Episiotomy for vaginal birth

 

Abstract

Background

Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear.

Objectives

The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008).

Selection criteria

Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy.

Data collection and analysis

The two review authors independently assessed trial quality and extracted the data.

Main results

We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison.

Authors' conclusions

Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

 

Plain language summary

Episiotomy for vaginal birth

Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or scalpel (episiotomy) to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy.

The review authors searched the medical literature for randomised controlled trials that compared episiotomy as needed (restrictive) compared with routine episiotomy to determine the possible benefits and harms for mother and baby. They identified eight trials involving more than 5000 women. For women randomly allocated to routine episiotomy 75.10% actually had an episiotomy whereas with a restrictive episiotomy policy 28.40% had an episiotomy. Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy. Both restrictive compared with routine mediolateral episiotomy and restrictive compared with midline episiotomy showed similar results to the overall comparison with the limited data on episiotomy techniques available from the present trials.

 

摘要

背景

會陰切開術與陰道生產

會陰切開術的目的在於防止陰道生產時會陰嚴重裂傷，但是否需要每次生產都做則值得探討。此外直切與斜切的優缺點也並不清楚。

目標

本文主旨在於評估選擇性會陰切開術與例行性會陰切開術的影響。

搜尋策略

搜尋 The Cochrane Pregnancy and Childbirth Group's Trials Register(March, 2008)的文獻。

選擇標準

隨機取樣來比較選擇性與例行性會陰切開術; 選擇性與例行性斜切會陰切開術; 選擇性與例行性直切會陰切開術; 直切與斜切會陰切開術的結果。

資料收集與分析

兩位作者獨立評估試驗品質與選取數據。

主要結論

我們蒐集了八個研究，包含5541個自然生產的產婦。在常規會陰切開這組中共2708個產婦，75.15% (2035/2708)有做會陰切開；選擇性會陰切開這組中有2733個產婦，會陰切開的比率是28.4% (776/2733)。比較起來,選擇性會陰切開術這一組有較少之嚴重會陰裂傷(相對危險性為0.67,95% 信心水準為0.49 – 0.91);較少縫合(相對危險性為0.71,95% 信心水準為0.61 – 0.81);較少之癒合併發症(相對危險性為0.66995% 信心水準為0.56 – 0.85)。但有較多之前側會陰裂傷(相對危險性為1.84,95% 信心水準為1.612.10)。至於在後側會陰裂傷(相對危險性為0.92,95% 信心水準為0.72 – 1.18);性交疼痛(相對危險性為1.02,95% 信心水準為0.90 – 1.16);尿失禁(相對危險性為0.98,95% 信心水準為0.79 – 1.20)或嚴重疼痛度各方面，選擇性與常規性之會陰切開術則較無差別。

作者結論

選擇性會陰切開術比例行性會陰切開術 有較多的優點。選擇性會陰切開術較少發生後側裂傷，縫合與併發症。兩組在大部分疼痛評估與嚴重陰道及會陰裂傷方面並無差異。唯獨選擇性會陰切開術會增加前側會陰裂傷的風險。

翻譯人

本摘要由周產期醫學會(Taiwan Society of Perinatology)郭鐘海翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

生產會造成陰道損傷,胎頭娩出時最常發生陰道口的裂傷,產程越快則越容易發生。裂傷部位可從會陰表皮擴及肌肉層,肛門括約肌甚至肛門。助產士或產科醫師可考慮先將會陰剪開或切開以利分娩並避免裂傷複雜難以縫合。有些接生機構是例行性實施會陰切開術。作者從八篇文獻共五千多人次的生產將選擇性會陰切開術與例行性會陰切開術做比較之後，認為選擇性實施會陰切開術應是較佳的選擇。可減少嚴重會陰裂傷，後側會陰裂傷，縫合以及產後一週之癒合併發症等(約減少12% – 31%)。至於傷口疼痛、尿失禁、性交疼痛與嚴重陰道會陰裂傷方面則無差異。唯獨較易發生前側會陰裂傷。至於會陰切開術是採直切或斜切，並沒有造成明顯的差異。