Pay
Content
Int Urogynecol J DOI 10.1007/s00192-012-1960-3
ORIGINAL ARTICLE
Different episiotomy techniques, postpartum perineal pain, and blood loss: an observational study
Kathrine Fodstad & Katariina Laine & Anne Cathrine Staff
Received: 7 June 2012 / Accepted: 25 September 2012 # The International Urogynecological Association 2012
Abstract Introduction and hypothesis The lateral episiotomy technique has been postulated to cause more postpartum perineal pain and blood loss compared to the midline and mediolateral episiotomy technique. The aim of the study was to explore the association with postpartum perineal pain and blood loss between different episiotomy techniques. Methods Clinical evaluation of episiotomy was performed 0–3 days after delivery on 300 participating women. Episiotomy technique was classified by millimeter distance from the incision point to the posterior fourchette and by angle from the sagittal plane in degrees. Postpartum perineal pain was scored on a visual analogue scale (VAS) the first day after delivery. Blood loss data were collected from medical charts. Different episiotomy techniques and different episiotomy incision point groups were compared in relation to perineal pain perception and blood loss. Results We found no difference between midline, mediolateral, and lateral episiotomy techniques in perineal pain perception the first postpartum day (p 0 0.74) or in estimated blood loss (p 0 0.38). No differences were found in perineal pain or blood loss between midline and lateral incision
Parts of the preliminary data were presented by the first author at the International Urogynecological Association 2011 Annual Meeting in Lisbon, where the abstract was selected for an oral presentation of 12 min. K. Fodstad (*) : K. Laine : A. C. Staff Department of Obstetrics and Gynaecology, Oslo University Hospital, Ullevål, Postboks 4956, Nydalen, 0424 Oslo, Norway e-mail: [email protected] K. Fodstad : K. Laine : A. C. Staff Faculty of Medicine, University of Oslo, Oslo, Norway
points. Mediolateral angles were significantly narrower than lateral angles (p <0.005). Physicians performed longer episiotomies than midwives (p <0.005), but episiotomy angle did not vary between professions (p 0 0.075). Conclusions No differences in perineal pain perception the first postpartum day and no differences in estimated blood loss were found when comparing different episiotomy techniques or when comparing midline and lateral incision points. Keywords Episiotomy . Angle . Perineum . Postpartum pain . Blood loss . Vaginal birth
Introduction Episiotomy is one of the most frequently practiced surgical procedures in obstetrics, defined as a surgical enlargement of the vaginal orifice by an incision of the perineum during the last part of the second stage of delivery [1, 2]. Episiotomy rates around the world differ considerably [3], but the recommendation today is restrictive use, and on indication only [4, 5], although indications may be highly subjective. Several episiotomy techniques are described in the literature, but only two are commonly addressed, namely, the midline and the mediolateral techniques (Fig. 1). Existing literature on lateral episiotomy is scarce, but the lateral technique seems to be a tradition in some European countries [6, 7]. The lateral episiotomy technique is defined as an incision commencing 1–2 cm lateral to the posterior fourchette, directed towards the ischial tuberosity [8–10]. Studies have also shown that lateral episiotomies are likely to be performed unintentionally [11–13]. The lateral technique may therefore be a more frequently used episiotomy than earlier perceived.
Int Urogynecol J
3 2 1
Fig. 1 Episiotomy intrapartum incision lines (1 midline, 2 mediolateral, and 3 lateral episiotomy technique). The figure illustrates incision points and incision angles with the sagittal/parasagittal plane when episiotomy is performed on distended perineum during crowning of the fetal head. The lateral episiotomy incision point is defined as commencing ≥10 mm from the posterior fourchette at the time of incision [10]
There is no international consensus on how to optimally perform the different episiotomy techniques [11], and obstetric textbook definitions and local performance guidelines differ considerably [10–12]. In some studies the episiotomy technique is not even specified. Mediolateral and lateral episiotomies have been postulated to cause more blood loss as well as more perineal pain and dyspareunia compared to the midline technique [9, 14–18], although no randomized controlled trials or large observational studies exploring this notion have been published previously. The primary aim of our study was to investigate perineal pain perception after different episiotomy techniques the first day after delivery. The secondary aim was to explore differences in estimated blood loss between different episiotomy techniques.
Materials and methods This study was conducted at the Department of Obstetrics, Oslo University Hospital, Ullevål, a tertiary referral hospital with an annual delivery rate of 7,000, and approved by the Regional Committee for Medical and Health Research Ethics, Southeastern Norway. In Norway spontaneous deliveries are attended by midwives, whereas instrumental deliveries by physicians. In our hospital all spontaneous deliveries are attended by two midwives and instrumental deliveries by both the attending and the resident doctor on call. The routine practice of having two accoucheurs present at all spontaneous deliveries was implemented to increase quality management and birth aid as well as patient safety. The routine hospital practice is to perform an examination of the perineum after vaginal
delivery which includes a digital anal examination to check for anal sphincter lacerations. If there is a vaginal laceration, a second-degree laceration, or suspected anal sphincter injury during spontaneous midwife-attended deliveries, the attending and resident physician on call are paged to examine and evaluate every case. Recruitment took place over a 1-year period from March 2010 through March 2011. All women with an episiotomy, who were available for recruitment in the maternity ward, were approached 0–2 days after delivery and invited to participate by the first author (KF). The inclusion criteria were (1) episiotomy performed during vaginal delivery, (2) delivery at more than 28 weeks gestation, (3) age >18 years, and (4) the ability to understand Norwegian or English. A total of 310 women were invited to participate and 300 (97 %) agreed to enroll in the study and signed an informed written consent. These women also participate in a longterm follow-up study that will be published later. All 300 participating women were examined by KF within 3 days postpartum. With the women in the lithotomy position, legs in stirrups, flexed at hip joints, a transparent plastic film with a fixed midline was placed on the perineum. The midline was determined anatomically from the midpoint of the introitus, running upwards through the clitoris, downwards through and past the anal orifice. The women’s episiotomy suture line was thereafter drawn on the transparent film using a permanent marker pen. The posterior fourchette, vaginal orifice, and the anal orifice were also marked on the plastic film. With the film placed on a flat surface, the length of the episiotomy and the shortest distance from the posterior fourchette to the incision point were measured in millimeters using a tape measure. The episiotomy angle from the sagittal or parasagittal plane was measured in degrees using a protractor. Measurements of episiotomy angle, length, and incision point on the plastic films were supervised by a senior obstetrician (KL). Based on the episiotomy measurements (incision point distance from the posterior fourchette and angle from the sagittal plane), we categorized episiotomies evaluated postpartum into four groups: midline, mediolateral, lateral, and nonclassifiable (Fig. 2 and Table 1). Our angle categorizations were chosen based on previous studies by Kalis et al. [19, 20], showing that a mediolateral incision angle is reduced 15–20° when compared to suture angle. We hypothesized that all episiotomies with an incision point lateral to the midline would have a similar reduction in angle when measured postpartum (illustrated in Figs. 1 and 2). Our incision point ranges for the different episiotomy techniques were chosen based on definitions of the mediolateral and lateral episiotomies. The lateral episiotomy is an incision commencing 10 mm or more from the midline [10]. Since definitions of correct incision points for the mediolateral technique have been shown to vary between textbooks,
Int Urogynecol J
analyzed both in a linear regression model and categorized, presented as frequencies, means, or medians, where appropriate. Univariate analyses were performed by chi-square test. A p value of <0.05 was chosen as the level of statistical significance.
3 2 1
Results Table 2 summarizes the clinical characteristics of the study group. The majority of participants were primiparous (n 0 252/300). Sixteen percent (n 0 48/300) had delivered previously, but 20 of these 48 women had delivered by cesarean section only and were therefore categorized as “vaginal primiparous” in the analyses (91 %, n 0 272/300). The documented indications for performing an episiotomy were instrumental vaginal delivery (53 %), breech presentation (6 %), fetal distress (13 %), fear of perineal laceration or obstetric anal sphincter injuries (OASIS, 12 %), and failure to progress during the second stage of labor (6 %). Midwives failed to document the episiotomy indication in 10 % of cases. Of the study participants, 56 had their episiotomy clinically examined the first postpartum day, 144 2 days after delivery, and 100 3 days postpartum. The examination day differed due to logistics: lack of availability of examination room and/or participant. Perineal pain perception was scored by 208 of 300 participants during an interview on the first postpartum day. Ninety-two participants were not available for this interview the first day after delivery. Episiotomy technique We categorized episiotomies into four groups (Table 1 and Fig. 2) based on the angle measured postpartum, incision point distance to the posterior fourchette, and our hypothesis that lateral episiotomies would have an incision to suture angle shrinkage as mediolateral episiotomies have been shown to have [20]. Based on our categorization the majority of episiotomies (44 %) were lateral and 36 % were nonclassifiable. Very few (7 %) were midline and 13 % were mediolateral episiotomies. All episiotomies with incision points commencing 4 – 9 mm from the posterior
Fig. 2 Episiotomy suture lines after delivery (1 midline, 2 mediolateral, and 3 lateral episiotomy technique). The mediolateral suture angle (2) measures 15–20° less than the mediolateral incision angle [20] in Fig. 1. We have hypothesized a similar reduction in angle for the lateral episiotomy (3) when comparing lateral incision angle (Fig. 1) to lateral suture angle (Fig. 2)
clinicians, institutions, and countries [11, 12], we chose a mediolateral/midline incision point range of 0–3 mm from the posterior fourchette. A nonclassifiable episiotomy technique was therefore categorized as incisions commencing 4–9 mm from the posterior fourchette (Table 1). Perineal pain measurements were scored on an 11-point visual analogue scale (VAS ranging from 0 to 10) by 208 of the 300 participants on the first postpartum day. All 300 women were interviewed in person by the first author, approached in their room and specifically asked to score perineal pain, stressing the term “perineal.” They were shown a VAS and explained that 0 represented “no pain” and 10 “worst thinkable pain.” Women that were not available in their room on the first postpartum day scored perineal pain retrospectively, but these participants (n 0 92) were excluded from the pain analyses due to possible recollection bias. Blood loss is routinely estimated by the midwife and/or physician in charge of the delivery and documented in the medical chart. It is a subjective estimation by inspection of tissues and blood clots. In cases of considerable hemorrhage, tissues are weighed to achieve a more exact estimate. Estimated blood loss up to the first 2 h after delivery (hereafter referred to as postpartum blood loss) and all other clinical variables were collected from medical records, and clinical information was verified in patient interviews. Statistical calculations were performed with SPSS (version 18.0, Chicago, IL, USA). Continuous variables were
Table 1 Definition of episiotomy techniques, categorization by postpartum measurement Midline n 0 20 Distance from incision point to the posterior fourchette (mm) Angle from the sagittal or parasagittal plane (°)
a
Mediolateral n 0 38 ≤3 25–60
Lateral n 0 133 ≥10 25–60
Nonclassifiable n 0 109a 4–9 All angles
≤3 <25
Of the 109 cases in the nonclassifiable group, 32 had a lateral incision point (≥10 mm), but either too acute (<25°) or too large an angle (>60°) to qualify as a lateral episiotomy
Int Urogynecol J Table 2 Clinical characteristics of the study group (n 0 300) for the different episiotomy techniques (classified postpartum). Values are given in means or frequencies
Characteristics n 0 300 Vaginal primiparousa (%) Maternal age (years) Spontaneous delivery (%) Instrumental delivery (%) Duration of second stage (min) Amount of blood loss (ml) Vaginal tears (%) Birth weight (g) Placental weight (g)
Midline episiotomy n 0 20 90 31 10.5 3.6 47 418 35 3,394 611
Mediolateral episiotomy n 0 38 95 30 16.5 9.6 47 422 26 3,504 608
Lateral episiotomy n 0 133 90 31 34.6 52.1 45 446 29 3,499 654
Nonclassifiable n 0 109 87 31 38.3 34.7 46 398 26 3,558 653
p
0.6 0.2 0.004 0.004 0.9 0.7 0.8 0.5 0.6
a
Twenty of the women listed as vaginal primiparous had one previous delivery, but by cesarean and therefore no previous vaginal birth
fourchette (n 0 75) were considered nonclassifiable regardless of angle. Also, lateral episiotomies (defined as incision point ≥10 mm from the posterior fourchette) either having too narrow a postpartum angle (<25°, n 0 9) or too large a postpartum angle (>60°, n 0 23) were grouped as nonclassifiable. We not only performed the outcome analyses by different episiotomy techniques, but repeated all analyses by an alternative episiotomy categorization based on incision point solely and regardless of episiotomy angle (0-3 mm; midline, 4-9 mm, and ≥10 mm; lateral incision point groups). Additionally we analyzed episiotomy length, angle, and distance from the posterior fourchette as continuous variables. We found that the mean lateral episiotomy angle was significantly larger than the mean mediolateral episiotomy angle (45.2 vs 30.3°, p <0.005). Lateral episiotomies were significantly longer than other episiotomy types performed (p <0.005). When comparing episiotomies performed by physicians to episiotomies performed by midwives, those cut by physicians were significantly longer, p <0.005. There was also a significant difference in mean incision point distance to the posterior fourchette between physicians and midwives (11.2 and 9.0 mm, respectively, p 0 0.004). The mean episiotomy angle, however, did not vary between professions. One third of physicians and one third of midwives performed a nonclassifiable episiotomy technique. Postpartum pain Perineal pain was scored on the first day after delivery by 208 of the 300 participants (Table 3). The 92 women who scored perineal pain on a different postpartum day were excluded from our perineal pain analyses, but did not differ clinically from those who scored perineal pain on the first postpartum day (n 0 208, data not shown). Most women reported low (0–3) or moderate (4–6) VAS scores, 37 and 43 %, respectively. Only 20 % reported high postpartum
pain scores (7–10). When comparing spontaneous to instrumental deliveries, we found no difference in the distribution of low, moderate, or high VAS score groups, p 0 0.08 (Table 3). When comparing different episiotomy techniques, we found no difference in VAS score distribution (Table 3). Linear regression analysis of VAS score as a continuous variable showed no association with episiotomy technique, p 0 0.24. Adjusting for delivery method, epidural analgesia during delivery, and any additional spontaneous vaginal tears did not alter our conclusions. When comparing our three categorized episiotomy incision point groups, there was no difference in postpartum perineal pain perception (Table 3). Incision point distance as a continuous variable showed no association with VAS scores, p 0 0.95 in a linear regression model. We compared short episiotomies (≤24 mm) to long episiotomies (≥35 mm) and found no difference in perineal pain perception related to episiotomy length for the VAS score group distribution (Table 3). Linear regression of episiotomy length as a continuous variable showed no association with VAS scores, p 0 0.97. All regression analyses were adjusted for delivery method, epidural analgesia during delivery, and additional vaginal tears without altering our conclusions. OASIS Of the 300 participants, 12 had an obstetric anal sphincter injury. None of these women had a lateral episiotomy. A midline episiotomy had been performed in 25 % of OASIS cases (n 0 3), 25 % had a mediolateral episiotomy (n 0 3), and 50 % of OASIS cases (n 0 6) had a nonclassifiable episiotomy, p 0 0.003. The majority (58.3 %, n 0 7) had a midline incision point (0–3 mm from the posterior fourchette), 33.3 % (n 0 4) had a nonclassifiable incision point (4–9 mm from the posterior fourchette), and only one woman had an incision point more than 10 mm from the midline, p 0 0.001. Mean incision point distance to midline was significantly shorter among
Int Urogynecol J Table 3 Percentage distribution of three VAS categories of perineal pain the first postpartum day (n 0 208/300) by episiotomy technique, analgesia, and maternal age
Characteristics Total n 0 208 Midline episiotomy (n 0 16) Mediolateral episiotomy (n 0 26) Lateral episiotomy (n 0 91) Nonclassifiable episiotomy (n 0 75) Episiotomy length ≤ 24 mm (n 0 46) Episiotomy length ≥35 mm (n 0 74) Episiotomy length 25–34 mm (n 0 88) Incision point from post fourchette (mm) 0–3 (n 0 43) Midline 4-9 (n 0 51) ≥10 (n 0 114) Lateral Episiotomy only (n 0 138) Additional vaginal tear (n 0 62) Obstetric anal sphincter injury (n 0 8) Spontaneous delivery (n 0 91) Instrumental delivery (n 0 117) Maternal age (years) 18–29 (n 0 103) 30–34 (n 0 130) 35–44 (n 0 67) Epidural during delivery (n 0 122) No epidural during delivery (n 0 86)
VAS scores 0–3 n 0 78 44 50 38 32 33 36 41 4–6 n 0 89 44 27 47 43 39 45 43 7–10 n 0 41 12 23 15 25 28 19 16
p 0.4
0.5
46 31 37 36 40 37 43 33
33 43 46 45 42 13 34 50
21 26 17 19 18 50 23 17
0.4
0.2
0.08
40 35 38 38 37
39 47 40 43 42
21 18 22 19 21
0.8
0.9
women with OASIS compared to women without OASIS (4.5 and 10.5 mm, respectively, p 0 0.002). Blood loss Postpartum blood loss varied from 100 to 2,000 ml (median 350 ml, mean 423 ml) and in most cases (74 %) blood loss was estimated to 400 ml or less. In a univariate analysis, higher birth weight and instrumental delivery were the only significant risk factors for excessive blood loss (Table 4). We found no differences in blood loss between episiotomy techniques, neither when dichotomizing postpartum blood loss into normal (0 – 499 ml) and excessive ( ≥ 500 ml) (Table 4) nor when analyzing blood loss as a continuous variable in a linear regression model, p 0 0.57. When comparing our three incision point groups, there was no difference in distribution of normal or excessive blood loss (Table 4). We found no association between blood loss and episiotomy incision point when analyzing both parameters as continuous variables, p 0 0.65. Adjusting for
delivery method, epidural analgesia and vaginal tears did not alter our conclusions. When comparing the shorter episiotomies (≤24 mm, n 0 70) to the longer (≥35 mm, n 0 176), there was no difference between blood loss groups related to episiotomy length (Table 4). However, when analyzing episiotomy length as a continuous variable we found a borderline significant p value of 0.06. In a multivariate regression analysis, birth weight was the only variable associated with an increased risk of a heavier bleed, but when excluding excessive blood loss of more than 800 ml, additional spontaneous vaginal tears were also shown to be a risk factor for increased blood loss, as expected, p 0 0.001.
Discussion Our study showed that lateral episiotomies were neither associated with more perineal pain the first postpartum day nor with more blood loss compared to the midline and mediolateral episiotomy techniques.
Int Urogynecol J Table 4 Clinical characteristics of total study group (n 0 300). Postpartum blood loss in two categories (normal and excessive) by episiotomy characteristics (evaluated postpartum)
Characteristics
Blood loss (ml) Normal 0–499 n 0 230 Excessive 500–2,000 n 0 70
p
Episiotomy length (mm) Short: ≤ 24 mm (n 0 70) Long: ≥ 35 mm (n 0 176) 25–35 mm (n 0 124) Episiotomy technique Midline (n 0 20) Mediolateral (n 0 38) Lateral (n 0 133) Non classifiable (n 0 109)
79 % 71 % 81 %
21 % 29 % 19 %
0.2
80 74 75 79
20 26 25 21
0.9
Incision point (mm distance from posterior fourchette) Incision point 0–3 (n 0 60) Midline 77 Incision point 4–9 (n 0 75) 81 Incision point ≥ 10 (n 0 165) Lateral 75 Delivery mode Spontaneous (n 0 133) Instrumental (n 0 167) Tears Episiotomy only (n 0 212) Additional vaginal tear (n 0 76) Obstetric anal sphincter injury (n 0 12) Parity (previous vaginal delivery) Para 0 Para 1-2 Age, mean (years) Birth weight, mean (g) Placental weight, mean (g) Duration of second stage, mean (min)
23 19 25
0.5
83 71
17 29
0.009
79 72 58
21 28 42
0.2
77 77 31 3471 634 46
23 23 31.5 3654 680 47
0.6
0.5 0.004 0.1 0.7
In addition to episiotomy techniques, we separately analyzed episiotomy incision points in relation to postpartum perineal pain perception, assessed by VAS scores. Regardless of whether the episiotomy incision point was lateral or midline, there was no difference in reported pain perception the first day after delivery or after adjusting for confounding factors such as delivery method, epidural analgesia, or additional vaginal tears. When assessing episiotomy length in relation to perineal pain perception, longer episiotomies were not perceived as more painful than shorter ones. To our knowledge, no study comparing postpartum perineal pain in relation to episiotomy technique or length has previously been published.
A weakness of this study is that we lack a vaginally delivered control group without episiotomy, but as we were primarily interested in assessing whether there were actual differences between episiotomy techniques in relation to perineal pain perception, we did not include such controls in our study. However, many previous studies have compared effects of episiotomy to no episiotomy and to spontaneous second-degree lacerations in regard to postpartum perineal pain [21–25], although all studies are on the mediolateral or midline episiotomy technique. Still, there seem to be many notions and myths linked to the lateral technique, possibly because there are very few publications on lateral
Int Urogynecol J
episiotomy in general. Misconceptions in the literature as to the correct definition of the lateral technique also exist [26]. Current studies [7, 11, 12] indicate that the lateral technique may in fact be practiced in several European countries, and possibly more frequently than earlier perceived. When using an alternative classification of episiotomies, by incision point solely and regardless of angle and technique, we found that a long distance from the incision point to the posterior fourchette was not associated with more postpartum perineal pain, supporting and strengthening our finding that lateral episiotomies (incision point ≥10 mm from the posterior fourchette) are not associated with more pain than other common episiotomy types. Our study showed that the lateral technique was the most frequently performed episiotomy in our unit, but that both mediolateral and midline episiotomies were performed, either intentionally or unintentionally. The midline episiotomy technique is, however, not recommended in our hospital due to the risk of the incision extending into the anal sphincter complex [17, 27]. We found that mean lateral episiotomy angle was significantly larger compared to mean mediolateral episiotomy angle and that lateral episiotomies were significantly longer than mediolateral episiotomies. This might indicate that the lateral episiotomy is easier to perform with a correctly large enough angle and length compared to the mediolateral episiotomy. However, our study has an overrepresentation of the lateral (n 0 133) compared to the mediolateral (n 0 38) technique, and such a hypothesis needs to be explored in larger studies. All clinical episiotomy assessments were performed postpartum, when there is no distension of the perineum due to crowning of the fetal head. The episiotomy suture angle measured therefore does not necessarily equal the actual incision angle (Figs. 1 and 2). We hypothesized that lateral episiotomies would have a similar reduction in angle as mediolateral episiotomy angles have been shown to have, when comparing incision to suture angle [19, 20]. There are, however, no studies reporting such an association for lateral episiotomies, and a potential reduction of lateral episiotomy incision to suture angle needs to be confirmed in future observational trials. Since we found mediolateral episiotomy angles to be significantly narrower than lateral episiotomy angles, this additionally raises the question of whether or not lateral episiotomies could be better suited than mediolateral episiotomies to prevent OASIS. If it is easier to maintain an optimally large angle when the episiotomy incision point is lateral and not midline, the lateral technique could possibly pose the lesser risk for anal sphincter lacerations. Large register studies on mediolateral and lateral episiotomy have shown a beneficial effect of episiotomy at instrumental delivery, namely, as being protective against OASIS [28–30], but large prospective observational studies are lacking. None of the 12 women with
OASIS in our study had a lateral episiotomy performed, and 11 of these 12 cases had an episiotomy with an incision point less than 10 mm from midline. Due to the low number of women with OASIS and our observational study design, we are cautious about drawing any conclusions as to lateral episiotomies being superior to mediolateral episiotomies in preventing OASIS, and our study was not designed to explore an OASIS-preventing effect of different episiotomy techniques. A randomized controlled trial would be a method of choice to explore such a hypothesis. As the episiotomies performed by doctors in our study nearly exclusively occurred during instrumental vaginal delivery and the episiotomies performed by midwives occurred (with two exceptions) during spontaneous delivery, it is not surprising that doctors performed longer episiotomies than midwives. Our findings on differences between midwives and doctors in episiotomy length also coincide with the studies by Tincello et al. [12] and Andrews et al. [13]. However, our study shows no significant difference in episiotomy angle between professions, in contrast to results in the two previously mentioned papers. A possible explanation could be that both professions in our unit favored the lateral episiotomy technique, supporting the hypothesis that lateral episiotomies may be easier to perform with a correct and wide enough angle compared to the mediolateral technique. One third of episiotomies (doctors and midwives equally represented) were nonclassifiable, meaning the incision point was incorrect according to our definitions, or the episiotomy angle was either too narrow or too large. Whether these episiotomies were intended to be mediolateral or lateral is unclear, but we cannot exclude incorrect training in either technique to be the cause of such a large nonclassifiable group. We found no association between episiotomy technique or episiotomy incision point related to estimated blood loss. Not surprisingly we did find an association between large infant birth weight and increased blood loss, which is a natural consequence of blood loss at birth being more strongly associated with uterine bleeding than bleeding from the actual episiotomy. To the best of our knowledge only a few studies have looked at episiotomy technique and association with blood loss per se. Baksu et al. [31] compared midline to mediolateral episiotomies and found a significant difference in blood loss between midline and mediolateral techniques when repair was performed after placental removal. No differences between techniques were found when repair was done before placental expulsion. This correlates with the blood loss-associated findings in our study, as our department practices episiotomy repair before placental expulsion. However, a limitation of our study is that the blood loss data are subjective estimations recorded by the accoucheur and not based on more objective
Int Urogynecol J
measurements such as postpartum reduction in hematocrit and hemoglobin levels. Several studies have assessed benefits and complications of episiotomies, but the results have been conflicting. A serious limitation in the existing literature, and a possible contributor to conflicting results, is the fact that the majority of studies lack an assessment of the actual episiotomy performed. Variations in mediolateral technique performance [11–13] and lack of specific technique documentation within and between obstetrical units may very well undermine previous evaluations of episiotomy complications and benefits. In conclusion, there seems to be little difference in perineal pain perception and postpartum blood loss between midline, mediolateral, and lateral episiotomy techniques. Our study adds important clinical information in demonstrating that lateral episiotomies and lateral incision points are not associated with augmented postpartum perineal pain or augmented postpartum blood loss compared to other episiotomy techniques performed.
Acknowledgments We thank Anette Schmidtke for contributing to quality control of data collection from the medical charts and Olivia Österberg for graphical illustrations, Figs. 1 and 2. This study received funding from the Norwegian Research Council and the Faculty of Medicine, University of Oslo, Norway. Conflicts of interest None.
References
1. Thacker SB, Banta HD (1983) Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860– 1980. Obstet Gynecol Surv 38:322–338 2. Carroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database Syst Rev 1:CD000081 3. Graham ID, Carroli G, Davies C, Medves JM (2005) Episiotomy rates around the world: an update. Birth 32:219–223 4. National Collaborating Centre for Women’s and Children’s Health (UK) (2007) Intrapartum care: care of healthy women and their babies during childbirth. NICE Clinical Guidelines, No. 55, pp 168–170 5. American College of Obstetricians-Gynecologists (2006) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 107:957–962 6. Räisänen SH, Vehviläinen-Julkunen K, Gissler M, Heinonen S (2009) Lateral episiotomy protects primiparous but not multiparous women from obstetric anal sphincter rupture. Acta Obstet Gynecol Scand 88:1365–1372 7. Grigoriadis T, Athanasiou S, Zisou A, Antsaklis A (2009) Episiotomy and perineal repair practices among obstetricians in Greece. Int J Gynaecol Obstet 106:27–29 8. Dudenhausen JW, Pschyrembel W (2001) Praktische Geburtshilfe mit geburtshilflichen Operationen (Practical obstetrics and obsterical operations), 9th edn. de Gruyter, Berlin 9. Flew JD (1944) Episiotomy. Br Med J 2:620–623 10. Kalis V, Laine K, de Leeuw JW, Ismail KM, Tincello DG (2012) Classification of episiotomy: towards a standardisation of terminology. BJOG 119:522–526
11. Kalis V, Stepan J Jr, Horak M, Roztocil A, Kralickova M, Rokyta Z (2008) Definitions of mediolateral episiotomy in Europe. Int J Gynaecol Obstet 100:188–189 12. Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevic Z (2003) Differences in episiotomy technique between midwives and doctors. BJOG 110:1041–1044 13. Andrews V, Thakar R, Sultan AH, Jones PW (2005) Are mediolateral episiotomies actually mediolateral? BJOG 112:1156–1158 14. Cleary-Goldman J, Robinson JN (2003) The role of episiotomy in current obstetric practice. Semin Perinatol 27:3–12 15. Banta D, Thacker SB (1982) The risks and benefits of episiotomy: a review. Birth 9:25–30 16. Myers-Helfgott MG, Helfgott AW (1999) Routine use of episiotomy in modern obstetrics. Should it be performed? Obstet Gynecol Clin North Am 26:305–325 17. Coats PM, Chan KK, Wilkins M, Beard RJ (1980) A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 87:408–412 18. Schünke M, Ross LM, Schulte E, Lamperti ED, Schumacher U (2005) Atlas of anatomy: general anatomy and musculoskeletal system. Georg Thieme, Stuttgart 19. Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z (2008) The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet 103:5–8 20. Kalis V, Landsmanova J, Bednarova B, Karbanova J, Laine K, Rokyta Z (2011) Evaluation of the incision angle of mediolateral episiotomy at 60 degrees. Int J Gynaecol Obstet 112:220–224 21. Chang SR, Chen KH, Lin HH, Chao YM, Lai YH (2011) Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: a prospective follow-up study. Int J Nurs Stud 48:409–418 22. Amorim Francisco A, Junqueira Vasconcellos de Oliveira SM, Barbosa da Silva FM, Bick D, Gonzalez Riesco ML (2010) Women’s experiences of perineal pain during the immediate postnatal period: a cross-sectional study in Brazil. Midwifery 27:e254–e259 23. Andrews V, Thakar R, Sultan AH, Jones PW (2008) Evaluation of postpartum perineal pain and dyspareunia–a prospective study. Eur J Obstet Gynecol Reprod Biol 137:152–156 24. Leeman L, Fullilove AM, Borders N, Manocchio R, Albers LL, Rogers RG (2009) Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables. Birth 36:283–288 25. Klein MC, Gauthier RJ, Robbins JM et al (1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 171:591–598 26. DeLancey JO (2008) Episiotomy: what’s the angle? Int J Gynaecol Obstet 103:3–4 27. Bodner-Adler B, Bodner K, Kaider A et al (2001) Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med 46:752–756 28. Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S (2011) High episiotomy rate protects from obstetric anal sphincter ruptures: a birth register-study on delivery intervention policies in Finland. Scand J Public Health 39:457–463 29. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ (2010) Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 150:142– 146 30. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW (2008) Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG 115:104–108 31. Baksu B, Davas I, Akyol A, Ozgul J, Ezen F (2008) Effect of timing of episiotomy repair on peripartum blood loss. Gynecol Obstet Invest 65:169–173
ORIGINAL ARTICLE
Different episiotomy techniques, postpartum perineal pain, and blood loss: an observational study
Kathrine Fodstad & Katariina Laine & Anne Cathrine Staff
Received: 7 June 2012 / Accepted: 25 September 2012 # The International Urogynecological Association 2012
Abstract Introduction and hypothesis The lateral episiotomy technique has been postulated to cause more postpartum perineal pain and blood loss compared to the midline and mediolateral episiotomy technique. The aim of the study was to explore the association with postpartum perineal pain and blood loss between different episiotomy techniques. Methods Clinical evaluation of episiotomy was performed 0–3 days after delivery on 300 participating women. Episiotomy technique was classified by millimeter distance from the incision point to the posterior fourchette and by angle from the sagittal plane in degrees. Postpartum perineal pain was scored on a visual analogue scale (VAS) the first day after delivery. Blood loss data were collected from medical charts. Different episiotomy techniques and different episiotomy incision point groups were compared in relation to perineal pain perception and blood loss. Results We found no difference between midline, mediolateral, and lateral episiotomy techniques in perineal pain perception the first postpartum day (p 0 0.74) or in estimated blood loss (p 0 0.38). No differences were found in perineal pain or blood loss between midline and lateral incision
Parts of the preliminary data were presented by the first author at the International Urogynecological Association 2011 Annual Meeting in Lisbon, where the abstract was selected for an oral presentation of 12 min. K. Fodstad (*) : K. Laine : A. C. Staff Department of Obstetrics and Gynaecology, Oslo University Hospital, Ullevål, Postboks 4956, Nydalen, 0424 Oslo, Norway e-mail: [email protected] K. Fodstad : K. Laine : A. C. Staff Faculty of Medicine, University of Oslo, Oslo, Norway
points. Mediolateral angles were significantly narrower than lateral angles (p <0.005). Physicians performed longer episiotomies than midwives (p <0.005), but episiotomy angle did not vary between professions (p 0 0.075). Conclusions No differences in perineal pain perception the first postpartum day and no differences in estimated blood loss were found when comparing different episiotomy techniques or when comparing midline and lateral incision points. Keywords Episiotomy . Angle . Perineum . Postpartum pain . Blood loss . Vaginal birth
Introduction Episiotomy is one of the most frequently practiced surgical procedures in obstetrics, defined as a surgical enlargement of the vaginal orifice by an incision of the perineum during the last part of the second stage of delivery [1, 2]. Episiotomy rates around the world differ considerably [3], but the recommendation today is restrictive use, and on indication only [4, 5], although indications may be highly subjective. Several episiotomy techniques are described in the literature, but only two are commonly addressed, namely, the midline and the mediolateral techniques (Fig. 1). Existing literature on lateral episiotomy is scarce, but the lateral technique seems to be a tradition in some European countries [6, 7]. The lateral episiotomy technique is defined as an incision commencing 1–2 cm lateral to the posterior fourchette, directed towards the ischial tuberosity [8–10]. Studies have also shown that lateral episiotomies are likely to be performed unintentionally [11–13]. The lateral technique may therefore be a more frequently used episiotomy than earlier perceived.
Int Urogynecol J
3 2 1
Fig. 1 Episiotomy intrapartum incision lines (1 midline, 2 mediolateral, and 3 lateral episiotomy technique). The figure illustrates incision points and incision angles with the sagittal/parasagittal plane when episiotomy is performed on distended perineum during crowning of the fetal head. The lateral episiotomy incision point is defined as commencing ≥10 mm from the posterior fourchette at the time of incision [10]
There is no international consensus on how to optimally perform the different episiotomy techniques [11], and obstetric textbook definitions and local performance guidelines differ considerably [10–12]. In some studies the episiotomy technique is not even specified. Mediolateral and lateral episiotomies have been postulated to cause more blood loss as well as more perineal pain and dyspareunia compared to the midline technique [9, 14–18], although no randomized controlled trials or large observational studies exploring this notion have been published previously. The primary aim of our study was to investigate perineal pain perception after different episiotomy techniques the first day after delivery. The secondary aim was to explore differences in estimated blood loss between different episiotomy techniques.
Materials and methods This study was conducted at the Department of Obstetrics, Oslo University Hospital, Ullevål, a tertiary referral hospital with an annual delivery rate of 7,000, and approved by the Regional Committee for Medical and Health Research Ethics, Southeastern Norway. In Norway spontaneous deliveries are attended by midwives, whereas instrumental deliveries by physicians. In our hospital all spontaneous deliveries are attended by two midwives and instrumental deliveries by both the attending and the resident doctor on call. The routine practice of having two accoucheurs present at all spontaneous deliveries was implemented to increase quality management and birth aid as well as patient safety. The routine hospital practice is to perform an examination of the perineum after vaginal
delivery which includes a digital anal examination to check for anal sphincter lacerations. If there is a vaginal laceration, a second-degree laceration, or suspected anal sphincter injury during spontaneous midwife-attended deliveries, the attending and resident physician on call are paged to examine and evaluate every case. Recruitment took place over a 1-year period from March 2010 through March 2011. All women with an episiotomy, who were available for recruitment in the maternity ward, were approached 0–2 days after delivery and invited to participate by the first author (KF). The inclusion criteria were (1) episiotomy performed during vaginal delivery, (2) delivery at more than 28 weeks gestation, (3) age >18 years, and (4) the ability to understand Norwegian or English. A total of 310 women were invited to participate and 300 (97 %) agreed to enroll in the study and signed an informed written consent. These women also participate in a longterm follow-up study that will be published later. All 300 participating women were examined by KF within 3 days postpartum. With the women in the lithotomy position, legs in stirrups, flexed at hip joints, a transparent plastic film with a fixed midline was placed on the perineum. The midline was determined anatomically from the midpoint of the introitus, running upwards through the clitoris, downwards through and past the anal orifice. The women’s episiotomy suture line was thereafter drawn on the transparent film using a permanent marker pen. The posterior fourchette, vaginal orifice, and the anal orifice were also marked on the plastic film. With the film placed on a flat surface, the length of the episiotomy and the shortest distance from the posterior fourchette to the incision point were measured in millimeters using a tape measure. The episiotomy angle from the sagittal or parasagittal plane was measured in degrees using a protractor. Measurements of episiotomy angle, length, and incision point on the plastic films were supervised by a senior obstetrician (KL). Based on the episiotomy measurements (incision point distance from the posterior fourchette and angle from the sagittal plane), we categorized episiotomies evaluated postpartum into four groups: midline, mediolateral, lateral, and nonclassifiable (Fig. 2 and Table 1). Our angle categorizations were chosen based on previous studies by Kalis et al. [19, 20], showing that a mediolateral incision angle is reduced 15–20° when compared to suture angle. We hypothesized that all episiotomies with an incision point lateral to the midline would have a similar reduction in angle when measured postpartum (illustrated in Figs. 1 and 2). Our incision point ranges for the different episiotomy techniques were chosen based on definitions of the mediolateral and lateral episiotomies. The lateral episiotomy is an incision commencing 10 mm or more from the midline [10]. Since definitions of correct incision points for the mediolateral technique have been shown to vary between textbooks,
Int Urogynecol J
analyzed both in a linear regression model and categorized, presented as frequencies, means, or medians, where appropriate. Univariate analyses were performed by chi-square test. A p value of <0.05 was chosen as the level of statistical significance.
3 2 1
Results Table 2 summarizes the clinical characteristics of the study group. The majority of participants were primiparous (n 0 252/300). Sixteen percent (n 0 48/300) had delivered previously, but 20 of these 48 women had delivered by cesarean section only and were therefore categorized as “vaginal primiparous” in the analyses (91 %, n 0 272/300). The documented indications for performing an episiotomy were instrumental vaginal delivery (53 %), breech presentation (6 %), fetal distress (13 %), fear of perineal laceration or obstetric anal sphincter injuries (OASIS, 12 %), and failure to progress during the second stage of labor (6 %). Midwives failed to document the episiotomy indication in 10 % of cases. Of the study participants, 56 had their episiotomy clinically examined the first postpartum day, 144 2 days after delivery, and 100 3 days postpartum. The examination day differed due to logistics: lack of availability of examination room and/or participant. Perineal pain perception was scored by 208 of 300 participants during an interview on the first postpartum day. Ninety-two participants were not available for this interview the first day after delivery. Episiotomy technique We categorized episiotomies into four groups (Table 1 and Fig. 2) based on the angle measured postpartum, incision point distance to the posterior fourchette, and our hypothesis that lateral episiotomies would have an incision to suture angle shrinkage as mediolateral episiotomies have been shown to have [20]. Based on our categorization the majority of episiotomies (44 %) were lateral and 36 % were nonclassifiable. Very few (7 %) were midline and 13 % were mediolateral episiotomies. All episiotomies with incision points commencing 4 – 9 mm from the posterior
Fig. 2 Episiotomy suture lines after delivery (1 midline, 2 mediolateral, and 3 lateral episiotomy technique). The mediolateral suture angle (2) measures 15–20° less than the mediolateral incision angle [20] in Fig. 1. We have hypothesized a similar reduction in angle for the lateral episiotomy (3) when comparing lateral incision angle (Fig. 1) to lateral suture angle (Fig. 2)
clinicians, institutions, and countries [11, 12], we chose a mediolateral/midline incision point range of 0–3 mm from the posterior fourchette. A nonclassifiable episiotomy technique was therefore categorized as incisions commencing 4–9 mm from the posterior fourchette (Table 1). Perineal pain measurements were scored on an 11-point visual analogue scale (VAS ranging from 0 to 10) by 208 of the 300 participants on the first postpartum day. All 300 women were interviewed in person by the first author, approached in their room and specifically asked to score perineal pain, stressing the term “perineal.” They were shown a VAS and explained that 0 represented “no pain” and 10 “worst thinkable pain.” Women that were not available in their room on the first postpartum day scored perineal pain retrospectively, but these participants (n 0 92) were excluded from the pain analyses due to possible recollection bias. Blood loss is routinely estimated by the midwife and/or physician in charge of the delivery and documented in the medical chart. It is a subjective estimation by inspection of tissues and blood clots. In cases of considerable hemorrhage, tissues are weighed to achieve a more exact estimate. Estimated blood loss up to the first 2 h after delivery (hereafter referred to as postpartum blood loss) and all other clinical variables were collected from medical records, and clinical information was verified in patient interviews. Statistical calculations were performed with SPSS (version 18.0, Chicago, IL, USA). Continuous variables were
Table 1 Definition of episiotomy techniques, categorization by postpartum measurement Midline n 0 20 Distance from incision point to the posterior fourchette (mm) Angle from the sagittal or parasagittal plane (°)
a
Mediolateral n 0 38 ≤3 25–60
Lateral n 0 133 ≥10 25–60
Nonclassifiable n 0 109a 4–9 All angles
≤3 <25
Of the 109 cases in the nonclassifiable group, 32 had a lateral incision point (≥10 mm), but either too acute (<25°) or too large an angle (>60°) to qualify as a lateral episiotomy
Int Urogynecol J Table 2 Clinical characteristics of the study group (n 0 300) for the different episiotomy techniques (classified postpartum). Values are given in means or frequencies
Characteristics n 0 300 Vaginal primiparousa (%) Maternal age (years) Spontaneous delivery (%) Instrumental delivery (%) Duration of second stage (min) Amount of blood loss (ml) Vaginal tears (%) Birth weight (g) Placental weight (g)
Midline episiotomy n 0 20 90 31 10.5 3.6 47 418 35 3,394 611
Mediolateral episiotomy n 0 38 95 30 16.5 9.6 47 422 26 3,504 608
Lateral episiotomy n 0 133 90 31 34.6 52.1 45 446 29 3,499 654
Nonclassifiable n 0 109 87 31 38.3 34.7 46 398 26 3,558 653
p
0.6 0.2 0.004 0.004 0.9 0.7 0.8 0.5 0.6
a
Twenty of the women listed as vaginal primiparous had one previous delivery, but by cesarean and therefore no previous vaginal birth
fourchette (n 0 75) were considered nonclassifiable regardless of angle. Also, lateral episiotomies (defined as incision point ≥10 mm from the posterior fourchette) either having too narrow a postpartum angle (<25°, n 0 9) or too large a postpartum angle (>60°, n 0 23) were grouped as nonclassifiable. We not only performed the outcome analyses by different episiotomy techniques, but repeated all analyses by an alternative episiotomy categorization based on incision point solely and regardless of episiotomy angle (0-3 mm; midline, 4-9 mm, and ≥10 mm; lateral incision point groups). Additionally we analyzed episiotomy length, angle, and distance from the posterior fourchette as continuous variables. We found that the mean lateral episiotomy angle was significantly larger than the mean mediolateral episiotomy angle (45.2 vs 30.3°, p <0.005). Lateral episiotomies were significantly longer than other episiotomy types performed (p <0.005). When comparing episiotomies performed by physicians to episiotomies performed by midwives, those cut by physicians were significantly longer, p <0.005. There was also a significant difference in mean incision point distance to the posterior fourchette between physicians and midwives (11.2 and 9.0 mm, respectively, p 0 0.004). The mean episiotomy angle, however, did not vary between professions. One third of physicians and one third of midwives performed a nonclassifiable episiotomy technique. Postpartum pain Perineal pain was scored on the first day after delivery by 208 of the 300 participants (Table 3). The 92 women who scored perineal pain on a different postpartum day were excluded from our perineal pain analyses, but did not differ clinically from those who scored perineal pain on the first postpartum day (n 0 208, data not shown). Most women reported low (0–3) or moderate (4–6) VAS scores, 37 and 43 %, respectively. Only 20 % reported high postpartum
pain scores (7–10). When comparing spontaneous to instrumental deliveries, we found no difference in the distribution of low, moderate, or high VAS score groups, p 0 0.08 (Table 3). When comparing different episiotomy techniques, we found no difference in VAS score distribution (Table 3). Linear regression analysis of VAS score as a continuous variable showed no association with episiotomy technique, p 0 0.24. Adjusting for delivery method, epidural analgesia during delivery, and any additional spontaneous vaginal tears did not alter our conclusions. When comparing our three categorized episiotomy incision point groups, there was no difference in postpartum perineal pain perception (Table 3). Incision point distance as a continuous variable showed no association with VAS scores, p 0 0.95 in a linear regression model. We compared short episiotomies (≤24 mm) to long episiotomies (≥35 mm) and found no difference in perineal pain perception related to episiotomy length for the VAS score group distribution (Table 3). Linear regression of episiotomy length as a continuous variable showed no association with VAS scores, p 0 0.97. All regression analyses were adjusted for delivery method, epidural analgesia during delivery, and additional vaginal tears without altering our conclusions. OASIS Of the 300 participants, 12 had an obstetric anal sphincter injury. None of these women had a lateral episiotomy. A midline episiotomy had been performed in 25 % of OASIS cases (n 0 3), 25 % had a mediolateral episiotomy (n 0 3), and 50 % of OASIS cases (n 0 6) had a nonclassifiable episiotomy, p 0 0.003. The majority (58.3 %, n 0 7) had a midline incision point (0–3 mm from the posterior fourchette), 33.3 % (n 0 4) had a nonclassifiable incision point (4–9 mm from the posterior fourchette), and only one woman had an incision point more than 10 mm from the midline, p 0 0.001. Mean incision point distance to midline was significantly shorter among
Int Urogynecol J Table 3 Percentage distribution of three VAS categories of perineal pain the first postpartum day (n 0 208/300) by episiotomy technique, analgesia, and maternal age
Characteristics Total n 0 208 Midline episiotomy (n 0 16) Mediolateral episiotomy (n 0 26) Lateral episiotomy (n 0 91) Nonclassifiable episiotomy (n 0 75) Episiotomy length ≤ 24 mm (n 0 46) Episiotomy length ≥35 mm (n 0 74) Episiotomy length 25–34 mm (n 0 88) Incision point from post fourchette (mm) 0–3 (n 0 43) Midline 4-9 (n 0 51) ≥10 (n 0 114) Lateral Episiotomy only (n 0 138) Additional vaginal tear (n 0 62) Obstetric anal sphincter injury (n 0 8) Spontaneous delivery (n 0 91) Instrumental delivery (n 0 117) Maternal age (years) 18–29 (n 0 103) 30–34 (n 0 130) 35–44 (n 0 67) Epidural during delivery (n 0 122) No epidural during delivery (n 0 86)
VAS scores 0–3 n 0 78 44 50 38 32 33 36 41 4–6 n 0 89 44 27 47 43 39 45 43 7–10 n 0 41 12 23 15 25 28 19 16
p 0.4
0.5
46 31 37 36 40 37 43 33
33 43 46 45 42 13 34 50
21 26 17 19 18 50 23 17
0.4
0.2
0.08
40 35 38 38 37
39 47 40 43 42
21 18 22 19 21
0.8
0.9
women with OASIS compared to women without OASIS (4.5 and 10.5 mm, respectively, p 0 0.002). Blood loss Postpartum blood loss varied from 100 to 2,000 ml (median 350 ml, mean 423 ml) and in most cases (74 %) blood loss was estimated to 400 ml or less. In a univariate analysis, higher birth weight and instrumental delivery were the only significant risk factors for excessive blood loss (Table 4). We found no differences in blood loss between episiotomy techniques, neither when dichotomizing postpartum blood loss into normal (0 – 499 ml) and excessive ( ≥ 500 ml) (Table 4) nor when analyzing blood loss as a continuous variable in a linear regression model, p 0 0.57. When comparing our three incision point groups, there was no difference in distribution of normal or excessive blood loss (Table 4). We found no association between blood loss and episiotomy incision point when analyzing both parameters as continuous variables, p 0 0.65. Adjusting for
delivery method, epidural analgesia and vaginal tears did not alter our conclusions. When comparing the shorter episiotomies (≤24 mm, n 0 70) to the longer (≥35 mm, n 0 176), there was no difference between blood loss groups related to episiotomy length (Table 4). However, when analyzing episiotomy length as a continuous variable we found a borderline significant p value of 0.06. In a multivariate regression analysis, birth weight was the only variable associated with an increased risk of a heavier bleed, but when excluding excessive blood loss of more than 800 ml, additional spontaneous vaginal tears were also shown to be a risk factor for increased blood loss, as expected, p 0 0.001.
Discussion Our study showed that lateral episiotomies were neither associated with more perineal pain the first postpartum day nor with more blood loss compared to the midline and mediolateral episiotomy techniques.
Int Urogynecol J Table 4 Clinical characteristics of total study group (n 0 300). Postpartum blood loss in two categories (normal and excessive) by episiotomy characteristics (evaluated postpartum)
Characteristics
Blood loss (ml) Normal 0–499 n 0 230 Excessive 500–2,000 n 0 70
p
Episiotomy length (mm) Short: ≤ 24 mm (n 0 70) Long: ≥ 35 mm (n 0 176) 25–35 mm (n 0 124) Episiotomy technique Midline (n 0 20) Mediolateral (n 0 38) Lateral (n 0 133) Non classifiable (n 0 109)
79 % 71 % 81 %
21 % 29 % 19 %
0.2
80 74 75 79
20 26 25 21
0.9
Incision point (mm distance from posterior fourchette) Incision point 0–3 (n 0 60) Midline 77 Incision point 4–9 (n 0 75) 81 Incision point ≥ 10 (n 0 165) Lateral 75 Delivery mode Spontaneous (n 0 133) Instrumental (n 0 167) Tears Episiotomy only (n 0 212) Additional vaginal tear (n 0 76) Obstetric anal sphincter injury (n 0 12) Parity (previous vaginal delivery) Para 0 Para 1-2 Age, mean (years) Birth weight, mean (g) Placental weight, mean (g) Duration of second stage, mean (min)
23 19 25
0.5
83 71
17 29
0.009
79 72 58
21 28 42
0.2
77 77 31 3471 634 46
23 23 31.5 3654 680 47
0.6
0.5 0.004 0.1 0.7
In addition to episiotomy techniques, we separately analyzed episiotomy incision points in relation to postpartum perineal pain perception, assessed by VAS scores. Regardless of whether the episiotomy incision point was lateral or midline, there was no difference in reported pain perception the first day after delivery or after adjusting for confounding factors such as delivery method, epidural analgesia, or additional vaginal tears. When assessing episiotomy length in relation to perineal pain perception, longer episiotomies were not perceived as more painful than shorter ones. To our knowledge, no study comparing postpartum perineal pain in relation to episiotomy technique or length has previously been published.
A weakness of this study is that we lack a vaginally delivered control group without episiotomy, but as we were primarily interested in assessing whether there were actual differences between episiotomy techniques in relation to perineal pain perception, we did not include such controls in our study. However, many previous studies have compared effects of episiotomy to no episiotomy and to spontaneous second-degree lacerations in regard to postpartum perineal pain [21–25], although all studies are on the mediolateral or midline episiotomy technique. Still, there seem to be many notions and myths linked to the lateral technique, possibly because there are very few publications on lateral
Int Urogynecol J
episiotomy in general. Misconceptions in the literature as to the correct definition of the lateral technique also exist [26]. Current studies [7, 11, 12] indicate that the lateral technique may in fact be practiced in several European countries, and possibly more frequently than earlier perceived. When using an alternative classification of episiotomies, by incision point solely and regardless of angle and technique, we found that a long distance from the incision point to the posterior fourchette was not associated with more postpartum perineal pain, supporting and strengthening our finding that lateral episiotomies (incision point ≥10 mm from the posterior fourchette) are not associated with more pain than other common episiotomy types. Our study showed that the lateral technique was the most frequently performed episiotomy in our unit, but that both mediolateral and midline episiotomies were performed, either intentionally or unintentionally. The midline episiotomy technique is, however, not recommended in our hospital due to the risk of the incision extending into the anal sphincter complex [17, 27]. We found that mean lateral episiotomy angle was significantly larger compared to mean mediolateral episiotomy angle and that lateral episiotomies were significantly longer than mediolateral episiotomies. This might indicate that the lateral episiotomy is easier to perform with a correctly large enough angle and length compared to the mediolateral episiotomy. However, our study has an overrepresentation of the lateral (n 0 133) compared to the mediolateral (n 0 38) technique, and such a hypothesis needs to be explored in larger studies. All clinical episiotomy assessments were performed postpartum, when there is no distension of the perineum due to crowning of the fetal head. The episiotomy suture angle measured therefore does not necessarily equal the actual incision angle (Figs. 1 and 2). We hypothesized that lateral episiotomies would have a similar reduction in angle as mediolateral episiotomy angles have been shown to have, when comparing incision to suture angle [19, 20]. There are, however, no studies reporting such an association for lateral episiotomies, and a potential reduction of lateral episiotomy incision to suture angle needs to be confirmed in future observational trials. Since we found mediolateral episiotomy angles to be significantly narrower than lateral episiotomy angles, this additionally raises the question of whether or not lateral episiotomies could be better suited than mediolateral episiotomies to prevent OASIS. If it is easier to maintain an optimally large angle when the episiotomy incision point is lateral and not midline, the lateral technique could possibly pose the lesser risk for anal sphincter lacerations. Large register studies on mediolateral and lateral episiotomy have shown a beneficial effect of episiotomy at instrumental delivery, namely, as being protective against OASIS [28–30], but large prospective observational studies are lacking. None of the 12 women with
OASIS in our study had a lateral episiotomy performed, and 11 of these 12 cases had an episiotomy with an incision point less than 10 mm from midline. Due to the low number of women with OASIS and our observational study design, we are cautious about drawing any conclusions as to lateral episiotomies being superior to mediolateral episiotomies in preventing OASIS, and our study was not designed to explore an OASIS-preventing effect of different episiotomy techniques. A randomized controlled trial would be a method of choice to explore such a hypothesis. As the episiotomies performed by doctors in our study nearly exclusively occurred during instrumental vaginal delivery and the episiotomies performed by midwives occurred (with two exceptions) during spontaneous delivery, it is not surprising that doctors performed longer episiotomies than midwives. Our findings on differences between midwives and doctors in episiotomy length also coincide with the studies by Tincello et al. [12] and Andrews et al. [13]. However, our study shows no significant difference in episiotomy angle between professions, in contrast to results in the two previously mentioned papers. A possible explanation could be that both professions in our unit favored the lateral episiotomy technique, supporting the hypothesis that lateral episiotomies may be easier to perform with a correct and wide enough angle compared to the mediolateral technique. One third of episiotomies (doctors and midwives equally represented) were nonclassifiable, meaning the incision point was incorrect according to our definitions, or the episiotomy angle was either too narrow or too large. Whether these episiotomies were intended to be mediolateral or lateral is unclear, but we cannot exclude incorrect training in either technique to be the cause of such a large nonclassifiable group. We found no association between episiotomy technique or episiotomy incision point related to estimated blood loss. Not surprisingly we did find an association between large infant birth weight and increased blood loss, which is a natural consequence of blood loss at birth being more strongly associated with uterine bleeding than bleeding from the actual episiotomy. To the best of our knowledge only a few studies have looked at episiotomy technique and association with blood loss per se. Baksu et al. [31] compared midline to mediolateral episiotomies and found a significant difference in blood loss between midline and mediolateral techniques when repair was performed after placental removal. No differences between techniques were found when repair was done before placental expulsion. This correlates with the blood loss-associated findings in our study, as our department practices episiotomy repair before placental expulsion. However, a limitation of our study is that the blood loss data are subjective estimations recorded by the accoucheur and not based on more objective
Int Urogynecol J
measurements such as postpartum reduction in hematocrit and hemoglobin levels. Several studies have assessed benefits and complications of episiotomies, but the results have been conflicting. A serious limitation in the existing literature, and a possible contributor to conflicting results, is the fact that the majority of studies lack an assessment of the actual episiotomy performed. Variations in mediolateral technique performance [11–13] and lack of specific technique documentation within and between obstetrical units may very well undermine previous evaluations of episiotomy complications and benefits. In conclusion, there seems to be little difference in perineal pain perception and postpartum blood loss between midline, mediolateral, and lateral episiotomy techniques. Our study adds important clinical information in demonstrating that lateral episiotomies and lateral incision points are not associated with augmented postpartum perineal pain or augmented postpartum blood loss compared to other episiotomy techniques performed.
Acknowledgments We thank Anette Schmidtke for contributing to quality control of data collection from the medical charts and Olivia Österberg for graphical illustrations, Figs. 1 and 2. This study received funding from the Norwegian Research Council and the Faculty of Medicine, University of Oslo, Norway. Conflicts of interest None.
References
1. Thacker SB, Banta HD (1983) Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860– 1980. Obstet Gynecol Surv 38:322–338 2. Carroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database Syst Rev 1:CD000081 3. Graham ID, Carroli G, Davies C, Medves JM (2005) Episiotomy rates around the world: an update. Birth 32:219–223 4. National Collaborating Centre for Women’s and Children’s Health (UK) (2007) Intrapartum care: care of healthy women and their babies during childbirth. NICE Clinical Guidelines, No. 55, pp 168–170 5. American College of Obstetricians-Gynecologists (2006) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 107:957–962 6. Räisänen SH, Vehviläinen-Julkunen K, Gissler M, Heinonen S (2009) Lateral episiotomy protects primiparous but not multiparous women from obstetric anal sphincter rupture. Acta Obstet Gynecol Scand 88:1365–1372 7. Grigoriadis T, Athanasiou S, Zisou A, Antsaklis A (2009) Episiotomy and perineal repair practices among obstetricians in Greece. Int J Gynaecol Obstet 106:27–29 8. Dudenhausen JW, Pschyrembel W (2001) Praktische Geburtshilfe mit geburtshilflichen Operationen (Practical obstetrics and obsterical operations), 9th edn. de Gruyter, Berlin 9. Flew JD (1944) Episiotomy. Br Med J 2:620–623 10. Kalis V, Laine K, de Leeuw JW, Ismail KM, Tincello DG (2012) Classification of episiotomy: towards a standardisation of terminology. BJOG 119:522–526
11. Kalis V, Stepan J Jr, Horak M, Roztocil A, Kralickova M, Rokyta Z (2008) Definitions of mediolateral episiotomy in Europe. Int J Gynaecol Obstet 100:188–189 12. Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevic Z (2003) Differences in episiotomy technique between midwives and doctors. BJOG 110:1041–1044 13. Andrews V, Thakar R, Sultan AH, Jones PW (2005) Are mediolateral episiotomies actually mediolateral? BJOG 112:1156–1158 14. Cleary-Goldman J, Robinson JN (2003) The role of episiotomy in current obstetric practice. Semin Perinatol 27:3–12 15. Banta D, Thacker SB (1982) The risks and benefits of episiotomy: a review. Birth 9:25–30 16. Myers-Helfgott MG, Helfgott AW (1999) Routine use of episiotomy in modern obstetrics. Should it be performed? Obstet Gynecol Clin North Am 26:305–325 17. Coats PM, Chan KK, Wilkins M, Beard RJ (1980) A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 87:408–412 18. Schünke M, Ross LM, Schulte E, Lamperti ED, Schumacher U (2005) Atlas of anatomy: general anatomy and musculoskeletal system. Georg Thieme, Stuttgart 19. Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z (2008) The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet 103:5–8 20. Kalis V, Landsmanova J, Bednarova B, Karbanova J, Laine K, Rokyta Z (2011) Evaluation of the incision angle of mediolateral episiotomy at 60 degrees. Int J Gynaecol Obstet 112:220–224 21. Chang SR, Chen KH, Lin HH, Chao YM, Lai YH (2011) Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: a prospective follow-up study. Int J Nurs Stud 48:409–418 22. Amorim Francisco A, Junqueira Vasconcellos de Oliveira SM, Barbosa da Silva FM, Bick D, Gonzalez Riesco ML (2010) Women’s experiences of perineal pain during the immediate postnatal period: a cross-sectional study in Brazil. Midwifery 27:e254–e259 23. Andrews V, Thakar R, Sultan AH, Jones PW (2008) Evaluation of postpartum perineal pain and dyspareunia–a prospective study. Eur J Obstet Gynecol Reprod Biol 137:152–156 24. Leeman L, Fullilove AM, Borders N, Manocchio R, Albers LL, Rogers RG (2009) Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables. Birth 36:283–288 25. Klein MC, Gauthier RJ, Robbins JM et al (1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 171:591–598 26. DeLancey JO (2008) Episiotomy: what’s the angle? Int J Gynaecol Obstet 103:3–4 27. Bodner-Adler B, Bodner K, Kaider A et al (2001) Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med 46:752–756 28. Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S (2011) High episiotomy rate protects from obstetric anal sphincter ruptures: a birth register-study on delivery intervention policies in Finland. Scand J Public Health 39:457–463 29. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ (2010) Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 150:142– 146 30. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW (2008) Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG 115:104–108 31. Baksu B, Davas I, Akyol A, Ozgul J, Ezen F (2008) Effect of timing of episiotomy repair on peripartum blood loss. Gynecol Obstet Invest 65:169–173
