Episiotomy and protecting the perineum

Episiotomy and
protecting the
perineum
Sari Räisänen, PhD, RM
Savonia University of Applied Sciences
Iisalmi, Finland
sari.raisanen@savonia.fi
7.7.2012

• Definition of obstetric anal sphincter injuries (OASIS)
• Incidence of OASIS
• Risk factors of OASIS
• Definitions of different episiotomy types
• Role of episiotomy in perineum protection
Content of the presentation
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INJURY DEFINITION
First degree Injury to perineal skin only
Second degree Injury to perineum involving perineal
muscles but not involving the anal
sphincter
Third degree Injury to the perineum involving the
anal sphincter complex
3a 50% of external sphincter thickness is
torn
3c Both external anal sphincter and
internal anal sphincter torn
Fourth degree Injury to external and internal sphincter
and anal epithelium
Definition of OASIS (Sultan 1999)
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Incidence of
OASIS
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• Varies between countries and continents:
• Differences in risk profile such as type of episiotomy
and population
• Differences in health care systems (free access vs.
prominent private sector)
• Different roles of professionals
• Classification
• Recognizing and reporting
Incidence of OASIS?
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Recognising (Andrews et al. 2006)
Visual inspection
and palpation
Endoanal
ultrasonography
• Understanding of perineal
anatomy
• Classification system
• Higher incidences, occult
injuries
• Clinical relevancy?
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• Under-documentation
• Might leads to blame of an individual
• Differences in registration procedures
• No data available
Reporting
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Country OASIS % in 2004
Denmark 3.5
UK: Scotland 2.6
Germany 2.2
UK: England 1.8
UK: Wales 1.8
Portugal 0.4
Slovenia 0.3
Italy 0.2
EURO-PERSITAT Project 2008
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Incidences of OASIS in the Nordic
countries (Laine et al.2009)
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Mode of delivery 1979 2004
Spontaneous vaginal 5.0 3.5
Operative vaginal 7.7 15.3
Incidence of OASIS (%) in the USA
between 1979 and 2004 (Frankman
et al. 2009)
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Risk factors of
OASIS
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• Factors associated with OASIS are widely recognized
• Differences in study design
• Differences in intervention used / lack of definitions:
such as episiotomy, manual perineum protection,
second stage of the birth
• Most risk factors are not modifiable
Background
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Study Nulliparity Birthweight Vacuum Episiotomy
Baghestan et al.
2010, Norway
Räisänen et al.
2009, Finland
de Leeuw et al.
2001,
Netherlands
Handa et al.
2001, USA
4.8 (4.7-5.0) 4000-4499 g
2.3 (2.2-2.3)
6.0 (5.4-6.6) Nulliparae
≥4.7 (3.9-5.6)
2.4 (2.2-2.6) By 500 g
1.5 (1.4-1.5)
2.0 (1.9-2.1) Medio-lateral
1.2 (1.2-1.3)
Nulliparae
3.9 (3.3-4.6)
Nulliparae
Lateral
0.83 (0.75-0.92)
1.7 (1.5-1.9) Medio-lateral
0.21 (0.19-0.23)
Midline
3. degree
0.89 (0.86-0.92)
4. degree
1.12 (1.05-1.19)
Risk factors of OASIS (adjusted OR (95% CI)
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• Maternal age
• Fetal head circumference
• Forceps
• Length of the second stage
of delivery
• Flexion of the fetal head
• Previous CS
• Epidural analgesia
• Shoulder dystocia
Other variables to be
discussed
• Maternal position
• Manual perineum protection
• Hot compression of the
perineum
• Fundal pressure -
Kristeller's maneuver
• Perineal massage
• Waterbirth
• Individuality of the
obstetrician/midwife
• Co-operation at delivery
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Definitions of
different
episiotomy types
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• The surgical enlargement of the vaginal orifice by an
incision of the perineum during the last part of the second
stage of delivery (Carroli & Mignini 2009)
• Definitions of episiotomy differs between textbooks and
research papers or are lacking. (Kalis et al. 2012)
Episiotomy
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• Origin of the initial incision
• Direction of the cut (angle)
• Length
Technical characteristics
of episiotomy (Kalis et al.
2012)
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Types of episiotomy (Kalis et al. 2012)
5
4
3
7
1
2
6

Type of episiotomy
Median (midline)
posterior fourchette
(midline)
„J shaped“
Mediolateral
Location of the initial
incision
posterior fourchette
(midline)
midline
two transverse cuts on each
side added
posterior fourchette
(midline)
posterior fourchette
(midline)
Lateral 1-2cm from the midline
Radical lateral
(Schuchardt incision)
1-2cm from the midline
Direction of the cut
Midline cut through the
central tendon of the
perineum
posterior fourchette
(midline)
at first midline,
then „J“ directed towards
the ischial tuberosity
directed laterally at an angle
of at least 60° towards the
ischial tuberosity
towards the ischial
tuberosity
towards the ischial
tuberosity and around the
rectum
Types of episiotomy (Kalis et al. 2012)
Anterior midline
midline, directed towards
the pubis 7.7.2012

• There is clear evidence to recommend a restrictive use of
episiotomy. (Carroli & Mignini 2009, Hartmann et al. 2005)
• Indications?
• Absolute: Fetal distress, where the birth needs to be
hastened. Relative?
• The most familiar type of the procedure that provides the
best outcome?
• Weak evidence from a single trial (Hartmann et al. 2005)
and several retrospective cohort studies suggests that harms
of midline episiotomy are greater than medio-lateral
episiotomy due to greater risk of OASIS.
Episiotomy policy
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• Restrictive
episiotomy policies
appear to have a
number of benefits
(immediate outcomes)
compared to policies
based on routine
episiotomy. (Carroli
& Mignini 2009)
Immediate outcomes of
episiotomy
• Immediate outcomes
following routine use
of episiotomy are no
better than those of
restrictive use.
(Hartmann et al.
2005)
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• The overall level of evidence on long-term sequelae
(fecal and urinary incontinence, pelvic floor function, and
future sexual function) is fair to poor.(Carroli & Mignini
2009, Hartmann 2005)
Long-term outcomes of
episiotomy
7.7.2012

• Episiotomy must be clearly defined and performed
accordingly.
• Rectal examinations must be made to detect the real
degree of perineal injury and
• International classification of perineal trauma should be
used to compare results of different studies.
Conclusions
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Risk factors of OASIS
and role of lateral
episiotomy in
perineum protection
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Parity Adjusted OR of OASIS
(95% CI)
First vaginal delivery
Second vaginal delivery 0.21 (0.19-0.24)
Third vaginal delivery
Fourth vaginal delivery
Fifth or more vaginal
delivery
Incidence of OASIS
across group of parities
1
0.06 (0.05-0.08)
0.03 (0.02-0.06)
0.02 (0.00-0.04)
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7.7.2012
Adjusted OR of OASIS among nulliparous
women (n=217,778) in singleton vaginal
deliveries between 1997 and 2007 in Finland
(Räisänen et al. 2009)

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Adjusted OR of OASIS among multiparous
women (n=296,963) in singleton vaginal
deliveries between 1997 and 2007 in Finland
(Räisänen et al. 2009)

7.7.2012
Adjusted OR of OASIS in hospitals with different
episiotomy rates among nulliparous and
multiparous women giving birth in hospitals with
more than 1000 deliveries annually between 1997
and 2007 in Finland. (Räisänen et al. 2011)

7.7.2012
Relationship between episiotomy rates (%) and OR
of OASIS in nulliparous women (n=154,175)
(R=0.53, p=0.02). (Räisänen et al. 2012a)

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Relationship between episiotomy rates (%) and OR
of OASIS in multiparous women (n=234,236)
(R=0.49, p=0.04). (Räisänen et al. 2012a)

7.7.2012
Relationship between OR of OASIS in
nulliparous and multiparous women (n=388,411)
(R=0.81, p≤0.001). (Räisänen et al. 2012a)

Delivery
intervention/characteristic
Vacuum extraction
Vacuum extraction1 Length of active 2nd stage of
birth
≤60 min.
≥61 min.
Birth weight

First vaginal
delivery,
adjusted OR
(95% CI)
OASIS and a prior
Second vaginal
delivery,
adjusted OR
(95% CI)
n 217,666 167,523 77,775
Cesarean section (CS)
Third vaginal
delivery,
adjusted OR
(95% CI)
Prior CS 1.45 (1.27-1.66) 0.85 (0.52-1.38) 0.84 (0.21-3.46)
7.7.2012

Incidnece of OASIS and
smoking (Räisänen et al.
2012c)
Nulliparous women,
adjusted OR (95% CI)
Non-smoking 1 1
Multiparous women,
adjusted OR (95% CI)
Given up smoking 0.87 (0.67 – 1.10) 0.23 (0.06 – 0.91)
Smoking 0.72 (0.62 – 0.84) 0.87 (0.64 – 1.18)
7.7.2012

• Lateral episiotomy was associated with 17% incidence of
OASIS, (adjusted OR 0.83, 95% CI 0.75-0.92) in
nulliparae.
• Lateral episiotomy was associated with 46% decreased
incidence of OASIS (adjusted OR 0.54, 95% CI 0.42-
0.70) in nulliparae delivered by vacuum extraction
• Previous Cesarean section is a risk factor of OASIS in
first vaginal delivery.
• Nulliparous women who were smokers had a 28% lower
incidence of OASIS.
• Restricting lateral episiotomy use may result in higher
OASIS rates.
Conclusions
7.7.2012

• Safety of the incision angle of medio-lateral episiotomy
• Comparisons between lateral and medio-lateral
episiotomy
Further resaerch
7.7.2012

• Andrews V, Sultan AH, Thakar R, Jones PW, 2006a. Occult anal sphincter
injuries--myth or reality? BJOG 113, 195-200.
• Baghestan E, Irgens LM, Bordahl PE, Rasmussen S, 2010. Trends in risk
factors for obstetric anal sphincter injuries in norway. Obstet.Gynecol. 116,
25-34.
• Carroli G, Mignini L, 2009. Episiotomy for vaginal birth. Cochrane
Database Syst.Rev., CD000081.
• De Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC, 2001. Risk factors
for third degree perineal ruptures during delivery. BJOG 108, 383-7.
• EURO-PERISTAT Project (2008) EUROPEAN PERINATAL HEALTH
REPORT. Available: http://www.europeristat.com
• Frankman EA, Wang L, Bunker CH, Lowder JL, 2009. Episiotomy in the
United States: has anything changed?. Am.J.Obstet.Gynecol. 200, 573.e1-
573.e7.
• Handa VL, Danielsen BH, Gilbert WM, 2001. Obstetric anal sphincter
lacerations. Obstet.Gynecol. 98, 225-230.
References
7.7.2012

• Hartmann K, Viswanathan M, Palmieri R, gartlehner G, Thorp J Jr,
Lohr KN, 2005. Outcomes of routine episiotomy: a systematic
review. JAMA 293(17):2141-8.
• Kalis V, Laine K, de Leeuw J, Ismail K, Tincello D (2012)
Classification of episiotomy: towards a standardisation of
terminology. BJOG 119, 522–6.
• Laine K, Gissler M, Pirhonen J, 2009. Changing incidence of anal
sphincter tears in four Nordic countries through the last decades.
Eur.J.Obstet.Gynecol.Reprod.Biol. 146(1):71-5.
• Räisänen SH, Vehvilainen-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(12):1365-72.
• Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S. High
episiotomy rate protects from obstetric anal sphincter ruptures: A
birth register-study on delivery intervention policies in finland. Scand
J Public Health. 2011;39:457-63.
References
7.7.2012

• Sultan A, 1999. Obstetric perineal injury and anal incontinence.
Clinical Risk 5, 193-196.
• Räisänen, Vehviläinen-Julkunen, Gissler, Heinonen. Hospital-based
episiotomy rates are inversely correlated with the risk of obstetric
anal sphincter injury. AJOG 2012a; 206 (4), 347e1-347e6.
• Räisänen S, Vehviläinen-Julkunen K, Cartwright R, Gissler M,
Heinonen S. 2012b. Vacuum assisted deliveries and the risk of
obstetric anal sphincter injuries – A retrospective register based study
in Finland. BJOG. Accepted.
• Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S. 2012c.
Smoking during pregnancy is associated with a decreased incidence
of obstetric anal sphincter injuries in nulliparous women. Plos One.
Accepted.
References
7.7.2012