International Urogynecology Journal

https://doi.org/10.1007/s00192-020-04308-2

ORIGINAL ARTICLE

Selective episiotomy versus no episiotomy for severe perineal

trauma: a systematic review with meta-analysis
Gláucia Miranda Varella Pereira 1 & Renato Sugahara Hosoume 2 & Marilene Vale de Castro Monteiro 3 &
Cassia Raquel Teatin Juliato 1 & Luiz Gustavo Oliveira Brito 1

Received: 12 September 2019 / Accepted: 7 April 2020

# The International Urogynecological Association 2020

Abstract
Introduction and hypothesis We hypothesized whether a non-episiotomy protocol or administration of selective episiotomy as
an intrapartum intervention would modify the incidence of obstetric anal sphincter injuries (OASIS).
Methods We registered this systematic review with the PROSPERO database (CRD42018111018). Prospective randomized
controlled trials (RCTs) were included from databases until February 2019. The primary outcome was OASIS, and the secondary
outcomes were any perineal trauma, duration of the second stage of labor, instrumental delivery, and post-partum hemorrhage.
The risk of bias (Cochrane Handbook) and the Grading of Recommendations, Assessment, Development and Evaluations
(GRADE) criteria were used to assess the RCTs.
Results A total of 1,833 results (PubMed 650, SCOPUS 1,144, Cochrane Library 33, LILACS 6) were obtained. However, only
2 studies fulfilled the criteria for quantitative analysis and meta-analysis (n = 574). The non-episiotomy arm included two
episiotomies (1.7% of deliveries), whereas the selective episiotomy included 33 episiotomies (21.4%). Performance of selective
episiotomy demonstrated no difference compared with that of the non-episiotomy group with regard to OASIS (OR = 0.46 [0.15–
1.39]; n = 543; I2 = 0%,p = 0.17), any perineal trauma (OR = 0.90 [0.61–1.33]; I2 = 0%, n = 546, p = 0.59), instrumental delivery
(OR = 1.40 [0.80–2.45]; I2 = 0%, n = 545, p = 0.24), duration of the second stage of labor (MD = -3.71 [−21.56, 14.14]; I2 =
72%,n = 546, p = 0.68), perineal pain (MD = 0.59 [0.01–1.17]; I2 = 0%,p = 0.05), and post-partum hemorrhage (OR = 1.75
[0.87–3.54]; I2 = 0%,n = 546,p = 0.12). The evaluated studies displayed a low risk of bias in at least four of the seven categories
analyzed. GRADE demonstrated a low certainty for severe perineal tears, postpartum hemorrhage, duration of the second stage of
labor, and a moderate certainty for any perineal tear.
Conclusions There was no significant difference between non-episiotomy and selective episiotomy regarding OASIS. No RCT
was able to confirm a benefit of the non-performance of episiotomies in the non-episiotomy arm.

Keywords Episiotomy . Meta-analysis . Perineal trauma . Systematic review

Introduction
This study was presented at the Joint Meeting of the American
Severe perineal trauma or obstetric anal sphincter injuries
Urogynecological Society and International Urogynecological
Association, Nashville, TN, USA, 24–28 September 2019 (OASIS) is an undesirable intrapartum outcome and should
be prevented or adequately repaired immediately. There are
* Luiz Gustavo Oliveira Brito some established risk factors that may be identified before the
lgobrito@gmail.com start of labor. However, none of these factors is entirely pre-
dictive. The prevalence of OASIS appears to be increasing,
1
Department of Obstetrics and Gynecology, State University of but the causes remain unknown. Overdiagnosis, or the pres-
Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade
Universitária, Campinas 13148-254, Brazil
ence of real defects, could potentially be causative [1]. Ideally,
2
the incidence of OASIS should be <5%, as this variable is
Centro de Referência em Saúde da Mulher (Mater-RP), Ribeirão
Preto, Brazil
considered a maternity quality indicator [2]. Therefore,
3
methods of prevention should be discussed with pregnant
Department of Obstetrics and Gynecology, Federal University of
Minas Gerais (UFMG), Belo Horizonte, Brazil
women during the antepartum and/or intrapartum periods.

Routine episiotomy increases the risk of OASIS [3] by
30%. Thus, selective episiotomy is the current recommenda-
tion. However, selective episiotomy remains a controversial
method for the prevention of perineal trauma. A recent review
has demonstrated that restrictive mediolateral episiotomy is
effective in reducing OASIS, but this has not been confirmed
among nulliparous women [4]. Another review focusing on
vacuum-assisted delivery has demonstrated similar results [5],
but the majority of studies are observational. When analyzing
episiotomies between women with OASIS and a control
group [6], a case–control study has shown that an episiotomy
angle of >30°, with a episiotomy–fourchette distance of
>5 mm, would reduce the risk of OASIS.
However, because the evidence is inconclusive, some pro-
fessionals have opted to refrain from performing episiotomies
[7] because there is potential for other complications such as
postpartum hemorrhage [8] and dyspareunia [9] following this
surgical procedure. Thus, there are inadequate data as to
whether not performing episiotomy may be useful in reducing
the incidence of OASIS. Consequently, we aimed to assess
whether not performing episiotomy (non-episiotomy) or
performing selective episiotomy would modify the incidence
of perineal trauma.
Materials and methods
Study selection and eligibility criteria
This systematic review followed the guidelines of the
Preferred Reporting Items for Systematic Review and Meta-
Analyses (PRISMA) statement for meta-analyses of interven-
tional studies [10, 11] and was registered (CRD
42018111018) in the PROSPERO database [12]. As this was
a systematic review, the local institutional review board
exempted the protocol from analysis. The research question
was formulated according to the Population, Intervention,
Comparator, Outcome Study (PICOS) design. Only prospec-
tive studies and randomized clinical trials (RCTs) from their
inception until February 2019 from the following databases
(PubMed, SCOPUS, Cochrane Library, LILACS) were in-
cluded. References and related articles from the databases
were also evaluated. No gray literature was consulted in this
review. Retrospective studies and case series, as well as stud-
ies comparing routine episiotomies, were excluded. A search
strategy with the terms (“zero episiotomy” OR “selective epi-
siotomy” OR “episiotomy” OR “non-episiotomy” OR “no
episiotomy”) (“RCT” OR “randomized clinical trial” OR “tri-
al” OR “prospective study”) was developed, with no language
restrictions. Reference lists of eligible studies were manually
searched to identify other relevant studies. Two reviewers
(G.M.V.P., R.S.H.) independently screened the titles and ab-
stracts of all retrieved articles. Abstracts that met the inclusion
Int Urogynecol J
criteria were selected for further analysis. Full-text articles
were subsequently assessed by the two reviewers and in the
event of disparities related to the previous analysis (titles/ab-
stracts) and full-text analysis, a third co-author (L.G.O.B) was
consulted for consensus.
Outcomes
Two intervention groups (selective/restrictive episiotomy and
non-episiotomy) were created. Selective or restrictive episiot-
omy considered any study that did not include patients who
underwent episiotomy, under all circumstances. We assumed
that this criterion would be related to professional judgment.
Non-episiotomy was confined to any trial arm, the goal of
which was not to perform episiotomy. The primary outcome
was OASIS (third- or fourth-degree perineal tear according to
ACOG or RCOG), any perineal trauma (first-, second-, third-
and fourth-degree perineal tears), duration of the second stage
of labor (min), instrumental delivery (forceps/vacuum), peri-
neal pain (defined by verbal numeric scale/visual pain scale),
and post-partum hemorrhage (defined as blood loss of
>500 ml).
Data extraction and quality assessment
Both reviewers independently conducted data extraction using
an electronic data form to record the study characteristics such
as sample size, inclusion and exclusion criteria, primary and
second outcomes, and randomization and allocation process-
es. For variables that were present in both studies but reported
differently (i.e., classified differently), we emailed the authors
seeking clarification so that data could be accurately analyzed.
Risk of bias (Cochrane Handbook for Systematic Reviews
of Intervention version 5.1.0 [13]) and the Grading of
Recommendations, Assessment, Development and
Evaluations (GRADE) [14] criteria were utilized by the two
reviewers to assess the randomized clinical trials. For risk of
bias, the studies were classified as “low risk,” “high risk,” and
“unclear risk” for the categories random sequence generation,
allocation concealment, blinding of participants and personnel,
blinding of outcome assessment, selective reporting, and other
biases (these include biases that do not fit into the aforemen-
tioned categories) [13]. The GRADE system was used to rate
the quality of evidence and to grade the strength of the recom-
mendations of the studies retrieved for quality analysis [14].
A meta-analysis was performed for each variable represent-
ed in at least two studies. A random-effects analysis was per-
formed if heterogeneity was >50% (I2 test). Odds ratio (OR)
and mean difference (MD) were plotted for dichotomous and
continuous variables respectively. Regarding perineal pain,
one study reported the results as means and the other as me-
dians. According to the Cochrane handbook, if the distribution
is normal, the median could be approximated for the mean and
Int Urogynecol J
the width of the interquartile range would be approximately
1.35 times the standard deviation. This calculation was used in
the meta-analysis. No funnel plot was performed owing to the
small number of studies evaluated.
Results
A total of 1,833 (PubMed 650, SCOPUS 1,144, Cochrane
Library 33, LILACS 6) results were retrieved from the data-
bases. After the exclusion of duplicates and screening, we
selected 9 articles for full-text assessment. Of these, 7 articles
were excluded because they did not fulfill the inclusion
criteria. Finally, 2 studies remained for quantitative analysis
and meta-analysis (Fig. 1) [15, 16], comprising 574 women.
Interestingly, Sagi-Dain et al. performed a subgroup analysis
for spontaneous vaginal birth and vacuum extraction [15].
The main characteristics of the studies included are shown
in Table 1. Mean maternal age ranged between 23 and
28 years. Gestational age and birth weight were similar in
the two groups. The episiotomy rate differed significantly be-
tween the studies, varying from 1.6–1.7% to 21.4%–26.5%
Fig. 1 Preferred Reporting Items
for Systematic Review and Meta-
Analyses (PRISMA) flowchart
for the selected studies
(p < 0.05). One RCT described episiotomy as “selective epi-
siotomy” and was performed according to the professional’s
clinical judgment [16]. The other RCT referred to episiotomy
as “mediolateral or lateral episiotomy” (45°–60°), 3–4 cm in
length [15]. The reason for performing two episiotomies in the
study by Amorim et al. in the non-episiotomy group was
prolonged second stage of labor [16]. Sagi-Dain et al. per-
formed 33 episiotomies in the non-episiotomy arm owing to
fetal distress, OASIS prevention, vacuum delivery, prolonged
second stage of labor, shoulder dystocia, and insufficient
space in the perineum [15].
Figure 2 presents the forest plots of the primary and sec-
ondary outcomes. Heterogeneity was low in most of the out-
comes (I2 = 0%), except for the duration of the second stage of
labor (I2 = 72%). Performing selective episiotomy resulted in
no notable difference compared with the non-episiotomy
group with regard to OASIS (OR = 0.46 [0.15–1.39]; n =
543; I2 = 0%, p = 0.17), any perineal trauma (OR = 0.90
[0.61–1.33]; I2 = 0%, n = 546, p = 0.59), instrumental delivery
(OR = 1.40 [0.80–2.45]; I2 = 0%, n = 545, p = 0.24), duration
of the second stage of labor (MD = −3.71 [−21.56, 14.14],
I2 = 72%, n = 546, p = 0.68), perineal pain (MD = 0.59 [0.01,

Table 1 Main characteristics of the studies included
Amorim 2017
Non-episiotomy Selective episiotomy
Maternal age (mean ± SD) 23.9 ± 6.3 23.5 ± 5.6
Gestational age (weeks) 39a 39a
Birthweight 3,283.7 ± 408.1 3,259.8 ± 398.4
(mean ± SD)
Episiotomy rate (%) 1.7 1.6
Episiotomy description According to healthcare
clinical judgment—no angle description
Inclusion criteria Women clinically stable, in active labor with
live full-term singleton (37–41 weeks);
vertex presentation; dilatation (6–8 cm)
a
Median
b
Mean
1.17], I2 = 0%, n = 299, p = 0.05), and post-partum hemor-
rhage (OR = 1.75 [0.87–3.54], I2 = 0%, n = 546, p = 0.12).
The risk of bias (Fig. 3) was low in four categories
in both studies; a high risk was observed for perfor-
mance bias and an unclear risk in detection and
reporting bias for the study conducted by Sagi-Dain
et al. [15] An unclear risk for performance, detection,
and attrition bias was seen for the study performed by
Amorim et al. [16] GRADE criteria (Table 2) showed
low certainty for OASIS, post-partum hemorrhage, and
duration of the second stage of labor (downgrade on
risk of bias and imprecision) and a moderate certainty
for any perineal tear (downgrade on risk of bias). We
did not include perineal pain in this table because of
differences in statistical analysis, but the quality of ev-
idence was subjectively very low.
Discussion
In this meta-analysis, no difference was observed when the
performance of selective episiotomy was compared with that
of non-episiotomy with respect to OASIS, any perineal trau-
ma, instrumental delivery, duration of the second stage of
labor, and post-partum hemorrhage [17].
Rates of perineal trauma varied according to the character-
istics of the women, conditions of delivery, and obstetric care
[18]. The incidence of OASIS did not differ significantly be-
tween the study groups and was <3.9%. In the study conduct-
ed by Sagi-Dain et al., none of the participants experienced
fourth-degree perineal trauma [15]. Amorim et al. did not
report these data separately [16]. Contrary to our findings, a
previous meta-analysis showed an association between
Int Urogynecol J
Sagi-Dain 2018
Non-episiotomy Selective episiotomy
(“standard care”)
28.7 ± 4.1 28.3 ± 4.6
39.5b 39.8b
3,228.4 ± 451.7 3,285.8 ± 413.6
21.4 26.5
Mediolateral or lateral episiotomy
(45°–60° angle; 3–4 cm in length)
Women in first vaginal labor
(including vaginal labor after C-section);
singleton pregnancy (>34 weeks); vertex
presentation; no contraindications for vaginal delivery
episiotomy and an increased risk of anal incontinence
(OR = 1.74 [1.28–2.38]) compared with non-episiotomy,
whether perineal laceration extended up to the structures of
the anal sphincter. In contrast, in this meta-analysis, such an
association was unclear because the studies included had
problems related to quality [19]. Sagi-Dain et al. included
women in their first delivery [15], and Amorim et al. reported
that the majority of the population studied consisted of pri-
miparous women (59.9%) [16]. Even with no differences re-
garding OASIS between the selective episiotomy and non-
episiotomy groups, this fact should be taken into consideration
because primiparous women are at a higher risk of severe
perineal trauma [20–22]. A prospective cohort study on pelvic
floor outcomes in primiparous women showed an association
between vaginal birth and obstetric anal sphincter injury and
an increase in anal incontinence symptoms [23]. Any perineal
trauma as an outcome also showed no difference when the
performance of the selective episiotomy was compared with
that of non-episiotomy in the present meta-analysis.
Regarding instrumental delivery, the American College of
Obstetrics and Gynecologists indicates operative vaginal de-
livery in cases of “prolonged second stage of labor, suspicion
of immediate or potential fetal commitment, and shortening of
the second stage of labor for maternal benefit” [24].
Additionally, according to the Royal College of
Obstetricians and Gynecologists, “in the absence of robust
evidence to support the routine use of episiotomy in operative
vaginal delivery, restrictive use of episiotomy, using the oper-
ator’s individual judgment, is supported” [25]. The use of
forceps was reported only once in the non-episiotomy group
in the study by Amorim et al. [16]. In their study, Sagi-Dain
et al. performed a subgroup analysis for spontaneous vaginal
deliveries and deliveries with vacuum extraction [15]. In this
Int Urogynecol J

Fig. 2 Forest plot with all the variables investigated (a severe perineal groups (selective and non-episiotomy). CI confidence interval, df degrees
trauma/OASIS, b any perineal trauma, c instrumental delivery, d second- of freedom, IV weighted mean difference, SD standard deviation
stage duration, e post-partum hemorrhage, and f perineal pain) regarding

case, we did not extend our analysis to the subgroups, thus with vacuum extraction in the non-episiotomy group versus
restricting the intent-to-treat analysis, evaluating 33 deliveries 26 with vacuum extraction in the standard care group [15].

Fig. 3 Risk of bias summary
There has been a decline in instrumental delivery in the USA
in recent years, with a rate of just >3% in 2013 [26]. Similarly,
the downward trend in the USA had also been observed in
episiotomy rates with instrumental vaginal delivery [27].
Instrumental vaginal delivery has also been shown to be a risk
factor for severe perineal trauma. However, this risk factor is
usually associated with other obstetric factors such as high
birth weight, large head circumference, and occiput posterior
fetal position [28]. In a retrospective cohort study, the use of
forceps and vacuum extraction were associated with the risk
of severe perineal trauma [29].
Two episiotomies were performed in each study group in
Amorim et al. owing to the prolonged second stage of labor,
whether or not in association with another clinical factor [16].
Of the 33 episiotomies performed in the non-episiotomy
group in the study by Sagi-Dain et al., three were performed
with the aim of reducing the second stage of labor [15]. It is
noteworthy that, in an additional analysis of secondary out-
comes, the second stage of labor was significantly shorter in
the non-episiotomy group than in the standard care group (p =
0.0139). However, in the same study, the authors could not
explain the reason for this finding [15]. In the present meta-
analysis, we used the overall results because the studies by
Amorim et al. and Sagi-Dain et al. also showed no differences
between groups [15, 16]. One study reported increased rates
of severe perineal trauma after a prolonged second stage of
labor. In this study, rates of severe perineal trauma increased as
Int Urogynecol J
the duration of the second stage of labor increased (5.1%:
<1 h, 8.4%: 1–2 h, 13.8%: 2–3 h, 33.6%: 3–4 h, 23.5%: 4–
5 h, 28.56%: >5 h) [30]. On the other hand, differences were
not found between a prolonged second stage and severe per-
ineal trauma in a randomized controlled trial [31].
Implementation of an intervention program for reducing per-
ineal trauma during the second stage of labor seemed to de-
crease the frequency of severe perineal trauma [32].
Historically, an episiotomy may be considered in cases where
a reduction of the second stage of labor is justified as a result
of intrapartum complications, such as shoulder dystocia and
instrumental delivery [24]. To date, existing evidence has not
indicated in which situations episiotomy is crucial, with selec-
tive episiotomy being the best practice [3].
Amorim et al. reported a blood loss of ≤257 ml in both
groups with no difference between groups [16]. They collected
blood using plastic bags, sponges, and gauzes that were subse-
quently weighed, correcting for the dry weight. However, Sagi-
Dain et al. did not report the method for measuring postpartum
hemorrhage, stating only the definition of postpartum hemor-
rhage frequency as “subjective evaluation >500 ml or with
hemodynamic instability” in the first hour after birth [15].
According to two acknowledged guidelines, postpartum hem-
orrhage is the most common cause of maternal deaths, account-
ing for one-quarter of maternal deaths worldwide [33–35].
However, there is no consensus regarding the definition of
postpartum hemorrhage, and one potential cause may be the
challenges of accurately estimating blood loss [36].
Episiotomy is related to increased blood loss [37], but perineal
trauma also plays a role. Increased blood loss originating from
perineal trauma was found in vaginal births in the sitting posi-
tion, and a linear association was observed between the recum-
bent, semi-sitting, and sitting positions and increased risk of
blood loss in women with perineal trauma. This could be ex-
plained by venous obstruction caused by the birthing stool or
hard mattress [38]. Other types of upright positions were also
associated with perineal trauma and blood loss [39]. In contrast,
the maternal position during the second delivery stage made
little or no difference to postpartum hemorrhage in the study
by Walker et al. [40]. Amorim et al. have relied on the WHO
recommendations and a humanized model of evidence-based
childbirth care that provides ongoing support and protection of
the perineum during childbirth according to the woman’s pref-
erences and institution protocols [16]. Sagi-Dain et al. did not
mention the birth positions chosen in their study [15].
Our study possesses considerable strengths because the
subject covered in this meta-analysis raises important ques-
tions about whether episiotomy should be performed in a set-
ting of labor. We included all randomized clinical studies pub-
lished up to February 2019 that compared the performance of
selective episiotomy with that of non-episiotomy, thereby
highlighting the need for further discussion about the impor-
tance of episiotomy. Our meta-analysis follows the guidelines
 Int Urogynecol J

Table 2 Quality of evidence (Grading of Recommendations, Assessment, Development and Evaluations [GRADE] criteria) and recommendations of the studies included

Certainty assessment Number of patients Effect Certainty

Risk of bias Inconsistency Indirectness Imprecision Other Selective Non-episiotomy Relative (95% CI) Absolute(95% CI)
considerations episiotomy

Third and fourth perineal tear

Seriousa Not serious Not serious Seriousc None 4/269 (1.5%) 9/274 (3.3%) OR 0.46 17 fewer per 1,000 ⨁⨁◯◯ Low
(0.15 to 1.39) (from 28 fewer to 12 more)
Postpartum hemorrhage
Seriousa Not serious Not serious Seriousc None 21/269 (7.8%) 13/277 (4.7%) OR 1.75 32 more per 1,000 ⨁⨁◯◯ Low
(0.87 to 3.54) (from 6 fewer to 102 more)
Second stage of labor
Seriousa Seriousb Not serious Seriousd None 269 277 – MD 3.71 lower ⨁◯◯◯ Very low
(21.56 lower to 14.14 higher)
Instrumental delivery
Seriousa Not serious Not serious Seriousc None 34/268 (12.7%) 26/277 (9.4%) OR 1.40(0.80 to 2.45) 33 more per 1,000 ⨁⨁◯◯ Low
(from 17 fewer to 109 more)
Any perineal tear
Seriousa Not serious Not serious Not serious None 196/269 (72.9%) 208/277 (75.1%) OR 0.90(0.61 to 1.33) 20 fewer per 1,000 ⨁⨁⨁◯ Moderate
(from 103 fewer to 49 more)

Number of studies: two. Study design: randomized trials

CI confidence interval, OR odds ratio, MD mean difference
a
Incomplete blinding and unblinded
b 2
I is large
c
Small number of events and wide confidence intervals
d
Wide confidence intervals

of the PRISMA, adding quality to the information reported.
The limitation of this meta-analysis is the minimal number of
studies included, which limits subgroup analysis or the appli-
cation of other refined techniques. We contacted the authors
for further information about conducting a subgroup analysis
comparing only primiparous participants; however, no reply
was received. If this information had been provided, it would
have enriched the discussion about the role of episiotomy
compared with that of non-episiotomy. We had no access to
the subgroup analysis from the Sagi-Dain study regarding
patients with vaginal delivery after a previous cesarean section
to evaluate whether this subgroup of women would have had
different outcomes with respect to perineal trauma.
Concerning instrumental delivery, we remained restricted to
an intent-to-treat analysis without extending our analysis to
subgroups, as previously highlighted. Moreover, many vari-
ables from the GRADE criteria regarding both studies re-
ceived very low to low quality, which warrants serious con-
sideration in order to guide future studies on this subject.
Authors’ contribution to the manuscript G.M. Pereira: project develop-
ment, data extraction/analysis, manuscript writing/editing; L.G. Brito:
project development, data analysis, manuscript writing/editing; R.S.
Hosoume: data extraction, manuscript writing/editing; M.V. Monteiro,
C.R. Juliato: data analysis and manuscript editing.
Funding Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
(CAPES) code 001.
Compliance with ethical standards
Conflicts of interests None.
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