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Different episiotomy techniques, postpartum perineal pain, and blood loss:

An observational study

Article  in  International Urogynecology Journal · October 2012

DOI: 10.1007/s00192-012-1960-3 · Source: PubMed

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Int Urogynecol J
DOI 10.1007/s00192-012-1960-3
ORIGINAL ARTICLE
Different episiotomy techniques, postpartum perineal pain,
and blood loss: an observational study
Kathrine Fodstad & Katariina Laine &
Anne Cathrine Staff
Received: 7 June 2012 / Accepted: 25 September 2012
# The International Urogynecological Association 2012
Abstract
Introduction and hypothesis The lateral episiotomy tech-
nique has been postulated to cause more postpartum perine-
al pain and blood loss compared to the midline and
mediolateral episiotomy technique. The aim of the study
was to explore the association with postpartum perineal pain
and blood loss between different episiotomy techniques.
Methods Clinical evaluation of episiotomy was performed
0–3 days after delivery on 300 participating women. Episi-
otomy technique was classified by millimeter distance from
the incision point to the posterior fourchette and by angle
from the sagittal plane in degrees. Postpartum perineal pain
was scored on a visual analogue scale (VAS) the first day
after delivery. Blood loss data were collected from medical
charts. Different episiotomy techniques and different episi-
otomy incision point groups were compared in relation to
perineal pain perception and blood loss.
Results We found no difference between midline, medio-
lateral, and lateral episiotomy techniques in perineal pain
perception the first postpartum day (p00.74) or in estimated
blood loss (p00.38). No differences were found in perineal
pain or blood loss between midline and lateral incision
Parts of the preliminary data were presented by the first author at the
International Urogynecological Association 2011 Annual Meeting in
Lisbon, where the abstract was selected for an oral presentation of
12 min.
K. Fodstad (*) : K. Laine : A. C. Staff
Department of Obstetrics and Gynaecology, Oslo University
Hospital, Ullevål,
Postboks 4956, Nydalen,
0424 Oslo, Norway
e-mail: kfodstad@ous-hf.no
K. Fodstad : K. Laine : A. C. Staff
Faculty of Medicine, University of Oslo,
Oslo, Norway
points. Mediolateral angles were significantly narrower than
lateral angles (p<0.005). Physicians performed longer epis-
iotomies than midwives (p<0.005), but episiotomy angle
did not vary between professions (p00.075).
Conclusions No differences in perineal pain perception the
first postpartum day and no differences in estimated blood
loss were found when comparing different episiotomy tech-
niques or when comparing midline and lateral incision
points.
Keywords Episiotomy . Angle . Perineum . Postpartum
pain . Blood loss . Vaginal birth
Introduction
Episiotomy is one of the most frequently practiced surgical
procedures in obstetrics, defined as a surgical enlargement
of the vaginal orifice by an incision of the perineum during
the last part of the second stage of delivery [1, 2]. Episiot-
omy rates around the world differ considerably [3], but the
recommendation today is restrictive use, and on indication
only [4, 5], although indications may be highly subjective.
Several episiotomy techniques are described in the liter-
ature, but only two are commonly addressed, namely, the
midline and the mediolateral techniques (Fig. 1). Existing
literature on lateral episiotomy is scarce, but the lateral
technique seems to be a tradition in some European
countries [6, 7]. The lateral episiotomy technique is defined
as an incision commencing 1–2 cm lateral to the posterior
fourchette, directed towards the ischial tuberosity [8–10].
Studies have also shown that lateral episiotomies are likely
to be performed unintentionally [11–13]. The lateral tech-
nique may therefore be a more frequently used episiotomy
than earlier perceived.

3
2 Recruitment took place over a 1-year period from March
1
Fig. 1 Episiotomy intrapartum incision lines (1 midline, 2 mediolat-
eral, and 3 lateral episiotomy technique). The figure illustrates incision
points and incision angles with the sagittal/parasagittal plane when
episiotomy is performed on distended perineum during crowning of
the fetal head. The lateral episiotomy incision point is defined as
commencing ≥10 mm from the posterior fourchette at the time of
incision [10]
There is no international consensus on how to optimally
perform the different episiotomy techniques [11], and ob-
stetric textbook definitions and local performance guidelines
differ considerably [10–12]. In some studies the episiotomy
technique is not even specified.
Mediolateral and lateral episiotomies have been postulat-
ed to cause more blood loss as well as more perineal pain
and dyspareunia compared to the midline technique [9,
14–18], although no randomized controlled trials or large
observational studies exploring this notion have been pub-
lished previously.
The primary aim of our study was to investigate perineal
pain perception after different episiotomy techniques the
first day after delivery. The secondary aim was to explore
differences in estimated blood loss between different episi-
otomy techniques.
Materials and methods
This study was conducted at the Department of Obstetrics,
Oslo University Hospital, Ullevål, a tertiary referral hospital
with an annual delivery rate of 7,000, and approved by the
Regional Committee for Medical and Health Research
Ethics, Southeastern Norway.
In Norway spontaneous deliveries are attended by mid-
wives, whereas instrumental deliveries by physicians. In our
hospital all spontaneous deliveries are attended by two mid-
wives and instrumental deliveries by both the attending and
the resident doctor on call. The routine practice of having
two accoucheurs present at all spontaneous deliveries was
implemented to increase quality management and birth aid
as well as patient safety. The routine hospital practice is to
perform an examination of the perineum after vaginal
Int Urogynecol J
delivery which includes a digital anal examination to check
for anal sphincter lacerations. If there is a vaginal laceration,
a second-degree laceration, or suspected anal sphincter in-
jury during spontaneous midwife-attended deliveries, the
attending and resident physician on call are paged to exam-
ine and evaluate every case.
2010 through March 2011. All women with an episiotomy,
who were available for recruitment in the maternity ward,
were approached 0–2 days after delivery and invited to
participate by the first author (KF). The inclusion criteria
were (1) episiotomy performed during vaginal delivery, (2)
delivery at more than 28 weeks gestation, (3) age >18 years,
and (4) the ability to understand Norwegian or English. A
total of 310 women were invited to participate and 300
(97 %) agreed to enroll in the study and signed an informed
written consent. These women also participate in a long-
term follow-up study that will be published later.
All 300 participating women were examined by KF with-
in 3 days postpartum. With the women in the lithotomy
position, legs in stirrups, flexed at hip joints, a transparent
plastic film with a fixed midline was placed on the perine-
um. The midline was determined anatomically from the
midpoint of the introitus, running upwards through the
clitoris, downwards through and past the anal orifice. The
women’s episiotomy suture line was thereafter drawn on the
transparent film using a permanent marker pen. The poste-
rior fourchette, vaginal orifice, and the anal orifice were also
marked on the plastic film. With the film placed on a flat
surface, the length of the episiotomy and the shortest dis-
tance from the posterior fourchette to the incision point were
measured in millimeters using a tape measure. The episiot-
omy angle from the sagittal or parasagittal plane was mea-
sured in degrees using a protractor. Measurements of
episiotomy angle, length, and incision point on the plastic
films were supervised by a senior obstetrician (KL). Based
on the episiotomy measurements (incision point distance
from the posterior fourchette and angle from the sagittal
plane), we categorized episiotomies evaluated postpartum
into four groups: midline, mediolateral, lateral, and non-
classifiable (Fig. 2 and Table 1). Our angle categorizations
were chosen based on previous studies by Kalis et al. [19,
20], showing that a mediolateral incision angle is reduced
15–20° when compared to suture angle. We hypothesized
that all episiotomies with an incision point lateral to the
midline would have a similar reduction in angle when
measured postpartum (illustrated in Figs. 1 and 2). Our
incision point ranges for the different episiotomy techniques
were chosen based on definitions of the mediolateral and
lateral episiotomies. The lateral episiotomy is an incision
commencing 10 mm or more from the midline [10]. Since
definitions of correct incision points for the mediolateral
technique have been shown to vary between textbooks,
Int Urogynecol J
3
2 1
Fig. 2 Episiotomy suture lines after delivery (1 midline, 2 medio-
lateral, and 3 lateral episiotomy technique). The mediolateral suture
angle (2) measures 15–20° less than the mediolateral incision angle
[20] in Fig. 1. We have hypothesized a similar reduction in angle for
the lateral episiotomy (3) when comparing lateral incision angle
(Fig. 1) to lateral suture angle (Fig. 2)
clinicians, institutions, and countries [11, 12], we chose a
mediolateral/midline incision point range of 0–3 mm from
the posterior fourchette. A nonclassifiable episiotomy tech-
nique was therefore categorized as incisions commencing
4–9 mm from the posterior fourchette (Table 1).
Perineal pain measurements were scored on an 11-point
visual analogue scale (VAS ranging from 0 to 10) by 208 of
the 300 participants on the first postpartum day. All 300
women were interviewed in person by the first author,
approached in their room and specifically asked to score
perineal pain, stressing the term “perineal.” They were shown
a VAS and explained that 0 represented “no pain” and 10
“worst thinkable pain.” Women that were not available in their
room on the first postpartum day scored perineal pain retro-
spectively, but these participants (n092) were excluded from
the pain analyses due to possible recollection bias.
Blood loss is routinely estimated by the midwife and/or
physician in charge of the delivery and documented in the
medical chart. It is a subjective estimation by inspection of
tissues and blood clots. In cases of considerable hemor-
rhage, tissues are weighed to achieve a more exact estimate.
Estimated blood loss up to the first 2 h after delivery
(hereafter referred to as postpartum blood loss) and all other
clinical variables were collected from medical records, and
clinical information was verified in patient interviews.
Statistical calculations were performed with SPSS (ver-
sion 18.0, Chicago, IL, USA). Continuous variables were
Table 1 Definition of episiotomy techniques, categorization by postpartum measurement
Distance from incision point to the posterior fourchette (mm)
Angle from the sagittal or parasagittal plane (°)
a
Of the 109 cases in the nonclassifiable group, 32 had a lateral incision point (≥10 mm), but either too acute (<25°) or too large an angle (>60°) to
qualify as a lateral episiotomy
analyzed both in a linear regression model and categorized,
presented as frequencies, means, or medians, where appro-
priate. Univariate analyses were performed by chi-square
test. A p value of <0.05 was chosen as the level of statistical
significance.
Results
Table 2 summarizes the clinical characteristics of the study
group. The majority of participants were primiparous (n0
252/300). Sixteen percent (n048/300) had delivered previ-
ously, but 20 of these 48 women had delivered by cesarean
section only and were therefore categorized as “vaginal
primiparous” in the analyses (91 %, n0272/300).
The documented indications for performing an episioto-
my were instrumental vaginal delivery (53 %), breech pre-
sentation (6 %), fetal distress (13 %), fear of perineal
laceration or obstetric anal sphincter injuries (OASIS,
12 %), and failure to progress during the second stage of
labor (6 %). Midwives failed to document the episiotomy
indication in 10 % of cases.
Of the study participants, 56 had their episiotomy clini-
cally examined the first postpartum day, 144 2 days after
delivery, and 100 3 days postpartum. The examination day
differed due to logistics: lack of availability of examination
room and/or participant. Perineal pain perception was
scored by 208 of 300 participants during an interview on
the first postpartum day. Ninety-two participants were not
available for this interview the first day after delivery.
Episiotomy technique
We categorized episiotomies into four groups (Table 1 and
Fig. 2) based on the angle measured postpartum, incision
point distance to the posterior fourchette, and our hypothesis
that lateral episiotomies would have an incision to suture
angle shrinkage as mediolateral episiotomies have been
shown to have [20]. Based on our categorization the major-
ity of episiotomies (44 %) were lateral and 36 % were
nonclassifiable. Very few (7 %) were midline and 13 %
were mediolateral episiotomies. All episiotomies with inci-
sion points commencing 4–9 mm from the posterior
Midline Mediolateral Lateral Nonclassifiable
n020 n038 n0133 n0109a
≤3 ≤3 ≥10 4–9
<25 25–60 25–60 All angles
 Int Urogynecol J

Table 2 Clinical characteristics

of the study group (n0300) for Characteristics Midline Mediolateral Lateral Nonclassifiable p
the different episiotomy techni- episiotomy episiotomy episiotomy
ques (classified postpartum). n0300 n020 n038 n0133 n0109
Values are given in means or
frequencies Vaginal primiparousa (%) 90 95 90 87 0.6
Maternal age (years) 31 30 31 31 0.2
Spontaneous delivery (%) 10.5 16.5 34.6 38.3 0.004
Instrumental delivery (%) 3.6 9.6 52.1 34.7 0.004
Duration of second stage (min) 47 47 45 46 0.9
a Amount of blood loss (ml) 418 422 446 398 0.7
Twenty of the women listed as
vaginal primiparous had one Vaginal tears (%) 35 26 29 26 0.8
previous delivery, but by cesar- Birth weight (g) 3,394 3,504 3,499 3,558 0.5
ean and therefore no previous Placental weight (g) 611 608 654 653 0.6
vaginal birth

fourchette (n075) were considered nonclassifiable regard-
less of angle. Also, lateral episiotomies (defined as incision
point ≥10 mm from the posterior fourchette) either having
too narrow a postpartum angle (<25°, n09) or too large a
postpartum angle (>60°, n023) were grouped as nonclassi-
fiable. We not only performed the outcome analyses by
different episiotomy techniques, but repeated all analyses
by an alternative episiotomy categorization based on inci-
sion point solely and regardless of episiotomy angle (0-3
mm; midline, 4-9 mm, and ≥10 mm; lateral incision point
groups). Additionally we analyzed episiotomy length, angle,
and distance from the posterior fourchette as continuous
variables.
We found that the mean lateral episiotomy angle was
significantly larger than the mean mediolateral episiotomy
angle (45.2 vs 30.3°, p<0.005). Lateral episiotomies were
significantly longer than other episiotomy types performed
(p<0.005).
When comparing episiotomies performed by physicians
to episiotomies performed by midwives, those cut by physi-
cians were significantly longer, p<0.005. There was also a
significant difference in mean incision point distance to the
posterior fourchette between physicians and midwives (11.2
and 9.0 mm, respectively, p00.004). The mean episiotomy
angle, however, did not vary between professions. One third
of physicians and one third of midwives performed a non-
classifiable episiotomy technique.
Postpartum pain
Perineal pain was scored on the first day after delivery by
208 of the 300 participants (Table 3). The 92 women who
scored perineal pain on a different postpartum day were
excluded from our perineal pain analyses, but did not differ
clinically from those who scored perineal pain on the first
postpartum day (n0208, data not shown). Most women
reported low (0–3) or moderate (4–6) VAS scores, 37 and
43 %, respectively. Only 20 % reported high postpartum
pain scores (7–10). When comparing spontaneous to instru-
mental deliveries, we found no difference in the distribution
of low, moderate, or high VAS score groups, p 00.08
(Table 3).
When comparing different episiotomy techniques, we
found no difference in VAS score distribution (Table 3).
Linear regression analysis of VAS score as a continuous
variable showed no association with episiotomy technique,
p00.24. Adjusting for delivery method, epidural analgesia
during delivery, and any additional spontaneous vaginal
tears did not alter our conclusions.
When comparing our three categorized episiotomy inci-
sion point groups, there was no difference in postpartum
perineal pain perception (Table 3). Incision point distance as
a continuous variable showed no association with VAS
scores, p00.95 in a linear regression model. We compared
short episiotomies (≤24 mm) to long episiotomies (≥35 mm)
and found no difference in perineal pain perception related
to episiotomy length for the VAS score group distribution
(Table 3). Linear regression of episiotomy length as a con-
tinuous variable showed no association with VAS scores,
p00.97. All regression analyses were adjusted for delivery
method, epidural analgesia during delivery, and additional
vaginal tears without altering our conclusions.
OASIS
Of the 300 participants, 12 had an obstetric anal sphincter
injury. None of these women had a lateral episiotomy. A
midline episiotomy had been performed in 25 % of OASIS
cases (n03), 25 % had a mediolateral episiotomy (n03), and
50 % of OASIS cases (n06) had a nonclassifiable episiotomy,
p00.003. The majority (58.3 %, n07) had a midline incision
point (0–3 mm from the posterior fourchette), 33.3 % (n04)
had a nonclassifiable incision point (4–9 mm from the poste-
rior fourchette), and only one woman had an incision point
more than 10 mm from the midline, p00.001. Mean incision
point distance to midline was significantly shorter among
Int Urogynecol J

Table 3 Percentage distribution

of three VAS categories of peri- Characteristics VAS scores
neal pain the first postpartum
day (n0208/300) by episiotomy 0–3 4–6 7–10
technique, analgesia, and mater- Total n0208 n078 n089 n041 p
nal age
Midline episiotomy (n016) 44 44 12 0.4
Mediolateral episiotomy (n026) 50 27 23
Lateral episiotomy (n091) 38 47 15
Nonclassifiable episiotomy (n075) 32 43 25

Episiotomy length≤24 mm (n046) 33 39 28 0.5

Episiotomy length ≥35 mm (n074) 36 45 19
Episiotomy length 25–34 mm (n088) 41 43 16

Incision point from post fourchette (mm)

0–3 (n043) Midline 46 33 21 0.4
4-9 (n051) 31 43 26
≥10 (n0114) Lateral 37 46 17

Episiotomy only (n0138) 36 45 19 0.2

Additional vaginal tear (n062) 40 42 18
Obstetric anal sphincter injury (n08) 37 13 50

Spontaneous delivery (n091) 43 34 23 0.08

Instrumental delivery (n0117) 33 50 17

Maternal age (years)

18–29 (n0103) 40 39 21 0.8
30–34 (n0130) 35 47 18
35–44 (n067) 38 40 22

Epidural during delivery (n0122) 38 43 19 0.9

No epidural during delivery (n086) 37 42 21

women with OASIS compared to women without OASIS (4.5
and 10.5 mm, respectively, p00.002).
Blood loss
Postpartum blood loss varied from 100 to 2,000 ml (median
350 ml, mean 423 ml) and in most cases (74 %) blood loss
was estimated to 400 ml or less. In a univariate analysis,
higher birth weight and instrumental delivery were the only
significant risk factors for excessive blood loss (Table 4).
We found no differences in blood loss between episioto-
my techniques, neither when dichotomizing postpartum
blood loss into normal (0–499 ml) and excessive (≥
500 ml) (Table 4) nor when analyzing blood loss as a
continuous variable in a linear regression model, p00.57.
When comparing our three incision point groups, there was
no difference in distribution of normal or excessive blood
loss (Table 4). We found no association between blood loss
and episiotomy incision point when analyzing both param-
eters as continuous variables, p 00.65. Adjusting for
delivery method, epidural analgesia and vaginal tears did
not alter our conclusions.
When comparing the shorter episiotomies (≤24 mm, n070)
to the longer (≥35 mm, n0176), there was no difference be-
tween blood loss groups related to episiotomy length (Table 4).
However, when analyzing episiotomy length as a continuous
variable we found a borderline significant p value of 0.06. In a
multivariate regression analysis, birth weight was the only
variable associated with an increased risk of a heavier bleed,
but when excluding excessive blood loss of more than 800 ml,
additional spontaneous vaginal tears were also shown to be a
risk factor for increased blood loss, as expected, p00.001.
Discussion
Our study showed that lateral episiotomies were neither
associated with more perineal pain the first postpartum day
nor with more blood loss compared to the midline and
mediolateral episiotomy techniques.
 Int Urogynecol J

Table 4 Clinical characteristics

of total study group (n0300). Characteristics Blood loss (ml)
Postpartum blood loss in two
categories (normal and exces- Normal Excessive
sive) by episiotomy characteris- 0–499 500–2,000
tics (evaluated postpartum) n0230 n070 p

Episiotomy length (mm)

Short: ≤ 24 mm (n070) 79 % 21 % 0.2
Long: ≥ 35 mm (n0176) 71 % 29 %
25–35 mm (n0124) 81 % 19 %

Episiotomy technique
Midline (n020) 80 20 0.9
Mediolateral (n038) 74 26
Lateral (n0133) 75 25
Non classifiable (n0109) 79 21

Incision point (mm distance from posterior fourchette)

Incision point 0–3 (n060) Midline 77 23 0.5
Incision point 4–9 (n075) 81 19
Incision point≥10 (n0165) Lateral 75 25

Delivery mode
Spontaneous (n0133) 83 17 0.009
Instrumental (n0167) 71 29

Tears
Episiotomy only (n0212) 79 21 0.2
Additional vaginal tear (n076) 72 28
Obstetric anal sphincter injury (n012) 58 42

Parity (previous vaginal delivery)

Para 0 77 23 0.6
Para 1-2 77 23

Age, mean (years) 31 31.5 0.5

Birth weight, mean (g) 3471 3654 0.004
Placental weight, mean (g) 634 680 0.1
Duration of second stage, mean (min) 46 47 0.7

In addition to episiotomy techniques, we separately ana-
lyzed episiotomy incision points in relation to postpartum
perineal pain perception, assessed by VAS scores. Regardless
of whether the episiotomy incision point was lateral or midline,
there was no difference in reported pain perception the first day
after delivery or after adjusting for confounding factors such as
delivery method, epidural analgesia, or additional vaginal
tears. When assessing episiotomy length in relation to perineal
pain perception, longer episiotomies were not perceived as
more painful than shorter ones. To our knowledge, no study
comparing postpartum perineal pain in relation to episiotomy
technique or length has previously been published.
A weakness of this study is that we lack a vaginally
delivered control group without episiotomy, but as we were
primarily interested in assessing whether there were actual
differences between episiotomy techniques in relation to
perineal pain perception, we did not include such controls
in our study. However, many previous studies have com-
pared effects of episiotomy to no episiotomy and to sponta-
neous second-degree lacerations in regard to postpartum
perineal pain [21–25], although all studies are on the medio-
lateral or midline episiotomy technique. Still, there seem to
be many notions and myths linked to the lateral technique,
possibly because there are very few publications on lateral
Int Urogynecol J
episiotomy in general. Misconceptions in the literature as to
the correct definition of the lateral technique also exist [26].
Current studies [7, 11, 12] indicate that the lateral technique
may in fact be practiced in several European countries, and
possibly more frequently than earlier perceived.
When using an alternative classification of episiotomies,
by incision point solely and regardless of angle and tech-
nique, we found that a long distance from the incision point
to the posterior fourchette was not associated with more
postpartum perineal pain, supporting and strengthening our
finding that lateral episiotomies (incision point ≥10 mm
from the posterior fourchette) are not associated with more
pain than other common episiotomy types.
Our study showed that the lateral technique was the most
frequently performed episiotomy in our unit, but that both
mediolateral and midline episiotomies were performed, ei-
ther intentionally or unintentionally. The midline episiotomy
technique is, however, not recommended in our hospital due
to the risk of the incision extending into the anal sphincter
complex [17, 27].
We found that mean lateral episiotomy angle was signifi-
cantly larger compared to mean mediolateral episiotomy angle
and that lateral episiotomies were significantly longer than
mediolateral episiotomies. This might indicate that the lateral
episiotomy is easier to perform with a correctly large enough
angle and length compared to the mediolateral episiotomy.
However, our study has an overrepresentation of the lateral
(n0133) compared to the mediolateral (n038) technique, and
such a hypothesis needs to be explored in larger studies.
All clinical episiotomy assessments were performed post-
partum, when there is no distension of the perineum due to
crowning of the fetal head. The episiotomy suture angle
measured therefore does not necessarily equal the actual
incision angle (Figs. 1 and 2). We hypothesized that lateral
episiotomies would have a similar reduction in angle as
mediolateral episiotomy angles have been shown to have,
when comparing incision to suture angle [19, 20]. There are,
however, no studies reporting such an association for lateral
episiotomies, and a potential reduction of lateral episiotomy
incision to suture angle needs to be confirmed in future
observational trials.
Since we found mediolateral episiotomy angles to be sig-
nificantly narrower than lateral episiotomy angles, this addi-
tionally raises the question of whether or not lateral
episiotomies could be better suited than mediolateral episiot-
omies to prevent OASIS. If it is easier to maintain an optimal-
ly large angle when the episiotomy incision point is lateral and
not midline, the lateral technique could possibly pose the
lesser risk for anal sphincter lacerations. Large register studies
on mediolateral and lateral episiotomy have shown a benefi-
cial effect of episiotomy at instrumental delivery, namely, as
being protective against OASIS [28–30], but large prospective
observational studies are lacking. None of the 12 women with
OASIS in our study had a lateral episiotomy performed, and
11 of these 12 cases had an episiotomy with an incision point
less than 10 mm from midline. Due to the low number of
women with OASIS and our observational study design, we
are cautious about drawing any conclusions as to lateral
episiotomies being superior to mediolateral episiotomies in
preventing OASIS, and our study was not designed to explore
an OASIS-preventing effect of different episiotomy techni-
ques. A randomized controlled trial would be a method of
choice to explore such a hypothesis.
As the episiotomies performed by doctors in our study
nearly exclusively occurred during instrumental vaginal de-
livery and the episiotomies performed by midwives oc-
curred (with two exceptions) during spontaneous delivery,
it is not surprising that doctors performed longer episioto-
mies than midwives. Our findings on differences between
midwives and doctors in episiotomy length also coincide
with the studies by Tincello et al. [12] and Andrews et al.
[13]. However, our study shows no significant difference in
episiotomy angle between professions, in contrast to results
in the two previously mentioned papers. A possible expla-
nation could be that both professions in our unit favored the
lateral episiotomy technique, supporting the hypothesis that
lateral episiotomies may be easier to perform with a correct
and wide enough angle compared to the mediolateral
technique.
One third of episiotomies (doctors and midwives equally
represented) were nonclassifiable, meaning the incision
point was incorrect according to our definitions, or the
episiotomy angle was either too narrow or too large. Wheth-
er these episiotomies were intended to be mediolateral or
lateral is unclear, but we cannot exclude incorrect training in
either technique to be the cause of such a large nonclassifi-
able group.
We found no association between episiotomy technique
or episiotomy incision point related to estimated blood loss.
Not surprisingly we did find an association between large
infant birth weight and increased blood loss, which is a
natural consequence of blood loss at birth being more
strongly associated with uterine bleeding than bleeding from
the actual episiotomy.
To the best of our knowledge only a few studies have
looked at episiotomy technique and association with blood
loss per se. Baksu et al. [31] compared midline to mediolateral
episiotomies and found a significant difference in blood loss
between midline and mediolateral techniques when repair was
performed after placental removal. No differences between
techniques were found when repair was done before placental
expulsion. This correlates with the blood loss-associated find-
ings in our study, as our department practices episiotomy
repair before placental expulsion. However, a limitation of
our study is that the blood loss data are subjective estimations
recorded by the accoucheur and not based on more objective

measurements such as postpartum reduction in hematocrit and
hemoglobin levels.
Several studies have assessed benefits and complications of
episiotomies, but the results have been conflicting. A serious
limitation in the existing literature, and a possible contributor
to conflicting results, is the fact that the majority of studies
lack an assessment of the actual episiotomy performed. Var-
iations in mediolateral technique performance [11–13] and
lack of specific technique documentation within and between
obstetrical units may very well undermine previous evalua-
tions of episiotomy complications and benefits.
In conclusion, there seems to be little difference in peri-
neal pain perception and postpartum blood loss between
midline, mediolateral, and lateral episiotomy techniques.
Our study adds important clinical information in demon-
strating that lateral episiotomies and lateral incision points
are not associated with augmented postpartum perineal pain
or augmented postpartum blood loss compared to other
episiotomy techniques performed.
Acknowledgments We thank Anette Schmidtke for contributing to
quality control of data collection from the medical charts and Olivia
Österberg for graphical illustrations, Figs. 1 and 2. This study received
funding from the Norwegian Research Council and the Faculty of
Medicine, University of Oslo, Norway.
Conflicts of interest None.
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