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Meta-Analysis
. 2017 Feb 8;2(2):CD000081.
doi: 10.1002/14651858.CD000081.pub3.

Selective versus routine use of episiotomy for vaginal birth

Hong Jiang  1 , Xu Qian  1 , Guillermo Carroli  2 , Paul Garner  3
Affiliations
Meta-Analysis

Selective versus routine use of episiotomy for vaginal birth

Hong Jiang et al. Cochrane Database Syst Rev. .

Abstract

Background: Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures.

Objectives: To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review.

Data collection and analysis: Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE.

Main results: This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial.For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence).For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported.One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered.

Authors' conclusions: In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

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Conflict of interest statement

Hong Jiang received support from the Effective Health care Research Consortium, funded by UK aid from the UK government for the benefit of developing countries (Grant: 5242) ‐ this award was paid to Hong Jiang's institution and was used to support the preparation of this review.

Xu Qian received support from the Effective Health care Research Consortium, funded by UK aid from the UK government for the benefit of developing countries (Grant: 5242) ‐ this award was paid to Xu Qian's institution and was used to support the preparation of this review.

Guillermo Carroli is the principal investigator on a large trial included in this review. Risk of bias assessment, data extraction were carried out by authors independent of GC. PG provided oversight on expression of data from this trial and interpretation of its findings with regard to this potential conflict of interest.

Paul Garner is the Director of the Effective Health Care Research Programme Consortium, a DFID funded research programme that aims to increase the number of decisions in low and middle income countries based on reliable evidence.

Figures

1
1
The rationale commonly used to justify routine episiotomy
2
2
Study flow diagram
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
5
5
Funnel plot of comparison: 1 Restrictive versus routine episiotomy (planned non‐instrumental), outcome: 1.1 Severe perineal/vaginal trauma
1.1
1.1. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 1 Severe perineal/vaginal trauma.
1.2
1.2. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 2 Severe perineal/vaginal trauma (grouped by trial implementation success).
1.3
1.3. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 3 Blood loss at delivery (mL).
1.4
1.4. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 4 Newborn Apgar score < 7 at 5 minutes.
1.5
1.5. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 5 Perineal infection.
1.6
1.6. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 6 Moderate or severe pain (visual analogue scale).
1.7
1.7. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 7 Dyspareunia long term (≥ 6 m).
1.8
1.8. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 8 Genital prolapse long term (≥ 6 m).
1.9
1.9. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 9 Urinary incontinence long term (≥ 6 m).
1.10
1.10. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 10 Need for perineal suturing.
1.11
1.11. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 11 Admission to special care baby unit.
1.12
1.12. Analysis
Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 12 Pain at different time points (any measure).
2.1
2.1. Analysis
Comparison 2 Restrictive versus routine episiotomy (non‐instrumental, subgroup by parity), Outcome 1 Severe perineal/vaginal trauma.
3.1
3.1. Analysis
Comparison 3 Restrictive versus routine episiotomy (non‐instrumental, subgroup midline‐midlateral), Outcome 1 Severe vaginal/perineal trauma.
4.1
4.1. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 1 Severe perineal/vaginal trauma.
4.2
4.2. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 2 Apgar < 7 at 5 minutes.
4.3
4.3. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 3 Perineal infection.
4.4
4.4. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 4 Moderate/severe dyspareunia long term (≥ 6 m).
4.5
4.5. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 5 Urinary incontinence long term (≥ 6 m).
4.6
4.6. Analysis
Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 6 Admission to special care baby unit.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Ali 2004 {published data only}
    1. Ali SS, Malik M, Iqbal J, Faruqi NJ. Routine episiotomy versus selective episiotomy in primigravidae. Annals of King Edward Medical College 2004;10(4):482‐4.
Belizan 1993 {published data only}
    1. Belizan J, Campodonica L, Carroli G, Gonzalez L, Lede R, Palermo M, et al. Routine vs selective episiotomy: a randomised controlled trial. Argentine Episiotomy Trial Collaborative Group. Lancet 1993;342(8886‐8887):1517‐8. - PubMed
Dannecker 2004 {published data only}
    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
    1. 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
Eltorkey 1994 {published data only}
    1. Eltorkey MM, Al Nuaim MA, Kurdi AM, Sabagh TO, Clarke F. Episiotomy, elective or selective: a report of random allocation trial. Journal of Obstetrics and Gynaecology 1994;14:317‐20.
Harrison 1984 {published data only}
    1. Harrison RF, Brennan M, North PM, Reed JV, Wickham EA. Is routine episiotomy necessary?. British Medical Journal 1984;288:1971‐5. - PMC - PubMed
House 1986 {published data only}
    1. House MJ, Cario G, Jones MH. Episiotomy and the perineum: a random controlled trial. Journal of Obstetrics and Gynaecology 1986;7:107‐10.
Juste‐Pina 2007 {published data only}
    1. Juste‐Pina A, Luque‐Carro R, Sabater‐Adan B, Sanz‐De Miguel E, Vinerta‐Serrano E, Cruz‐Guerreiro E. Selective episiotomy versus routine episiotomy in nuliparous women with vaginal delivery performed by midwives [Episiotomia selectiva frente a episiotomia rutinaria en nuliparas con parto vaginal realizado por matronas]. Matronas Profesion 2007;8(3‐4):5‐11.
    1. Luque‐Carro R, Subiron‐Valera AB, Sabater‐Adan B, Sanz De Miguel E, Juste‐Pina A, Cruz‐Guerreiro E. Selective episiotomy versus routine episiotomy. Assessment three years after (2007‐2008). Matronas Profesion 2011;12(2):41‐8.
Klein 1992 {published data only}
    1. Klein M, Gauthier R, Jorgensen S, North B, Robbins J, Kacrorowski J, et al. McGill/University of Montreal multicentre episiotomy trial. Innovations in Perinatal Care. Proceedings of the 9th Birth Conference; 1990 Nov 11‐13; San Francisco, USA. 1990:45‐55.
    1. Klein MC, Gauthier RJ, Jorgensen SH, Robbins JM, Kaczorowski J, Johnson B, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? [Forebygger episiotomi perineal trauma och forsvagning av backenbotten?]. Jordemodern 1993;106(10):375‐7. - PubMed
    1. Klein MC, Gauthier RJ, Jorgensen SH, Robbins JM, Kaczorowski J, Johnson B, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation?. Online Journal of Current Clinical Trials 1992;Doc 10:0‐29. Accessed 17.12.2009. - PubMed
    1. Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology 1994;171:591‐8. - PubMed
    1. Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. Canadian Medical Association Journal 1995;153:769‐79. - PMC - PubMed
Murphy 2008b {published data only}
    1. Macleod M, Goyder K, Howarth L, Bahl R, Strachan B, Murphy D. Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two‐centre randomised controlled trial of restrictive versus routine use of episiotomy. BJOG: an International Journal of Obstetrics and Gynaecology 2013;120(8):1020‐7. - PubMed
    1. Murphy DJ. Randomised controlled trial of restrictive versus routine use of episiotomy for instrumental vaginal delivery ‐ a multi‐centre pilot study (ongoing trial). National Research Register (www.nrr.nhs.uk) (accessed 6 July 2006).
    1. Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG: an international journal of obstetrics and gynaecology 2008;115(13):1695‐703. - PubMed
Rodriguez 2008 {published data only}
    1. Rodriguez A, Arenas EA, Osorio AL, Mendez O, Zuleta JJ. Selective vs routine midline episiotomy for the prevention of third‐ or fourth‐degree lacerations in nulliparous women. American Journal of Obstetrics and Gynecology 2008;198(3):285.e1‐4. - PubMed
Sleep 1984 {published data only}
    1. Sleep J, Grant AM. West Berkshire perineal management trial: three year follow up. BMJ 1987;295:749‐51. - PMC - PubMed
    1. Sleep J, Grant AM, Garcia J, Elbourne D, Spencer J, Chalmers I. The Reading episiotomy trial ‐ a randomised trial comparing two policies for managing the perineum during spontaneous vaginal delivery. Proceedings of 23rd British Congress of Obstetrics and Gynaecology; 1983 July 12‐15; Birmingham, UK. 1983:24.
    1. Sleep J, Grant AM, Garcia J, Elbourne DR, Spencer JAD, Chalmers I. West Berkshire perineal management trial. British Medical Journal 1984;289:587‐90. - PMC - PubMed
Sulaiman 2013 {published data only}
    1. Sulaiman AS, Ahmad S, Ismail NA, Rahman RA, Jamil MA, Mohd Dali AZ. A randomized control trial evaluating the prevalence of obstetrical anal sphincter injuries in primigravida in routine versus selective mediolateral episiotomy. Saudi Medical Journal 2013; Vol. 34, issue 8:819‐23. - PubMed

References to studies excluded from this review

Amorim 2015 {published data only}
    1. Amorim MMR, Neto AHF, Katz L, Coutinho I, Melo I, Leal NV. Selective episiotomy compared with implementation of a nonepisiotomy protocol. A randomized clinical trial. Obstetrics & Gynecology 2015;125(5 Suppl):41S‐42S.
    1. Melo I, Katz L, Coutinho I, Amorim MM. Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial. Reproductive Health 2014;11(1):66. - PMC - PubMed
Coats 1980 {published data only}
    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
Detlefsen 1980 {published data only}
    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
Dong 2004 {published data only}
    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.
El‐Din 2014 {published data only}
    1. El‐Din AS, Kamal MM, Amin MA. Comparison between two incision angles of mediolateral episiotomy in primiparous women: a randomized controlled trial. Journal of Obstetrics and Gynaecology Research 2014;40(7):1877‐82. - PubMed
Golmakani 2011 {published data only}
    1. Golmakani N, Saeidi SR, Mazloum R, Soltani B. Evaluation of perineal trauma in primiparous women with routine and selective episiotomy. Iranian Journal of Obstetrics, Gynecology and Infertility 2011;13(6):32‐8.
Henriksen 1992 {published data only}
    1. Henriksen TB, Bek KM, Hedegaard M, Secher NJ. Episiotomy and perineal lesions in spontaneous vaginal deliveries. British Journal of Obstetrics and Gynaecology 1992;99:950‐4. - PubMed
    1. 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;156:3176‐9. - PubMed
Islam 2013 {published data only}
    1. Islam A, Hanif A, Ehsan A, Arif S, Niazi SK, Niazi AK. Morbidity from episiotomy. JPMA. The Journal of the Pakistan Medical Association 2013;63(6):696‐701. - PubMed
Javed 2007 {published data only}
    1. Javed I, Shoaib T, Bhutta S. Liberal versus restricted use of episiotomy in primigravida. Journal of Surgery Pakistan 2007;12(3):106‐9.
Karbanova 2013 {published data only}
    1. Karbanova J, Rusavy Z, Betincova L, Jansova M, Necesalova P, Kalis V. Clinical evaluation of early postpartum pain and healing outcomes after mediolateral versus lateral episiotomy. International Journal of Gynecology and Obstetrics 2014;127(2):152‐7. - PubMed
    1. Karbanova J, Rusavy Z, Betincova L, Jansova M, Parizek A, Kalis V. Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy. International Journal of Gynecology and Obstetrics 2014;124(1):72‐6. - PubMed
    1. Karbanova J, Rusavy Z, Betincova L, Jansova M, Parizek A, Kalis V. Mediolateral vs. lateral episiotomy and associated intrapartal complications in primiparous women. International Urogynecology Journal and Pelvic Floor Dysfunction 2013; Vol. 24:S66‐S67.
    1. Karbonava J, Rusavy Z, Betincova L, Jansova M, Necesalova P, Kalis V. Clinical evaluation of early postpartum pain and the healing outcomes of mediolateral versus lateral episiotomy. Journal of Maternal‐Fetal & Neonatal Medicine 2014;27(Suppl 1):83.
    1. Necesalova P, Karbanova J, Rusavy Z, Pastor Z, Jansova M, Kalis V. Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sexual & Reproductive Healthcare 2016;8:25‐30. - PubMed
Moini 2009 {published data only}
    1. Moini A, Yari RE, Eslami B. Episiotomy and third‐ and fourth‐degree perineal tears in primiparous Iranian women. International Journal of Gynecology & Obstetrics 2009;104(3):241‐2. - PubMed
Roy 2015 {published data only}
    1. Roy P, Sujatha MS, Biswas B, Chatterjee A, Roy P. A comparative study of perineal morbidity in vaginal delivery with and without episiotomy. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 2015;4(5):1442‐5.
Sawant 2015 {published data only}
    1. Sawant G, Kumar D. Randomized trial comparing episiotomies with Braun‐Stadler episiotomy scissors and EPISCISSORS‐60. Medical Devices: Evidence and Research 2015;8:251‐4. - PMC - PubMed
Shembekar 2009 {published data only}
    1. Shembekar C, Tajpuriya S. Comparison of routine versus selective episiotomy in normal labour: a randomized controlled study. International Journal of Gynecology & Obstetrics 2009;107(Suppl 2):S336.
Swift 2014 {published data only}
    1. ACTRN12612000285853. A prospective, randomised study Comparing cUrved versus straighT scissors to reduce episiotomy extension The CUT Trial. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362182 Date first received: 1 March 2012.
    1. Swift A, Webster J, Conroy AM, Hampton S, Kirby SJ, Minuzzo L, et al. Curved versus straight scissors to avoid 3rd and 4th degree perineal tears: a randomised feasibility study. Women and Birth 2014;27(3):163‐7. - PubMed
Werner 1991 {published data only}
    1. Werner CH, Schuler W, Meskendahl I. Midline episiotomy versus medio‐lateral episiotomy ‐ a randomized prospective study. International Journal of Gynecology and Obstetrics 1991;36 Suppl:33.

References to ongoing studies

NCT02356237 {published data only}
    1. NCT02356237. The effect of episiotomy on advanced perineal tears and other maternal and fetal outcomes ‐ randomized controlled multicentric trial (EPITRIAL). clinicaltrials.gov/show/NCT02356237 Date first received: 1 February 2015.
TCTR20150212001 {published data only}
    1. TCTR20150212001. Restrictive versus routine episiotomy: a randomized controlled trial. clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&sme... Date first received 12 February 2015.

Additional references

ACOG 2006
    1. American College of Obstetricians and Gynecologists. ACOG practice bulletin. Episiotomy. Clinical management guidelines for obstetrician‐gynecologists. Number 71, April 2006. Obstetrics & Gynecology 2006;107(4):957‐62. - PubMed
Banta 1982
    1. Banta D, Thacker SB. The risks and benefits of episiotomy: a review. Birth 1982;9(1):25‐30. - PubMed
Borghi 2002
    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 & Gynecology 2002;186(2):221‐8. - PubMed
Cargill 2004
    1. Cargill YM, MacKinnon CJ, Arsenault MY, Bartellas E, Daniels S, Gleason T, et al. Clinical Practice Obstetrics Committee. Guidelines for operative vaginal birth. Journal of Obstetrics & Gynaecology Canada: JOGC 2004;26(8):747‐61. - PubMed
Catling‐Paull 2013
    1. Catling‐Paull C, Coddington RL, Foureur MJ, Homer CSE, on behalf of the Birthplace in Australia Study and the National Publicly‐funded Homebirth Consortium. Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years. Medical Journal of Australia 2013;198(11):616‐20. [PUBMED: 23919710] - PubMed
Cunningham 1993
    1. Cunningham FG. Conduct of normal labor and delivery. In: Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III editor(s). Williams Obstetrics. 19. Norwalk, CT: Appleton and Lange, 1993:371‐93.
Fernando 2006
    1. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews 2006, Issue 3. [DOI: 10.1002/14651858.CD002866.pub2] - DOI - PubMed
FIGO 2012
    1. FIGO Safe Motherhood and Newborn Health (SMNH) Committee. Management of the second stage of labor. International Federation of Gynecology and Obstetrics 2012;119:110‐6.
Frankman 2009
    1. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed?. American Journal of Obstetrics and Gynecology 2009;200(5):e1‐e7. - PubMed
Garner 1982
    1. Garner P. Dyspareunia after episiotomy. British Journal of Sexual Medicine 1982;1:1‐3.
GRADE Working Group 2009
    1. GRADE Working Goup. List of GRADE working group publications and grants. www.gradeworkinggroup.org/publications/index.htm 2009.
Graham 1997
    1. Graham ID. Episiotomy‐Challenging Obstetric Interventions. Blackwell Science, 1997.
Graham 2005
    1. Graham ID, Carroli G, Davies C, Medves JM. Episiotomy rates around the world: an update. Birth 2005;7(313):21. - PubMed
Guyatt 2008
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P, et al. GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924‐6. - PMC - PubMed
Hamilton 1861
    1. Hamilton G. Classical observations and suggestions in obstetrics. Edinburgh Medical Journal 1861;7(313):21.
Hartmann 2005
    1. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005;293(17):2141‐8. [PUBMED: 15870418] - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327:557‐60. - PMC - PubMed
Higgins 2011
    1. Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.handbook.cochrane.org.
Homsi 1994
    1. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR Jr. Episiotomy: risks of dehiscence and rectovaginal fistula. Obstetrical & Gynecological Survey 1994;49:803‐8. - PubMed
Kalis 2012
    1. Kalis V, Laine K, Leeuw JW, Ismail KM, Tincello DG. Classification of episiotomy: towards a standardisation of terminology. BJOG: an international journal of obstetrics & gynaecology 2012;119(5):522‐6. - PubMed
Kettle 2008
    1. Kettle C, Tohill S. Perineal care. Clinical Evidence 2008;9:1401. - PMC - PubMed
Kliner 2014
    1. Kliner M, Garner P. When trial authors write Cochrane Reviews: competing interests need to be better managed. Cochrane Database of Systematic Reviews 2014; Vol. 9. [DOI: 10.1002/14651858.ED000089] - DOI - PMC - PubMed
Lede 1991
    1. Lede R, Moreno M, Belizan JM. Reflections on the routine indications for episiotomy. Sinopsis Obstétrico‐Ginecológica 1991;38:161‐6.
Liberati 2009
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta‐analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Medicine 2009;6:e1000100. - PMC - PubMed
Lynch 1997
    1. Lynch CM, Pinelli DM, Cruse CW, Spellacy WN, Sinnott JT, Shashy RG. Maternal death from postpartum necrotizing fasciitis arising in an episiotomy: a case report. Infectious Diseases in Obstetrics and Gynecology 1997;5(5):341‐4. - PMC - PubMed
Melo 2014
    1. Melo I, Katz L, Coutinho I, Amorim MM. Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial. Reproductive Health 2014;11(1):66. - PMC - PubMed
Murphy 2008a
    1. Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG: an international journal of obstetrics and gynaecology 2008;115(13):1695‐703. - PubMed
Ould 1741
    1. Ould F. A Treatise of Midwifery. London: J Buckland, 1741.
Priddis 2013
    1. Priddis H, Dahlen H, Schmied V, Sneddon A, Kettle A, Brown C, et al. Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000 ‐ 2008: a population based data linkage study. BMC Pregnancy and Childbirth 2013;13:89. - PMC - PubMed
Qian 2001
    1. Qian X, Smith H, Zhou L, Liang J, Garner P. Evidence‐based obstetrics in four hospitals in China: an observational study to explore clinical practice, women's preferences and provider's views. BMC Pregnancy and Childbirth 2001;1:1. - PMC - PubMed
RCOG 2007
    1. Royal College of Obstetricians and Gynaecologists. The Management of Third‐ and Fourth‐Degree Perineal Tears. Green‐Top Guideline. 2nd Edition. RCOG, 2007.
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Räisänen 2011
    1. Räisänen S, Vehviläinen‐Julkunen K, Gisler M, Heinonen S. A population‐based register study to determine indications for episiotomy in Finland. International Journal of Gynecology and Obstetrics 2011;115:26‐30. - PubMed
Steiner 2012
    1. Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E. Episiotomy: the final cut?. Archives of Gynecology and Obstetrics 2012;286(6):1369‐73. - PubMed
Thacker 1983
    1. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860‐1980. Obstetrical & Gynecological Survey 1983;38:322‐38. - PubMed

References to other published versions of this review

Carroli 2009
    1. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD000081.pub2] - DOI - PMC - PubMed
Carroli 2012
    1. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2012, Issue 2. [DOI: 10.1002/14651858.CD000081.pub2] - DOI - PMC - PubMed
Hay‐Smith 1995a
    1. Hay‐Smith J. Liberal use of episiotomy for spontaneous vaginal delivery. [revised 05 May 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther CA (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CD ROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Hay‐Smith 1995b
    1. Hay‐Smith J. Midline vs mediolateral episiotomy. [revised 26 January 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther CA (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CD ROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.

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