doi: 10.56294/shp2024132

REVIEW 

Episiotomy: beneficial for the doctor, the woman, or neither? Comparison with vaginal tear based on the complications of the technique

Episiotomía: beneficiosa para el médico, la mujer, ¿o ninguno? Comparación con desgarro vaginal en base a las complicaciones de la técnica

Agustina Campo¹ *

¹Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Carrera de Medicina. Buenos Aires, Argentina.

Cite as: Campo A. Episiotomy: beneficial for the doctor, the woman, or neither? Comparison with vaginal tear based on the complications of the technique. South Health and Policy. 2024; 3:132. https://doi.org/10.59471/shp2024132

Submitted: 14-08-2023                   Revised: 03-01-2024                   Accepted: 22-06-2024                 Published: 23-06-2024

Editor: Dr. Telmo Raúl Aveiro-Róbalo

Corresponding author: Agustina Campo *

ABSTRACT

Introduction: episiotomy, a surgical incision in the perineum during vaginal delivery, has been used with the goal of reducing high-grade tears. However, currently its routine use has led to reconsidering the benefits of this technique, since it can lead to complications that, in some cases, can be avoided. On the other hand, vaginal tear is not always high grade and is not a necessary condition in a vaginal birth, so the deliberate use of episiotomy is not justified, which can, in the end, have more complications than what it is intended to avoid.

Objective: to analyze the complications of episiotomy compared to those of perineal tear.

Method: systematic review of articles published in the last 4 years.

Keywords: Episiotomy; Anal Sphincter; Delivery; Obstetrics; Perineum.

RESUMEN

Introducción: la episiotomía, una incisión quirúrgica en el perineo durante el parto vaginal, ha sido utilizada con el objetivo de reducir los desgarros de alto grado. Sin embargo, actualmente su uso rutinario dio lugar a replantear los beneficios de esta técnica, ya que puede derivar en complicaciones que, en algunos casos, pueden ser evitadas. Por otro lado, el desgarro vaginal no siempre es de alto grado y tampoco es una condición necesaria en un parto vaginal, por lo que no se justifica el uso deliberado de la episiotomía que puede, finalmente, tener más complicaciones que lo que pretende evitar. 

Objetivo: analizar las complicaciones de la episiotomía comparadas con las del desgarro perineal.

Método: revisión sistemática de artículos publicados en los últimos 4 años.

Palabras clave: Episiotomía; Esfínter Anal; Parto; Obstetricia; Periné.

INTRODUCTION

An episiotomy is a surgical incision of the perineum that aims to enlarge the vaginal opening.⁽¹⁾ The indications for episiotomy were originally aimed at preventing spontaneous lacerations or tears, as it was considered that a controlled wound with defined margins would be easier to suture than an excessive and unpredictable tear of the tissues.^(2,3) The logic behind this practice was that a planned incision would allow for better repair and healing, potentially reducing postpartum complications.^(4,5) On the other hand, it was discovered over time that a history of episiotomy could become a risk factor for more severe lacerations due to the extent of the incision.^(6,7) This means that, although episiotomy could prevent certain types of tears, it also guarantees significant perineal trauma and can predispose women to more severe injuries, complicating the recovery process and increasing morbidity by causing the very injuries it was intended to prevent in the first place.^(8,9,10) Thus, episiotomy has been subject to reevaluation and debate in current obstetric practice.^(11,12)

In addition, no significant difference was observed in the duration of the second stage of labor between women who underwent an episiotomy and those who experienced spontaneous lacerations. Finally, episiotomy rates were higher (63 %) when women were encouraged to push compared to those who were not (39 %). In this regard, it is advisable to allow sufficient time for the perineum to relax its tissues, thereby reducing the rate of lacerations and the need for episiotomy.^(3,4)

These findings led to a reevaluation of the widespread practice of episiotomy, suggesting that its benefits were not as clear as previously thought.

Usually, only two main types of episiotomy (median and mediolateral) are discussed, but seven different incisions have been described.⁽¹¹⁾

Perineal tearing is a complication of vaginal delivery and is an injury that can affect the perineum, cervix, vagina, and vulva. It can occur spontaneously or iatrogenically. Tears can be classified into grades that determine their progression and complications.⁽¹⁾

There are four grades of perineal lacerations:

· First-degree tears, where the injury is limited to the perineal skin, are superficial, painless, and rarely require treatment.

· Second-degree tears are injuries to the perineum that affect the perineal muscles but do not extend to the anal sphincter; these are painful and usually bleed, requiring sutures.

· Third-degree tears affect the anal sphincter and, in turn, have three subtypes: (1) where <50 % of the thickness of the external anal sphincter is torn, (2) where >50 % of the thickness of the external anal sphincter is torn, and (3) where both the external and internal anal sphincters are torn.

· Finally, fourth-degree tears affect the anal sphincter complex (third-degree) along with the anal epithelium.

The most common immediate complication of all degrees of tearing is bleeding, which, if quickly controlled with pressure or surgically, does not lead to serious consequences. In addition to bleeding, in the immediate postpartum period, women may experience pain and prolonged suturing, which delays mother-child bonding. There is also a risk of infection, which can delay wound healing and even cause dehiscence.^(9,10)

Third- and fourth-degree perineal tears carry the highest risk of complications for women. If they are not detected in time or appropriately repaired, women may experience consequences that reduce their quality of life. The main complications include bleeding, ongoing perineal pain, fecal incontinence, urinary incontinence, and painful sexual intercourse. In addition, due to the social and emotional implications of these complications, they can affect psychological well-being and lead to depression.⁽³⁾

Episiotomy is not a free technique; it can lead to several complications that make us reflect on whether it is necessary or whether its use is truly more beneficial than the possible complications of a spontaneous tear, bearing in mind that these are not always severe and can even heal properly without medical intervention and with few or no complications. Episiotomy is currently being reevaluated and debated in medical practice. Although its objective is to prevent severe tears and facilitate tissue repair, its benefits are questioned because it can lead to complications such as pain, urinary incontinence, fecal incontinence, dyspareunia, and depression.^(10,11)

The option of allowing spontaneous perineal tears during vaginal delivery appears to result in less medical intervention when these are low-grade. It is necessary to investigate/reflect on the benefits of deliberately performing episiotomy and whether this leads to fewer complications, reduces the rate of higher-grade tears, and ultimately benefits women in the short and long term.⁽⁴⁾

METHOD

A systematic and descriptive cross-sectional review was carried out. Scientific studies were collected based on a search for information about postpartum complications in women who underwent vaginal delivery with episiotomy and women who underwent vaginal delivery with tearing. Filters were used to isolate these population groups.

Initially, relevant scientific studies were searched on the PubMed platform, yielding 4 212 results. After establishing the publication period between 2020 and 2024, the results were reduced to 855 studies.

Keywords such as “OASIS,” “perineum,” “dyspareunia,” and “pain” were used to collect studies relevant to this work, resulting in 62 studies. Finally, after reading and analyzing them, 12 studies were selected with sufficient and relevant information for the topic of this thesis.

RESULTS

In the study presented by Grażyna Bączek, Sylwia Rychlewicz, et al., 19599 births were analyzed, of which 4001 (20,41 %) underwent episiotomy. From this last group, the relationship with the characteristics of the study population was analyzed, showing that the highest percentage of age range was between 26-30 years (40,56 %) and 31-35 years (37,02 %). Other data on population characteristics were analyzed but were not statistically relevant for this study.

The study above also analyzed the incidence of episiotomy about variables that occur before delivery. Within the group of women who underwent episiotomy, relevant data with a causal relationship (p-value < 0,05) showed that this technique was more common in women who were pregnant for the first time (6,5 %), women who were giving birth for the first time (71,5 %), women who had previous cesarean sections (9 %), and women with a higher BMI. With an even greater influence, it was observed that episiotomy was performed in women who were induced with oxytocin and in those who underwent epidural anesthesia (46,6 %). The duration of labor was compared between women who underwent episiotomy and women who did not undergo this procedure, and it was shown that labor was shorter in the latter group. Another relevant and influential cause was that episiotomy was performed more frequently in women who were accompanied by a family member during delivery (74,6 %). (figure 1).

The following figure summarizes the data on the characteristics of the population and the most relevant variables before delivery.

Figure 1. Data

CONCLUSIONS

The information gathered for this research indicates that there is still no clear indication of episiotomy, which raises questions about its use. This uncertainty may result in the deliberate use of the technique or, conversely, in its complete disregard, leading to serious consequences.

The standardized use of episiotomy, without considering the appropriate indications, can harm women, as this technique is not without risks. It can result in heavy bleeding, infections, hematomas, perineal pain, and tears that extend to the anal sphincter. In the long term, consequences may include dyspareunia, difficulty, pain during bowel movements, and a restriction in certain postures and movements.

The lack of studies on precise indications for episiotomy creates uncertainty among women, who may misinterpret its use as obstetric violence. In most cases, pregnant women do not receive adequate information from health professionals about episiotomy and its indications. This can result in traumatic experiences that go beyond physical problems, such as decreased sex drive and reduced confidence in future vaginal deliveries.

Women's experiences lead us to reflect on our responsibility to promote this technique and provide reassurance. Adequate information reassures women, generating greater confidence in the birth process. By identifying the absolute indications for episiotomy and providing more comprehensive information, we can accurately inform pregnant women. This will allow them to participate in the choice of their obstetric care, considering options such as first- or second-degree tearing rather than a deliberate episiotomy, as the latter can cause similar or even worse injuries, prolonging the hospital stay.

In cases where episiotomy is unavoidable, it is essential to inform women about pelvic floor exercises that facilitate better postpartum recovery. In addition, more efficient episiotomy techniques, such as using EPISCISSORS-60®, should be investigated, and recovery strategies that minimize the impact on the perineal tissue should be adopted. These may include suturing techniques with less impact, cold therapies, and natural oils.

Given the consequences, it is essential to reduce the use of episiotomy to only those cases where it is truly necessary, where its use is the alternative to prevent significant complications. We must reconsider the indications for episiotomy, as it is not a treatment in itself but a tool intended to avoid more severe injuries, mainly third- and fourth-degree tears. Identifying and reducing the risk factors associated with these complications is crucial, which would allow for a lower incidence of indiscriminate episiotomies.

The goal of future research should focus on recognizing the risk factors for third- and fourth-degree tears, especially among nulliparous women, who receive the highest percentage of episiotomies. Although episiotomy can reduce the incidence of anal sphincter tears when used correctly, we should not assume its necessity in all cases. By rethinking its use and considering women's experiences, we can move toward more informed and respectful obstetric care.

REFERENCES

1. Aguiar BM, Silva TPRD, Pereira SL, et al. Factors associated with the performance of episiotomy. Rev Bras Enferm. 2020;73(suppl 4):e20190899. doi:10.1590/0034-7167-2019-0899.

2. Alexander JW, Karantanis E, Turner RM, Faasse K, Watt C. Patient attitude and acceptance towards episiotomy during pregnancy before and after information provision: a questionnaire. Int Urogynecol J. 2020;31(3):521-8. doi:10.1007/s00192-019-04003-x.

3. Bączek G, Rychlewicz S, Sys D, Rzońca P, Teliga-Czajkowska J. Episiotomy for medical indications during vaginal birth—retrospective analysis of risk factors determining the performance of this procedure. J Clin Med. 2022;11(15):4334. doi:10.3390/jcm11154334.

4. Hartinah A, Usman AN, Sartini, et al. Care for perineal tears in vaginal delivery: an update for midwife. Gac Sanit. 2021;35(Suppl 2):S216-20. doi:10.1016/j.gaceta.2021.10.024.

5. He S, Jiang H, Qian X, Garner P. Women’s experience of episiotomy: a qualitative study from China. BMJ Open. 2020;10(7):e033354. doi:10.1136/bmjopen-2019-033354.

6. Klein MC, Kaczorowski J. Routine use of episiotomy with forceps should not be encouraged. CMAJ. 2020;192(8):E190. doi:10.1503/cmaj.74132.

7. Koh LM, van Roon Y, Pradhan A, Pathak S. Impact of the EPISCISSORS-60 mediolateral episiotomy scissors on obstetric anal sphincter injuries: a 2-year data review in the United Kingdom. Int Urogynecol J. 2020;31(9):1729-34. doi:10.1007/s00192-019-04201-7.

8. MacLellan J, Webb SS, Byrne C, et al. Informed consent in episiotomy: co-analysis with midwives and distillation of best practice. Birth. 2023;50(4):773-80. doi:10.1111/birt.12721.

9. Radnia N, Khansari S, Jiriaei N, Hosseini SA, Salemi L, Hamoon M. The relationship between perineal size and episiotomy during delivery. J Med Life. 2022;15(11):1379-83. doi:10.25122/jml-2021-0390.

10. Sultan AH, de Leeuw JW. Episiotomy and operative vaginal delivery: do we need more evidence? BJOG. 2021;128(10):1672-3. doi:10.1111/1471-0528.16783.

11. Tantengco OAG, Velayo CL. Episiotomy practice and perineal trauma in the Philippines. Lancet Reg Health West Pac. 2022;19:100381. doi:10.1016/j.lanwpc.2022.100381.

12. Zhang D, Bo K, Montejo R, et al. Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: systematic review and meta-analysis of randomized clinical trials. Acta Obstet Gynecol Scand. 2024;103(6):1015-27. doi:10.1111/aogs.14744.

FUNDING

None.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTION

Conceptualization: Agustina Campo.

Data curation: Agustina Campo.

Formal analysis: Agustina Campo.

Research: Agustina Campo.

Methodology: Agustina Campo.

Project management: Agustina Campo.

Resources: Agustina Campo.

Software: Agustina Campo.

Supervision: Agustina Campo.

Validation: Agustina Campo.

Visualization: Agustina Campo.

Writing – original draft: Agustina Campo.

Writing – review and editing: Agustina Campo.