Episiotomy and third‐ and fourth‐degree perineal tears in primiparous Iranian women

Abstract

Episiotomy is perhaps the most frequently performed operative procedure during childbirth to facilitate delivery and prevention of perineal and rectal trauma. There is no evidence that routine or prophylactic episiotomy reduces the risk of severe perineal tears. Restrictive episiotomy policies appear to have a number of benefits, such as fewer posterior perineal tears, less suturing, and fewer complications [1]. However, some studies have reported that episiotomy protects against the occurrence of third-degree laceration and decreased the likelihood of it occurring [2], [3]. Unpublished data from our hospital suggest that the recent rate of episiotomy in primiparous women is about 39%, which is higher than evidence-based recommendations for optimal patient care. The main aim of the present study was to compare the rate of third- and fourth-degree perineal tears in two groups of women who did (group 1) and did not (group 2) undergo episiotomy. From April 2007 until March 2008, 283 primiparous women with a full term singleton pregnancy and no underlying problems participated in this randomized clinical trial at the Arash Hospital, in Tehran, Iran. Informed consent was provided by all participants. Exclusion criteria were noncephalic and cephalic presentations except occiput anterior and fetal macrosomia. Using Epi Info software (CDC, Atlanta, GA, USA) and the total rate of severe perineal tears in the two groups, the power of the study was more than 90%. P < 0.05 was considered significant. The mean age of the women in both groups was not significantly different (23.25 ± 5 vs 24.22 ± 4.41 years, P = 0.09). Average body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) was higher in the women who did not undergo episiotomy (group 2) compared with those who did have the procedure (28.45 ± 2.48 vs 27.63 ± 1.87, P = 0.002). Average head circumference was also higher in group 2 (34.98 ± 1.54 vs 34.54 ±1.73 cm, P = 0.025). Average birth weight was similar in both groups (3238.91 ± 399.99 vs 3158.22 ± 345.81 g, P = 0.07). The total rate of severe perineal tears in group 1 was significantly higher than in group 2 (18 cases [13.14%] vs 3 cases [2.05%], P = 0.0007). The 1-minute APGAR score was significantly different between the two groups (P = 0.05), but there was no difference at 5 minutes (P = 0.51). Short-term (after delivery) and long-term (after 6–8 weeks) complications were more common in group 1 (Table 1). The episiotomy odds ratio of 6.75 (95% CI, 3.93–23.95; P = 0.0006) was the only identified risk factor. Other variables (maternal age and BMI, birth weight and head circumference) had no significant effect on perineal tears. The present study demonstrated that routine episiotomy is associated with an increased risk of third- and fourth-degree tears and subsequent complications especially pain, dyspareunia, and incontinence. The study is consistent with others [1], [4] and supports the recommendation that routine episiotomy should be abandoned in obstetric centers in Iran.