Evaluation of accuracy of mediolateral episiotomy incisions using a training model

Abstract

Background: Episiotomy is one of the most commonly performed surgical procedures worldwide. In the UK the use of episiotomy is selective, rather than routine, and a right mediolateral episiotomy (RMLE) is considered standard practice. According to The National Institute of Health and Care Excellence (NICE, 2007) guideline for intrapartum care such an episiotomy should be cut at an angle between 45° and 60° to the vertical axis. Recent evidence suggests that the angle of incision of mediolateral episiotomy (MLE) is associated with risk of obstetric anal sphincter injury (OASIS).

Objective: to assess the accuracy of individual practitioner's techniques when performing a RMLE.

Design: an audit of practice against nationally set standards.

Setting: at a national midwifery conference and prior to three multiprofessional perineal repair training workshops in the West Midlands region of the UK.

Participants: 144 midwives and 53 obstetric trainees.

Measurements: practitioners were asked to perform a RMLE incision on a bespoke training model, which is designed to give a realistic representation of a stretched perineum at crowning of the baby's head. Four parameters were measured: (1) distance of the starting point from the midline; (2) angle subtended to the perpendicular; (3) length and (4) shape of the incision (curved, straight or J-shaped).

Findings: of the 197 incisions performed only 12.7% (14.6%, n=21/144 of midwives and 7.5%, n=4/53 of obstetricians) complied with the defined technique of a RMLE for correctness of angle and placement. A 2-sided Fisher's exact test showed no significant difference between previous attendance at perineal management training and incision accuracy.

Keywords: Childbirth; Episiotomy; Midwifery; Obstetrics; Perineum.