Episiotomy

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Medical Intern: Forat Obid
 ‫يقول ابن القيم رحمه هللا‪:‬‬

‫"إذا أصبح العبد وأمسى وليس همه إال هللا وحده‪ ،‬تحمل هللا سبحانه حوائجه كلها‪ ،‬وحمل عنه كل ما‬

‫فر غ قلبه لمحبته‪ ،‬ولسانه لذكره‪ ،‬وجوارحه لطاعته‪..‬‬

‫أهمه‪ ،‬و ّ‬

‫و إن أصبح وأمسى والدنيا همه حمله هللا همومها‪ ،‬وغمومها‪ ،‬وأنكادها‪ ،‬ووكله إلى نفسه‪ ،‬فشغل قلبه‬

‫عن محبته بمحبة الخلق‪ ،‬وشغل لسانه عن ذكره بذكرهم‪ ،‬و جوارحه عن طاعته بخدمتهم و أشغالهم‪،‬‬

‫فهو يكدح كدح الوحوش في خدمة غيره كالكير ينفخ بطنه‪ ،‬ويعصر أضالعه في نفع غيره‪ ،‬فكل من‬

‫أعرض عن عبودية هللا‪ ،‬و طاعته‪ ،‬ومحبته بلي بعبودية المخلوق‪ ،‬ومحبته‪ ،‬وخدمته"‪.‬‬
‫‪) say: “Whoever is focused only on‬ﷺ ‪The Messenger of Allah‬‬
‫‪this Dunya, Allah will confound his affairs and make him fear‬‬
‫‪poverty constantly, and he will not get anything of this world‬‬
‫‪except that which has been decreed for him. Whoever is‬‬
‫‪focused on the Hereafter, Allah will settle his affairs for him and‬‬
‫‪make him feel content with his lot, and his provision and‬‬
‫‪worldly gains will undoubtedly come to him).‬‬
 Episiotomy

It’s a surgically planned incision on the perineum

and the posterior vaginal wall during the second

stage of labor to enlarge the pelvic soft tissue

outlet and thereby prevent severe perineal

laceration.
 Prevalence of
Episiotomy

• Episiotomy known in the field of OBGYN for more than 300 years.

• By 1979, episiotomy was performed in approximately 63% of all

deliveries in the United States. In some countries it reached 96%.

• In 1996, the World Health Organization (WHO) recommended an

episiotomy rate of approximately 10 percent.

• In 2018, the WHO advised against routine or liberal use of

episiotomy for individuals undergoing spontaneous vaginal

delivery. Selective episiotomy cases to be identified.

1.Intrapartum care for a positive childbirth experience. World Health Organization. 2017.
https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/.
https://www.ajog.org/article/S0002-9378(08)02241-2/fulltext
 - Reduce the risk of perineal trauma. Lack of
- Reduce pelvic dysfunction and prolapse.
evidence in
- Reduce urinary and fecal incontinence.
many areas.
- Baby: Shorter 2nd stage of labor and helps in
instrumental deliveries, less shoulder dystocia.

Benefits and Risks

of Episiotomy
- Extension of the incision, leading to third- and fourth-
degree tears, particularly for median episiotomy.
- Risk of unsatisfactory anatomic results (eg, skin tags,
asymmetry, fistula, narrowing of introitus).
- Increased blood loss.
- Higher rates of infection.
- Increased risk of severe perineal laceration in
subsequent deliveries.

Pergialiotis V, Bellos I, Fanaki M, et al. Risk factors for severe perineal trauma during childbirth: An updated meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 247:94.

van Bavel J, Hukkelhoven CWPM, de Vries C, et al. The effectiveness of mediolateral

episiotomy in preventing obstetric anal sphincter injuries during operative vaginal delivery: a ten-year analysis of a national registry. Int Urogynecol J 2018; 29:407.
 Episiotomy and Fetus:

- Expedite delivery of the fetus: In some cases, such as

with a category III fetal heart rate tracing that does not
respond to resuscitative measures.
- Operative vaginal delivery – Episiotomy can be used
to facilitate placement of the forceps or vacuum
extractor in women with a narrow vaginal outlet.
• In a systematic review and meta-analysis of 15 studies comparing
mediolateral or lateral episiotomy with no episiotomy in primiparous
women undergoing vacuum assisted delivery, mediolateral or lateral
episiotomy was associated with an approximately 50% reduction in
risk of anal sphincter laceration compared with no episiotomy.
Lund NS, Persson LK, Jangö
H, et al. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a system
atic review and meta-analysis.
Guidelines

National guidelines from 2008-2019 studied and compared, with 13 national guidelines
identified. Prevention of OASI (Obstetric Anal Sphincter Dysfunction) during
instrumental delivery using a mediolateral episiotomy was recommended in seven
guidelines. One reported there was insufficient evidence to recommend episiotomy for
all instrumental deliveries. The German and Danish guidelines only mentioned
episiotomy with vacuum delivery, while forceps delivery was not mentioned.

Roper, J. C., Amber, N., Wan, O., Sultan, A. H., & Thakar, R. (2020). Review of available national
guidelines for obstetric anal sphincter injury. International urogynecology journal, 31(11), 2247–2259.
https://doi.org/10.1007/s00192-020-04464-5
Guidelines

✓ = included and recommended, (✓) = recommended with restrictions, i = 

insufficient evidence for recommendation, N = not mentioned
 Episiotomy & Perineal
Laceration

• In a 2014 meta-analysis of 22 observational studies that included

over 651,000 women (2.4 percent with severe lacerations),
median episiotomy was associated with a nearly 4X increased
risk of third- or fourth-degree perineal lacerations but
mediolateral episiotomy did not increase the risk.
• A 2020 meta-analysis with 43 studies and 716,000 women (3.1
percent with severe lacerations) reported an increased risk of
anal sphincter laceration with median episiotomy but not with
mediolateral episiotomy. Mediolateral episiotomy was not
protective but also not associated with an increased risk.

Pergialiotis V, Vlachos D, Protopapas

A, et al. Risk factors for severe perineal lacerations during childbirth. Int J Gynaecol Obstet
 Mediolatral Episiotomy

Higher risk of anal sphincter laceration.

- Mediolateral episiotomy is associated

with increased blood loss.
- Mediolateral episiotomy has historically
been thought to result in more perineal
pain and dyspareunia.
Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric
haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993; 48:15.
Median Episiotomy
 RCO
G
ACO
WHO
G
Mediolateral is
Several studies have shown that an angle of 60
degrees is associated with a lower risk of third-
advisable rather
degree tears and injury to the anal sphincter. This
evidence, however, is not based on large
than median
randomized controlled trials. episiotomy
Kalis V, Landsmanova J, Bednarova B, Karbanova J, Laine K, Rokyta Z. Evaluation of the incision angle of mediolateral episiotomy at 60
degrees. Int J Gynaecol Obstet. 2011 Mar;112(3):220-4. [PubMed] [Reference list]
Royal College of Obstetricians and Gynaecologists. Green-top guideline No. 26: Operative vaginal delivery, 2011.
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg26.pdf (Accessed on August 03, 2016).
Selective vs Routine
Episiotomy

• Selective use of episiotomy compared with its routine use during vaginal
birth is associated with lower rates of posterior perineal trauma, less
suturing, and fewer healing complications.
• According to a Cochrane database review by Xu Qian et al., the
implementation of a selective episiotomy policy in women undergoing non-
operative vaginal delivery, resulted in significantly fewer women with severe
perineal trauma when compared to women who underwent routine
episiotomy.

Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000081. 
Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst
Rev. 2017 Feb 08;2:CD000081. 
 Restrictive Episiotomy:

In a meta-analysis of 12 trials comparing restrictive episiotomy use

with routine use in women expecting an unassisted vaginal birth,

restrictive episiotomy resulted in up to 30% fewer women

sustaining severe perineal or vaginal trauma.

Jiang H, Qian X, Carroli

G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Datab
ase
 IMPACT ON FUTURE
DELIVERIES

In a review of over 6000 deliveries that compared women with

episiotomy at first delivery versus those without, women with prior

episiotomy had a greater number of severe perineal lacerations (4.8

versus 1.7 percent) and more second-degree lacerations (51.3

versus 26.7 percent) at the time of subsequent delivery.

Alperin M, Krohn MA, Parviainen

K. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal deli
very.
Delivery after OASI

Research in the role of elective episiotomy during a subsequent vaginal

delivery following OASI (Obstetric Anal Sphincter Dysfunction) has
recently been published. D’Souza et al. concluded that mediolateral
episiotomy in subsequent vaginal deliveries decreases the recurrence
rate of OASI in women who have had a previous OASI by 80%.

D’Souza JC, Monga A, Tincello DG, Sultan AH, Thakar R, Hillard TC, et al. Maternal outcomes in subsequent delivery after previous obstetric anal
sphincter injury (OASI): a multi-Centre retrospective cohort study. Int Urogynecol J. 2019. 10.1007/s00192-019-03983-0.  [PMC free article] [PubMed] [
Ref list]
Guidelines

✓ = included and recommended, (✓) = recommended with restrictions, i = 

insufficient evidence for recommendation, N = not mentioned
 Take Home Message

• One must ensure that the benefits of the procedure outweigh the
risks during the decision-making process.
• Routine use of episiotomy has fallen out of favor based on
evidence of increased complications with use.
• Episiotomy is now performed on an individualized basis.
• Mediolateral episiotomy is associated with a lower risk of third-
and fourth-degree laceration than a median episiotomy.
 References:
 Up to Date
 MOH
 WHO
 RCOG
 ACOG
 Medscape
 Systematic review, clinical trials, Cochrane reviews, national guidelines.
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