Does episiotomy increase perineal laceration

length in primiparous women? - POEMs

Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women.
Am J Obstet Gynecol 2001; 185:444-50.
* BACKGROUND Episiotomy was initially used based on theoretical beneIit, with little
evidence supporting claims that it prevented severe perineal lacerations or pelvic Iloor
dysIunction. As principles oI evidence-based medicine have begun to inIluence obstetrical
practice, the utility oI routine episiotomy has been called into question. Several observational
studies have suggested that episiotomy increases the risk oI third-and Iourth-degree lacerations.
A recent Cochrane review oI 6 randomized controlled clinical trials comparing routine versus
restricted use oI episiotomy showed that episiotomy was associated with more second-degree
perineal trauma, without signiIicant diIIerences in dyspareunia, severe perineal trauma, or severe
pain. Although all but one oI the trials included in the review used mediolateral episiotomy, the
one randomized trial conducted in North America (which used midline episiotomy) showed
similar results. Despite these data, episiotomy remains a common practice perIormed in more
than 40 oI deliveries in the United States.
* POPULATION STUDIED The authors oI this study enrolled 80 pregnant women at term who
had not had previous vaginal deliveries. The 62 who went on to have vaginal deliveries were
included in the analysis. The participants' mean age was 26.3 years. The majority (92) had
prenatal care, and most (88) had epidural analgesia during labor. Approximately one Iourth oI
the women (28) had Iorceps or vacuum-assisted delivery. A Iew had malpresentations, with
6 in the occiput posterior position.
* STUDY DESIGN AND VALIDITY This small observational study looked at a range oI
variables hypothesized to be related to perineal laceration length, including maternal
demographics, size oI genital hiatus and perineal body, Ietal size and presentation, duration oI
second stage oI labor, level oI experience oI birth attendant, operative vaginal delivery, and
episiotomy. AIter delivery, one oI the study authors measured perineal laceration length, and Ior
10 patients 3 additional observers measured laceration length to assess interrater reliability.
Observers were blinded to one another's measurements but not to the other variables included in
the analysis. The authors used logistic regression and Mann-Whitney U test to determine which
variables were associated with laceration length.
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COPYRIGHT 2001 Appleton & Lange
COPYRIGHT 2002 Gale Group