Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury?

Gachon, Bertrand; Menard, Carine Fradet; Pierre, Fabrice H.F.; Fritel, Xavier

doi:10.1007/s00404-019-05174-0

Cited by 20 publications

(17 citation statements)

References 17 publications

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“…Finally, the reduction that we observed between 2016 and 2017 boosted the general downward trend (rate of change of about − 20%), showing the potential impact of the national debate about episiotomy practice in France 29 , 44 . The reduction in the episiotomy rate deserves to be compared to the obstetric anal sphincter injuries (OASIS) rate considering that there is concern about an increase in OASIS associated with a decrease in episiotomies 4 , 9 , 28 , 45 – 48 . Based on our previous study 28 , we found that severe perineal tears (third and fourth degrees) significantly increased in women who had non-operative vaginal deliveries.…”

Section: Discussionmentioning

confidence: 99%

Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries

Clesse

Cottenet

Lighezzolo-Alnot

et al. 2020

Sci Rep

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Episiotomy use has decreased due to the lack of evidence on its protective effects from maternal obstetric anal sphincter injuries. Indications for episiotomy vary considerably and there are a great variety of factors associated with its use. The aim of this article is to describe the episiotomy rate in France between 2013 and 2017 and the factors associated with its use in non-operative vaginal deliveries. In this retrospective population-based cohort study, we included vaginal deliveries performed in French hospitals (N = 584) and for which parity was coded. The variable of interest was the rate of episiotomy, particularly for non-operative vaginal deliveries. Trends in the episiotomy rates were studied using the Cochran-Armitage test. Hierarchical logistic regression was used to identify variables associated with episiotomy according to maternal age and parity. Between 2013 and 2017, French episiotomy rates fell from 21.6 to 14.3% for all vaginal deliveries (p < 0.01), and from 15.5 to 9.3% (p < 0.01) for all non-operative vaginal deliveries. Among non-operative vaginal deliveries, epidural analgesia, non-reassuring fetal heart rate, meconium in the amniotic fluid, shoulder dystocia, and newborn weight (≥ 4,000 g) were risk factors for episiotomy, both for nulliparous and multiparous women. On the contrary, prematurity reduced the risk of its use. For nulliparous women, breech presentation was also a risk factor for episiotomy, and for multiparous women, scarred uterus and multiple pregnancies were risk factors. In France, despite a reduction in episiotomy use over the last few years, the factors associated with episiotomy have not changed and are similar to the literature. This suggests that the decrease in episiotomies in France is an overall tendency which is probably related to improved care strategies that have been relayed by hospital teams and perinatal networks.

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Section: Discussionmentioning

confidence: 99%

Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries

Clesse

Cottenet

Lighezzolo-Alnot

et al. 2020

Sci Rep

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“…A small pilot randomized trial failed to identify any significant preventive effect 9 . Although several retrospective studies, mainly European national cohort studies, have reported that mediolateral episiotomy has a protective effect against OASI 10 – 12 , these studies appear to have reported a high rate of episiotomy and a high rate of OASI in the few cases without episiotomy, which seem to be not concordant with French practices. In our country, the 2005 national guidelines recommended restricted use of episiotomy during vaginal delivery, including instrumental delivery 13 .…”

Section: Introductionmentioning

confidence: 91%

French guidelines for restrictive episiotomy during instrumental delivery were not followed by an increase in obstetric anal sphincter injury

Gachon

Fritel

Rivière

et al. 2022

Sci Rep

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The objective was to assess the influence of the French guidelines in favor of a restrictive use of episiotomy on both episiotomy and obstetric anal sphincter injury (OASI) rates during instrumental delivery. It was aulticenter study involving 193 maternities between 2000 and 2016. We included women with a singleton pregnancy, with cephalic presentation at 34 weeks of gestation or more who underwent an instrumental delivery. The study period was divided into three phases: 2000–2005 (reference) 2006–2011, and 2012–2016. We calculated the adjusted relative risk (aRR) of episiotomy and OASI and investigated for changes in episiotomy and OASI rates over time by using Prais–Winsten regression. We considered 96,035 deliveries. The episiotomy’s risk was lower in 2006–2011 (69.4%) and 2012–2016 (59.1%) compared to 2000–2005 (81.2%), respectively: aRR 0.93 [0.92–0.95] and 0.89 [0.87–0.90]. The OASI’s risk was higher in 2006–2011 (2.5%) and 2012–2016 (3.1%) compared to 2000–2005, respectively: aRR 1.30 [1.10–1.53]) and 1.57 [1.33–1.85]. However, Prais–Winsten regression showed no difference in the OASI rate during the study period. We observed a massive decrease in episiotomy use and a moderate increase in crude OASI’s rate but multivariate analysis failed to report an association between these outcomes.

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“…The results of observational studies are contradictory [ 10 – 20 ], and their conclusions may be limited owing to insufficient consideration of the confounding bias by indication. The implementation of a very restrictive episiotomy policy could even be associated with an increase in OASIs incidence during forceps delivery [ 21 ]. The major problem when evaluating OASIs is that maternal, fetal and medical characteristics are different in the episiotomy and no episiotomy groups.…”

Section: Introductionmentioning

confidence: 99%

Mediolateral episiotomy and risk of obstetric anal sphincter injuries and adverse neonatal outcomes during operative vaginal delivery in nulliparous women: a propensity-score analysis

Desplanches

Marchand-Martin

Szczepanski³

et al. 2022

BMC Pregnancy Childbirth

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Background The potential protective effect of mediolateral episiotomy for obstetrical anal sphincter injuries (OASIs) remains controversial during operative vaginal delivery because of the difficulties to take into account the risk factors and clinical conditions at delivery; in addition, little is known about the potential benefits of mediolateral episiotomy on neonatal outcomes. The objectives were to investigate the associations between mediolateral episiotomy and both OASIs and neonatal outcomes, using propensity scores. Methods We performed a retrospective population-based observational study from a perinatal registry that includes all births in a French region between 2010 and 2017. All nulliparous women with singleton pregnancy delivering by operative vaginal deliveries at 37 weeks gestational age or later were included. Inverse-probability-of-treatment weighting with propensity scores was used to minimize indication bias. OASIs was defined as third and fourth-degree tears according to Royal College of Obstetricians and Gynecologists. Two neonatal outcomes were studied: condition at birth (5-min Apgar score less than 7 and/or umbilical artery pH less than 7.10), and admission to neonatal intensive care unit. Results The study population consisted of 7589 women; 2880 (38.0%) received mediolateral episiotomy. After applying propensity scores, episiotomy was associated with a lower rate of OASIs in forceps/spatula delivery (2.3 vs 6.8%, Risk Ratio (RR) 0.38, 95% Confidence Interval (CI) 0.28–0.52) and in vacuum delivery (1.3 vs 3.4%, RR 0.27, 95% CI 0.20–0.38) as compared with no episiotomy. Mediolateral episiotomy was associated with better condition at birth in case of forceps/spatula delivery (4.5 vs 8.8%, RR 0.56, 95% CI 0.39–0.81). In cases of fetal distress (40.7%), mediolateral episiotomy was associated with better condition of infant at birth in women who delivered by forceps/spatula (4.2 vs 13.5%, RR 0.52, 95% CI 0.31–0.89). No association was found with neonatal unit admission (RR 0.93, 95% CI 0.50–1.74). Conclusions Use of mediolateral episiotomy was associated with a lower rate of OASIs during operative vaginal delivery, and in infants it was associated with better condition at birth following forceps/spatula delivery.

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Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury?

Cited by 20 publications

References 17 publications

Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries

Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries

French guidelines for restrictive episiotomy during instrumental delivery were not followed by an increase in obstetric anal sphincter injury

Mediolateral episiotomy and risk of obstetric anal sphincter injuries and adverse neonatal outcomes during operative vaginal delivery in nulliparous women: a propensity-score analysis

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