Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury?
Our main objective was to investigate whether the implementation of a restrictive episiotomy policy in operative deliveries changes the incidence of obstetric anal sphincter injury (OASI).
This is an observational study over an 11-year period in Poitiers University Maternity, France. We included women with vaginal operative deliveries after 34 gestational weeks for singleton births in cephalic presentation. We collected data on the mother and operative delivery characteristics: indication, instrument, epidural analgesia, labor length, episiotomy, OASI, and birthweight. We investigated the changes in the mediolateral episiotomy (MLE) and OASI rates and the association between MLE and OASI. The primary outcome was the evolution of the OASI and MLE rates. The secondary outcome was the occurrence of OASI during operative delivery with or without MLE.
In total, 2357 operative deliveries were assessed, including 847 vacuum-, 1350 forceps- and 160 spatula-assisted deliveries. Of these, 950 were performed with MLE and 1407 without; 37 OASIs (3.9%) occurred in the MLE group, and 137 (9.7%) in the no-MLE group. Between 2005 and 2015, MLE use decreased from 78.5 to 16.2% and OASI occurrence increased from 3.1 to 12.7%. The increase in OASI occurrence was significant for forceps deliveries, but not for vacuum or spatula deliveries. Operative delivery with MLE was associated with a three times lower OASI occurrence than that without MLE (adjusted OR = 0.29, 95% CI [0.20–0.43]).
Implementation of a restrictive MLE policy for operative delivery seems to be associated with an increase in OASI incidence with forceps, but not with vacuum.
KeywordsObstetric anal sphincter injury Episiotomy Instrumental delivery Perineal trauma Childbirth
BG: wrote the main text of this manuscript, contribution to the study design, contribution to data analysis and interpretation, contribution to statistical analysis. He wrote the revised version of the manuscript. CFM: data collection, data analysis, statistical analysis, and review of each version of the manuscript. She reviewed the revised version of the manuscript. FP: contribution to the study design, contribution to data analysis and interpretation and review of each version of the manuscript. She reviewed the revised version of the manuscript. XF: contribution to the study design, contribution to data analysis and interpretation, contribution to statistical analysis, draft the work. She reviewed the revised version of the manuscript.
There was no funding for this study.
Compliance with ethical standards
Conflict of interest
The authors have no conflict of interest to disclose.
Ethical committee approval was not required for this study because we solely reported on anonymized data from patient’s medical records. These data have been collected in accordance with our usual practices and patients underwent no supplementary procedures for this investigation. Upon admission, each patient at our institution receives an institutional chart that specifically mention the possibility that anonymized medical data collected during hospitalization could be used for medical research.
- 1.Fritel X, Gachon B, Desseauve D, Thubert T (2018) Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention. Gynecol Obstet Fertil Senol 46:419–426Google Scholar
- 3.Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 29. The management of third- and fourth-degree perineal tears 2015. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/. Accessed 7 July 2018
- 6.Jiang H, Qian X, Carroli G, Garner P (2017) Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD000081.pub3
- 7.Van Bavel J, Hukkelhoven C, de Vries C, Papatsonis DNM, de Vogel J, Roovers JWR et al (2018) 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 29:407–413CrossRefGoogle Scholar
- 11.De Vogel J, Van der Leeuw-van Beek A, Gietelink D, Vujkovic M, De Leeuw JW, Van Bavel J et al (2012) The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol 206:404e401–405Google Scholar
- 14.CNGOF (2006) Episiotomy: recommendations of the CNGOF for clinical practice. J Gynecol Obstet Biol Reprod 34:275–279Google Scholar
- 18.Hamilton EF, Smith S, Yang L, Warrick P, Ciampi A (2011) Third- and fourth-degree perineal lacerations: defining high-risk clinical clusters. Am J Obstet Gynecol 204(309):e301–306Google Scholar
- 19.Simo Gonzalez M, Porta Roda O, Perello Capo J, Gich Saladich I, Calaf Alsina J (2015) Mode of vaginal delivery: a modifiable intrapartum risk factor for obstetric anal sphincter injury. Obstet Gynecol Int. https://doi.org/10.1155/2015/679470
- 20.Enquête national périnatale 2016. 2016. https://www.xn--epop-inserm-ebb.fr/wp-content/uploads/2017/10/ENP2016_rapport_complet.pdf. Accessed 28 Mar 2019
- 21.Ducarme G, Pizzoferrato AC, de Tayrac R, Schantz C, Thubert T, Le Ray C et al (2018) Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines. J Gynecol Obstet Hum Reprod. https://doi.org/10.1016/j.jogoh.2018.12.002
- 22.Lanz D, Moore P, Daru J (2018) Consent in obstetric emergency research—there is yet more to learn. BJOG. https://doi.org/10.1111/1471-0528.15340