioner ved spontane vaginale fodsler] Ugeskrift for Laeger. 1994;156(21):3176–9. - PubMed
    1. Werner Ch, Schuler W, Meskendahl I. Midline episiotomy versus medio-lateral episiotomy - a randomized prospective study; Proceedings of 13th World Congress of Gynaecology and Obstetrics (FIGO) (Book 1); Singapore. 1991; Sep 15-20, p. 33. 1991.

References to ongoing studies

    1. Murphy DJ. Randomised controlled trial of restrictive versus routine use of episiotomy for instrumental vaginal delivery - a multi-centre pilot study. National Research Register; [accessed 6 July 2006]. www.nrr.nhs.uk

Additional references

    1. Aldridge AN, Watson P. Analysis of end results of labor in primiparas after spontaneous versus prophylactic methods of delivery. American Journal of Obstetrics and Gynecology. 1935;30:554–65.
    1. Borghi J, Fox-Rushby J, Bergel E, Abalos E, Hutton G, Carroli G. The cost-effectiveness of routine versus restrictive episiotomy in Argentina. American Journal of Obstetrics and Gynecology. 2002;186:221–8. - PubMed
    1. Buekens P, Lagasse R, Dramaix M, Wollast E. Episiotomy and third degree tears. British Journal of Obstetrics and Gynaecology. 1985;92:820–3. - PubMed
    1. Chalmers I, Hetherington J, Elbourne D, Keirse MJNC, Enkin M. Materials and methods used in synthesizing evidence to evaluate the effects of care during pregnancy and childbirth. In: Chalmers I, Enkin MWE, Keirse MJNC, editors. Effective care in pregnancy and childbirth. Oxford University Press; Oxford: 1989. pp. 39–65.
    1. Cunningham FG. Conduct of normal labor and delivery. In: Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III, editors. Williams obstetrics. 19th Edition Appleton and Lange; Norwalk, CT: 1993. pp. 371–93.

References to other published versions of this review

    1. Hay-Smith J, The Cochrane Collaboration . Liberal use of episiotomy for spontaneous vaginal delivery. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther CA, editors. The Cochrane Pregnancy and Childbirth Database. Update Software; Oxford: 1995. [database on disk and CD ROM] Issue 2 . Pregnancy and Childbirth Module . revised 05 May 1994.
    1. Hay-Smith J, The Cochrane Collaboration . Midline vs mediolateral episiotomy. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther CA, editors. The Cochrane Pregnancy and Childbirth Database. 2. Update Software; Oxford: 1995. [database on disk and CD ROM] Issue 2 . Pregnancy and Childbirth Module. revised 26 January 1994.

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