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JOGC

Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries

Published:April 16, 2019DOI:https://doi.org/10.1016/j.jogc.2019.02.016

      Abstract

      Objective

      The purpose of this study was to describe associations between episiotomy at the time of forceps or vacuum-assisted delivery and obstetrical anal sphincter injuries (OASIS).

      Methods

      This population-based retrospective cohort study used delivery information from a provincial perinatal clinical database. Full-term, singleton, in-hospital, operative vaginal deliveries of vertex-presenting infants from April 1, 2006 to March 31, 2016 were identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations between episiotomy and third- or fourth-degree lacerations were calculated in multiple logistic regression models (Canadian Task Force Classification II-2).

      Results

      Episiotomy was performed in 34% of 52 241 operative vaginal deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of vacuum deliveries. Episiotomy was associated with increased odds of severe perineal lacerations for vacuum deliveries among women with (OR 2.48; 95% CI 1.96–3.13) and without (OR 1.12; 95% CI 1.02–1.22) a prior vaginal delivery. Among forceps deliveries, episiotomy was associated with increased odds of OASIS for those with a previous vaginal delivery (OR 1.52; 95% CI 1.12–2.06), but it was protective for women with no previous vaginal delivery (OR 0.73; 95% CI 0.67–0.79). Midline compared with mediolateral episiotomy increased the odds of OASIS in forceps deliveries (OR 2.73; 95% CI 2.37–3.13) and vacuum deliveries (OR 1.94; 95% CI 1.65–2.28).

      Conclusion

      In conclusion, results suggest that episiotomy should be used with caution, particularly among women with a previous vaginal delivery and in the setting of vacuum-assisted delivery. Episiotomy may protect against OASIS in forceps-assisted deliveries for women without a prior vaginal delivery.

      Résumé

      Objectif

      L'objectif de cette étude était de décrire les associations entre l'épisiotomie au moment d'un accouchement par forceps ou par ventouse et les lésions obstétricales du sphincter anal (LOSA).

      Méthodologie

      Cette étude de cohorte rétrospective fondée sur la population a analysé des renseignements sur les accouchements tirés d'une base de données cliniques périnatales provinciale. Les accouchements vaginaux opératoires à terme d'un seul bébé en présentation du sommet survenus à l'hôpital entre le 1er avril 2006 et le 31 mars 2016 ont été recensés. Les rapports de cotes (RC) et les intervalles de confiance (IC) à 95 % pour les associations entre l'épisiotomie et les lacérations de troisième et de quatrième degré ont été calculés au moyen de plusieurs modèles de régression logistique (classification II-2 du Groupe d'étude canadien).

      Résultats

      Une épisiotomie a été pratiquée dans 34 % des 52 241 accouchements vaginaux opératoires. Des LOSA sont survenues dans 21 % des accouchements par forceps et 7,6 % des accouchements par ventouse. L'épisiotomie a été associée à un risque accru de lacérations périnéales graves lors d'un accouchement par ventouse chez les femmes ayant déjà (RC : 2,48; IC à 95 % : 1,96–3,13) ou n'ayant jamais (RC : 1,12; IC à 95 % : 1,02–1,22) accouché par voie vaginale. Dans les cas d'accouchement par forceps, l'épisiotomie a été associée à un risque accru de LOSA chez les femmes ayant déjà accouché par voie vaginale (RC : 1,52; IC à 95 % : 1,12–2,06), mais elle était protectrice chez les femmes n'ayant jamais accouché par voie vaginale (RC : 0,73; IC à 95 % : 0,67–0,79). Comparativement à l'épisiotomie médiolatérale, l'épisiotomie médiane augmentait le risque de LOSA lors des accouchements par forceps (RC : 2,73; IC à 95 % : 2,37–3,13) et par ventouse (RC : 1,94; IC à 95 % : 1,65–2,28).

      Conclusion

      En conclusion, les résultats semblent indiquer que l'épisiotomie devrait être utilisée avec prudence, surtout chez les femmes ayant déjà accouché par voie vaginale et dans les cas d'accouchement par ventouse. L'épisiotomie peut avoir un effet protecteur contre les LOSA lors d'un accouchement par forceps chez les femmes n'ayant jamais accouché par voie vaginale.

      Key Words

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      Linked Article

      • Letter: The Type of Episiotomy Should Be Studied Carefully
        Journal of Obstetrics and Gynaecology Canada Vol. 41Issue 11
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          We read the study by Frenette et al., published recently in JOGC, with great interest.1 These authors retrospectively investigated the incidence and risk factors associated with obstetric anal sphincter injuries (OASIS) during operative vaginal delivery among parous and nulliparous women. Despite their large retrospective cohort study, some issues deserve further clarification.
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