OBSTETRICS

Impact of Episiotomy During Operative

Vaginal Delivery on Obstetrical Anal
Sphincter Injuries
Priscilla Frenette, MD, MSc;1 Susan Crawford, MSc;2 Jane Schulz, MD;1
Maria B. Ospina, PhD1
1
Department of Obstetrics and Gynecology, University of Alberta, Lois Hole Hospital for Women, Edmonton, AB
2
Alberta Perinatal Health Program, Calgary, AB

Conclusion: In conclusion, results suggest that episiotomy should be

used with caution, particularly among women with a previous
P. Frenette vaginal delivery and in the setting of vacuum-assisted delivery.
Episiotomy may protect against OASIS in forceps-assisted
Abstract deliveries for women without a prior vaginal delivery.

Objective: The purpose of this study was to describe associations

Résumé
between episiotomy at the time of forceps or vacuum-assisted
delivery and obstetrical anal sphincter injuries (OASIS).

tude e
Objectif : L’objectif de cette e
tait de de

crire les associations
Methods: This population-based retrospective cohort study used entre l’e
pisiotomie au moment d’un accouchement par forceps
delivery information from a provincial perinatal clinical database. ou par ventouse et les le
sions obste
tricales du sphincter anal
Full-term, singleton, in-hospital, operative vaginal deliveries of (LOSA).
vertex-presenting infants from April 1, 2006 to March 31, 2016 were
Méthodologie : Cette e
tude de cohorte re
trospective fonde
e sur la
identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for
population a analyse
des renseignements sur les accouchements
associations between episiotomy and third- or fourth-degree

s d’une base de donne
tire
es cliniques pe
rinatales provinciale. Les
lacerations were calculated in multiple logistic regression models
accouchements vaginaux ope
ratoires a  terme d’un seul be
be

en
(Canadian Task Force Classification II-2).
pre
sentation du sommet survenus a  l’ho
^ pital entre le 1er avril
Results: Episiotomy was performed in 34% of 52 241 operative vaginal 2006 et le 31 mars 2016 ont e
te

recense
s. Les rapports de cotes
deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of (RC) et les intervalles de confiance (IC) a  95 % pour les
vacuum deliveries. Episiotomy was associated with increased odds associations entre l’e
pisiotomie et les lace
rations de troisie me et
of severe perineal lacerations for vacuum deliveries among women de quatrie me degre
ont e

te

calcule
s au moyen de plusieurs
with (OR 2.48; 95% CI 1.96−3.13) and without (OR 1.12; 95% CI mode  les de re

gression logistique (classification II-2 du Groupe
1.02−1.22) a prior vaginal delivery. Among forceps deliveries, d’e
tude canadien).
episiotomy was associated with increased odds of OASIS for those
Résultats : Une e
pisiotomie a e
te

pratique
e dans 34 % des 52 241
with a previous vaginal delivery (OR 1.52; 95% CI 1.12−2.06), but it
accouchements vaginaux ope
ratoires. Des LOSA sont survenues
was protective for women with no previous vaginal delivery (OR
dans 21 % des accouchements par forceps et 7,6 % des
0.73; 95% CI 0.67−0.79). Midline compared with mediolateral
accouchements par ventouse. L’e
pisiotomie a e
te

associe
e a
 un
episiotomy increased the odds of OASIS in forceps deliveries (OR
risque accru de lace
rations pe
rine

ales graves lors d’un
2.73; 95% CI 2.37−3.13) and vacuum deliveries (OR 1.94; 95% CI
accouchement par ventouse chez les femmes ayant de
ja
 (RC :
1.65−2.28).
2,48; IC a 95 % : 1,96−3,13) ou n’ayant jamais (RC : 1,12; IC a  95 %
: 1,02−1,22) accouche
par voie vaginale. Dans les cas
Key Words: Episiotomy, obstetrical extraction, obstetrical delivery, d’accouchement par forceps, l’e
pisiotomie a e
te

associe
e a un
anal canal injuries risque accru de LOSA chez les femmes ayant de
ja
 accouche
par
voie vaginale (RC : 1,52; IC a  95 % : 1,12−2,06), mais elle e
tait
Corresponding author: Dr. Maria B. Ospina, Department of
protectrice chez les femmes n’ayant jamais accouche
par voie
Obstetrics and Gynecology, University of Alberta, Lois Hole Hospital
vaginale (RC : 0,73; IC a  95 % : 0,67−0,79). Comparativement a 
for Women, Edmonton, AB. mospina@ualberta.ca

pisiotomie me
l’e
diolate
rale, l’e

pisiotomie me
diane augmentait le
Competing interests: See Acknowledgements. risque de LOSA lors des accouchements par forceps (RC : 2,73; IC
Each author has indicated that they meet the journal’s requirements  95 % : 2,37−3,13) et par ventouse (RC : 1,94; IC a
a  95 % :
for authorship. 1,65−2,28).
Information included in this paper was presented in an oral Conclusion : En conclusion, les re
sultats semblent indiquer que
presentation on April 20, 2018 at the University of Alberta
pisiotomie devrait e
l’e ^tre utilise

e avec prudence, surtout chez
Department of Obstetrics and Gynecology Research Day. les femmes ayant de
ja
 accouche
par voie vaginale et dans les
Received on January 14, 2019 cas d’accouchement par ventouse. L’e
pisiotomie peut avoir un
effet protecteur contre les LOSA lors d’un accouchement par
Accepted on February 12, 2019

000 JOGC 000 2019  1

OBSTETRICS

par voie
forceps chez les femmes n’ayant jamais accouche
vaginale.
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2019;000(000):1−8
https://doi.org/10.1016/j.jogc.2019.02.016
INTRODUCTION
bstetrical anal sphincter injuries (OASIS) include
O perineal lacerations that disrupt the anal sphincter
and/or anal mucosa during vaginal delivery.1,2 These
injuries are a significant cause of maternal morbidity in both
the short term and the long term.2−4 The incidence of
anal incontinence, one of the most severe complications,
approaches 40% among those affected by OASIS.2−5
Although multiple antepartum and intrapartum factors have
been associated with severe perineal lacerations, the use of
forceps or vacuum at the time of delivery has been consis-
tently found to be a strong predictor of obstetrical trauma.3−8
In North America, rates of operative vaginal delivery have
fallen over recent decades with corresponding rises in the
number of Caesarean sections performed.9,10 A recent move-
ment to decrease Caesarean section rates has led to renewed
interest in forceps and vacuum deliveries.10 However, a recent
study of Canadian births from 2004 to 2014 revealed increas-
ing rates of obstetrical trauma that were more pronounced
among operative vaginal deliveries compared with non-instru-
mental deliveries.9 Similar findings have been reported in the
United Kingdom.11 Possible explanations for these trends
include improved detection and reporting of third- and
fourth-degree lacerations, decreasing practitioner experience
with or comfort level in using forceps and vacuum, and the
possibility that these deliveries are being selectively performed
in only the most difficult cases.9,11 Whatever the reason, these
findings emphasize the need to identify interventions that
may reduce the risk of severe perineal trauma during opera-
tive vaginal deliveries.
Episiotomy, a surgical incision made in the posterior vagina
and perineum at the time of vaginal delivery, was once champ-
ioned as a method to protect against OASIS.4 Routine episiot-
omy in the setting of normal vaginal delivery has largely been
abandoned; however, its utility in the setting of operative vagi-
nal delivery remains controversial.4,12−15 Some observational
studies have shown episiotomy at the time of forceps or vac-
uum delivery to be associated with lower rates of third- and
2  000 JOGC 000 2019
fourth-degree lacerations,16−20 whereas other studies have
demonstrated no effect.21−23 Still others have found episiot-
omy to be associated with an increased risk of severe perineal
trauma.24−26 The lone published randomized controlled trial
(RCT) found no significant difference in the rate of third- and
fourth-degree lacerations for women randomized to routine
versus restrictive use of episiotomy. However, the trial was
underpowered to detect an effect.22 Some conflicting findings
could potentially be explained by differences in the study pop-
ulations; there is evidence to suggest that the type of episiot-
omy performed and a woman’s history of prior vaginal
delivery may play a role in the magnitude and/or direction of
the relationship between episiotomy and OASIS.1,2,4,27−30
The objective of this study was to determine whether the
use of episiotomy at the time of operative vaginal delivery
was protective against OASIS in women in Alberta. We
also sought to determine whether the association differed
on the basis of a history of previous vaginal delivery, type
of instrumental delivery, and type of episiotomy.
MATERIALS AND METHODS
We conducted a retrospective cohort study of all term (≥37
weeks gestational age) singleton vaginal deliveries of ver-
tex-presenting infants in Alberta hospitals from January 1,
2006 to December 31, 2016 during which vacuum or for-
ceps were used. Cases in which rotational forceps were
used were excluded from analyses, as were cases in which
both vacuum and forceps were used in the same delivery.
Data were obtained from the Alberta Perinatal Health Pro-
gram registry. The Alberta Perinatal Health Program is a
validated clinical perinatal database that collects maternal
and perinatal data from the provincial delivery record for
all deliveries at ≥20 weeks of gestation occurring in a hos-
pital or attended by a registered midwife at home or at a
birthing centre in the Province of Alberta. Data are sup-
plied to the Alberta Perinatal Health Program through
paper records, secure electronic transfer, or direct data
entry at the site of delivery. Data entry is performed by
trained personnel at both the Alberta Perinatal Health
Program office and delivery sites. A validation process is
performed to ensure accuracy of the data before its release
by cross-checking more than 100 data elements for concor-
dance and reviewing patients’ charts for clarification when
discrepancies are identified.
For each case meeting the inclusion criteria, the following
demographic and obstetrical variables were extracted: mater-
nal age at delivery, gestational age at delivery, history of vagi-
nal delivery (determined by subtracting the number of
previous Caesarean sections from maternal parity), epidural
 Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries
anaesthesia in labour, type of operative vaginal delivery (for-
ceps or vacuum), birth weight (>4000 g and ≤4000 g), infant
sex, type of episiotomy, type of perineal laceration, duration
of second stage of labour (>1 hour and ≤1 hour), induction
of labour, and use of oxytocin augmentation. These variables
have previously been identified as risk factors for OASIS.2
The primary outcome was the diagnosis of a third- or fourth-
degree perineal laceration as recorded in the delivery record.
Demographic and obstetrical variables were compared for
those deliveries with and without episiotomies by using chi-
square tests and Student t tests for categorical and continuous
variables, respectively. The frequencies of third- or fourth-
degree tears were determined for the overall cohort, as well as
for vacuum and forceps-assisted deliveries. The cohort was
then divided into women with a previous vaginal delivery and
women without a previous vaginal delivery, and the analyses
were repeated for each group. To investigate the association
between episiotomy and the outcome of third- or fourth-
degree laceration, multiple logistic regression models were
constructed separately for forceps and vacuum-assisted deliv-
eries. A large proportion of deliveries in the perinatal registry
had no record of the type of episiotomy that was performed.
Therefore, logistic regression models were constructed for
the overall cohort using episiotomy as a binary outcome (yes/
no). Subgroup analyses using multiple logistic regression were
performed after excluding deliveries with missing episiotomy
data to evaluate the association between type of episiotomy
(midline vs. mediolateral) and third- or fourth-degree lacera-
tion among operative vaginal deliveries. Odds ratios (ORs)
and 95% confidence intervals (CIs) for associations between
Figure. Study methods flow chart.
episiotomy and third- or fourth-degree lacerations were
reported. Statistical analyses were performed using SPSS Sta-
tistics software version 19.0 (IBM Corp., Armonk, NY).
Ethics approval for this study was obtained from the
University of Alberta’s Health Research Ethics Board
(Pro00078740).
RESULTS
There were 56 070 operative vaginal deliveries that met the
inclusion criteria (Figure). After excluding those deliveries
with no available data on episiotomy, 52 241 remained in
the cohort. Of these, 14 665 (28.1%) were forceps-assisted
and 37 576 (71.9%) were vacuum-assisted deliveries.
Episiotomy was performed in 17 824 (34%) deliveries.
Demographic and obstetrical characteristics of the episiot-
omy and no-episiotomy groups are presented in Table 1.
Episiotomy was more common than among forceps
(55.6%) than vacuum (25.7%) deliveries. Women with an
episiotomy were less likely to have had a previous vaginal
delivery (11.3%) than women without an episiotomy
(32.4%). Episiotomy was also associated with second
stage of labour >1 hour, birth weight >4000 g, epidural
anaesthesia, augmentation with oxytocin, and gestational
age >40 weeks. A third- or fourth-degree laceration
occurred in 5942 (11.4%) of all deliveries, in 21% of for-
ceps deliveries, and in 7.6% of vacuum deliveries. Episiot-
omy compared with no episiotomy was associated with
more third- and fourth-degree lacerations in the overall
cohort (14.4% vs. 9.8%; P < 0.001) and in the subset of
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OBSTETRICS

Table 1. Demographic and obstetrical characteristics

performed in 72.3% of cases and midline episiotomies in
of study population 27.7%. After adjusting for potential confounders (Table 3),
midline episiotomy increased the likelihood of third- and
Patient Episiotomy No episiotomy
characteristics (n = 17 824) (n = 34 417) P value
fourth-degree lacerations both in forceps (OR 2.73; 95%
CI 2.37−3.13) and vacuum deliveries (OR 1.94; 95% CI
Forceps delivery 8151 (45.7%) 6514 (18.9%) <0.001
1.65−2.28).
Vacuum delivery 9673 (54.3%) 27 903 (81.1%) <0.001
Previous vaginal 2016 (11.3%) 11 159 (32.4%) <0.001
delivery DISCUSSION
Induced labour 6458 (36.2%) 12 631 (36.7%) 0.220
Second stage of 12 154 (68.2%) 18 204 (52.9%) <0.001
The results of this study suggest that the relationship
labour >1 hour between episiotomy and OASIS in operative vaginal deliv-
Augmentation with 8051 (45.2%) 12 519 (36.4%) <0.001 eries varies according to the type of instrument used and a
oxytocin woman’s obstetrical history. In the setting of forceps-
Epidural 13 936 (78.2%) 25 956 (75.4%) <0.001 assisted deliveries, we found that episiotomy could reduce
Male infant 9853 (55.3%) 18 845 (54.8%) 0.215 the likelihood of a third- or fourth-degree laceration among
Birth weight >4000 g 1806 (10.1%) 2738 (8.0%) <0.001 women with no previous vaginal deliveries. However, episi-
Gestational age 3435 (19.3%) 5977 (17.4%) <0.001
otomy was a risk factor for third- and fourth-degree lacera-
>40 weeks tions in forceps deliveries for women with a previous
Maternal age at 28.27 29.17 0.914 vaginal delivery and in vacuum deliveries for both groups.
deliverya
Third- or fourth-degree laceration The finding that obstetrical history influences the relation-
Overall cohort 2560 (14.4%) 3382 (9.8%) <0.001 ship between episiotomy and OASIS is not new. Several
Forceps deliveries 1581 (19.4%) 1496 (23.0%) <0.001
previous studies of operative and non-operative vaginal
deliveries reported a decreased risk of obstetrical trauma
Vacuum deliveries 979 (10.1%) 1886 (6.8%) <0.001
a
when episiotomy was used for nulliparous women but an
Mean years.
increased risk or no effect when it was used in multiparous
populations.28−30 One possible explanation is that clini-
vacuum deliveries (10.1% vs. 6.8%; P < 0.001). Among cians perform episiotomies more liberally among nullipa-
forceps deliveries, episiotomy was associated with fewer rous patients but reserve the procedure for multiparous
third- and fourth degree lacerations compared with no epi- women deemed to already be at particularly high risk for
siotomy (19.4% vs. 23.0%; P < 0.001). severe perineal lacerations. Another possible explanation is
that episiotomy disrupts the tissue integrity of the relatively
Multivariate analyses predicting third- or fourth-degree lac- elastic perineum of a woman with a previous vaginal deliv-
eration for women with and without a prior vaginal deliv- ery, thereby interfering with the normal stretch that could
ery are presented in Table 2. After controlling for potential otherwise occur to accommodate the delivery. In contrast,
confounding variables, episiotomy remained protective the unyielding tissue of a woman without a prior vaginal
against third- and fourth-degree lacerations among forceps delivery is less likely to stretch adequately to permit deliv-
deliveries for women with no previous vaginal deliveries ery without significant trauma. An episiotomy could there-
(OR 0.73; 95% CI 0.67−0.79), but episiotomy was associ- fore be an effective method of controlling tearing in this
ated with increased odds of third- and fourth-degree lacer- subgroup of women.
ations among those with one or more previous vaginal
deliveries (OR 1.52; 95% CI 1.12−2.06). Among vacuum The results of our study have varying concordance with
deliveries, episiotomy was a risk factor for third- and existing literature on the topic. Our data are supported by
fourth-degree laceration in both women without a previous a 2006 retrospective cohort study by Kudish et al. that
vaginal delivery (OR 1.12; 95% CI 1.02−1.22) and those demonstrated an increased risk of anal sphincter injury
with one or more previous vaginal deliveries (OR 2.48; when episiotomy was combined with vacuum delivery for
95% CI 1.96−3.13). both nulliparous and multiparous women.25 The risk was
more pronounced for multiparous women, a trend we also
A subgroup analysis of deliveries in which the type of observed in our cohort. The study also found an increased
episiotomy was known included 11 139 cases (Figure). risk of severe perineal lacerations in forceps deliveries
There were 5375 forceps-assisted deliveries and 5764 among multiparous women, but unlike in our study, these
vacuum-assisted deliveries. Mediolateral episiotomies were investigators did not find a protective effect among

4  000 JOGC 000 2019

 Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries

Table 2. Multiple regression model predicting third-degree and fourth-degree laceration for women with and without
previous vaginal delivery
Women with no previous vaginal delivery Women with ≥1 previous vaginal delivery
Patient Forceps deliveries Vacuum deliveries Forceps deliveries Vacuum deliveries
characteristics OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Episiotomy
Yes 0.73 (0.67−0.79) 1.12 (1.02−1.22) 1.52 (1.12−2.06) 2.48 (1.96−3.13)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Maternal age at delivery
≤19 0.54 (0.42−0.71) 0.55 (0.45−0.68) a
1.08 (0.43−2.72)
20−29 0.97 (0.88−1.06) 0.83 (0.75−0.91) 0.67 (0.47−0.96) 0.58 (0.45−0.74)
30−34 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
35−39 0.92 (0.79−1.07) 0.82 (0.70−0.97) 0.80 (0.54−1.19) 0.96 (0.74−1.24)
≥40 0.63 (0.43−0.92) 0.99 (0.70−1.40) 0.88 (0.44−1.76) 0.37 (0.19−0.73)
Induced labour
Yes 1.01 (0.92−1.11) 1.03 (0.94−1.13) 0.84 (0.60−1.18) 0.90 (0.72−1.14)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Epidural
Yes 0.90 (0.77−1.06) 0.67 (0.61−0.74) 0.99 (0.64−1.53) 0.61 (0.49−0.75)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Gestational age >40 weeks
Yes 1.08 (0.97−1.20) 1.15 (1.03−1.29) 0.77 (0.49−1.21) 0.96 (0.71−1.28)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Augmentation with oxytocin
Yes 1.15 (1.05−1.26) 1.08 (0.98−1.18) 0.92 (0.66−1.27) 1.06 (0.84−1.34)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Birth weight >4000 g
Yes 1.34 (1.16−1.53) 2.06 (1.80−2.37) 1.38 (0.94−2.05) 1.55 (1.19−2.03)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Second stage of labour >1 hour
Yes 1.14 (1.02−1.27) 1.40 (1.27−1.54) 1.37 (1.00−1.88) 1.81 (1.45−2.26)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Infant sex
Female 0.98 (0.90−1.06) 0.95 (0.87−1.03) 0.85 (0.62−1.16) 1.02 (0.83−1.25)
Male 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
CI: confidence interval; OR: odds ratio.
a
No observations for this group

nulliparous women.25 Robinson et al. also reported an
increased risk of OASIS when episiotomy was combined
with vacuum in their cohort of nulliparous women but no
significant association among forceps deliveries.23 Other
studies have demonstrated no significant difference in the
rates of obstetrical trauma when episiotomy was combined
with either vacuum- or forceps-assisted deliveries.21,26
Our findings conflict with the results of Jango et al., who
found a protective effect of mediolateral episiotomy among
nulliparous women undergoing vacuum-assisted delivery.20
Three additional cohort studies from the Netherlands also
reported decreased obstetrical trauma when mediolateral
episiotomy was combined with vacuum or forceps,
although nulliparous and multiparous women were not
analyzed separately in two of these investigations.16,18,19
Additionally, the proportions of women diagnosed with
severe perineal trauma in the studies by Jango et al.
(6.5%),20 De Leeuw et al. (3.5%),19 and de Vogel et al.
(5.7%)16 were substantially lower than what we found in

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OBSTETRICS

Table 3. Multivariable model predicting third-degree and

vaginal delivery, other studies have used parity as their basis
fourth-degree laceration among women with a known for analysis. This could cause some women with a previous
episiotomy type Caesarean section but no previous vaginal delivery to be
classified as multiparous. However, these women may in
Patient Forceps deliveries Vacuum deliveries
characteristics OR (95% CI) OR (95% CI) fact be more similar to nulliparous women with respect to
Episiotomy
their baseline OASIS risk.31 Additionally, although some
studies, including ours, performed separate analyses for
Midline 2.73 (2.37−3.13) 1.94 (1.65−2.28)
women on the basis of obstetrical history, others adjusted
Mediolateral 1.00 (reference) 1.00 (reference)
for parity in regression models.
Previous vaginal delivery
Yes 0.62 (0.47−0.80) 0.61 (0.47−0.80) Another factor that could contribute to the discordance is
No 1.00 (reference) 1.00 (reference) the type of episiotomy included in each study. Although we
Maternal age at delivery were unable to control for type of episiotomy in the overall
≤19 0.55 (0.38−0.79) 0.74 (0.54−1.03) cohort because of missing data, our subgroup analysis sug-
20−29 0.92 (0.80−1.07) 0.81 (0.67−0.97) gests that midline episiotomy increases the risk of third-
30−34 1.00 (reference) 1.00 (reference)
and fourth-degree lacerations when combined with vac-
uum or forceps compared with mediolateral episiotomy. In
35−39 0.98 (0.77−1.25) 0.88 (0.63−1.23)
the midline approach, an incision is made in the posterior
≥40 1.17 (0.72−1.90) 0.87 (0.42−1.78)
fourchette extending inferiorly towards the anal sphincter,
Induced labour
whereas in the mediolateral approach the incision is
Yes 0.98 (0.84−1.13) 1.12 (0.94−1.34) directed away from the sphincter at an angle of at least 60
No 1.00 (reference) 1.00 (reference) degrees.1 Few studies have directly compared midline with
Epidural mediolateral episiotomy in the setting of operative vaginal
Yes 0.87 (0.70−1.09) 0.73 (0.62−0.87) delivery; however, there is evidence from non-instrumental
No 1.00 (reference) 1.00 (reference) deliveries that a midline approach significantly increases
Gestational age >40 weeks the risk of severe perineal lacerations compared with the
Yes 1.22 (1.03−1.45) 1.12 (0.91−1.37) mediolateral technique.2,4 A 2015 systematic review and
No 1.00 (reference) 1.00 (reference) meta-analysis found an increased risk of severe perineal
Augmentation with oxytocin
lacerations among vacuum deliveries for nulliparous
women who underwent midline but not mediolateral episi-
Yes 0.98 (0.86−1.13) 0.85 (0.72−1.01)
otomy.27 In our subset analysis, almost three quarters of
No 1.00 (reference) 1.00 (reference)
episiotomies were mediolateral; however, we cannot be cer-
Birth weight >4000 g
tain that this result could be extrapolated to the overall
Yes 1.41 (1.16−1.72) 1.66 (1.33−2.06) cohort because 37.5% of episiotomy types were unknown.
No 1.00 (reference) 1.00 (reference)
Second stage of labour >1 hour A final factor that could explain the discordance in the liter-
Yes 1.34 (1.13−1.58) 1.46 (1.23−1.73) ature relates to geographic differences. Many of the studies
No 1.00 (reference) 1.00 (reference) that have shown harmful effects or no impact of episiotomy
Infant sex
among operative vaginal deliveries have been conducted in
Female 0.97 (0.85−1.10) 1.02 (0.88−1.20)
North America23−25 and the United Kingdom,21,26 whereas
other studies showing a protective effect have emerged
Male 1.00 (reference) 1.00 (reference)
from other parts of Europe, such as the Netherlands and
CI: confidence interval; OR: odds ratio.
Denmark.16,18−20 It is therefore possible that some differ-
ences may be explained by variations in clinical practice or
our study (11.4%), a finding suggesting that our study pop- study populations in different geographic areas.
ulations may have differed.
There are several limitations of this study. First, the use of
Several factors could explain the discordance in the litera- an observational design rather than an RCT carries a
ture. First, some of the conflicting results could be greater risk of potential bias. To date, only one RCT has
explained by the manner in which a woman’s obstetrical been published on this question, and it was underpowered
history was classified and analyzed. Although we chose to to detect an effect with a sample size of 200.22 In our
classify women on the basis of a history of a previous cohort, women who underwent an episiotomy compared

6  000 JOGC 000 2019

 Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries
with those who did not were more likely to have had a
birth weight >4000 g, a second stage of labour >1 hour,
and augmentation with oxytocin, all of which are risk fac-
tors for OASIS. This finding supports the notion that
some clinicians were practising a restrictive approach to
episiotomy, where the procedure was used selectively in
women believed to be at greatest risk for perineal trauma.
Although these baseline characteristics were controlled for
in regression models, it is possible that we were unable to
capture other factors that contributed to the decision to
perform an episiotomy, such as the presence of fetal dis-
tress. Next, this study relied on a clinical perinatal registry.
Therefore, there is a possibility that some clinical informa-
tion may have been incorrectly recorded or coded in the
database, although a validation procedure is followed
before release of the data. Additionally, we were unable to
control for type of episiotomy in the overall cohort because
of the large volume of missing data for this variable.
Finally, it has been established that third- and fourth-
degree perineal lacerations are frequently underrecognized
and underreported.2 This is a limitation of any study evalu-
ating OASIS. However, it is reassuring that the incidence
of perineal trauma in our study is consistent with the num-
bers previously reported in the literature.2,8,9,23,32 Strengths
of our study include its large sample size, which is one of
the largest reported in the literature. Additionally, we used
a robust, well-established provincial perinatal database with
multiple demographic and clinical variables recorded.
Finally, we were able to analyze data on the basis of a
woman’s history of prior vaginal delivery, rather than parity
alone, which may better reflect baseline OASIS risk.
CONCLUSION
The results of this study suggest that episiotomy may be use-
ful for reducing the risk of OASIS in the setting of forceps-
assisted deliveries in women without a prior vaginal delivery
but that it should be used with caution among women with
a previous vaginal delivery and in the setting of vacuum-
assisted delivery. However, episiotomy may be indicated
even in the foregoing circumstances to expedite delivery
when the well-being of the fetus or mother is at risk. Finally,
where episiotomy is clinically indicated, a mediolateral
approach should be used over a midline approach to reduce
the risk of OASIS. Future research that further characterizes
possible interactions between the type of episiotomy and a
woman’s obstetrical history would be helpful.
Acknowledgements
This research has been funded by the generous supporters of
the Lois Hole Hospital for Women through the Women and
Children’s Health Research Institute. The authors acknowl-
edge the Alberta Perinatal Health Program for their in-kind
contributions of data collection and statistical analysis.
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