Question: Is there any evidence that episiotomy protects against third /fourth degree tears?
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A Cochrane review to determine the possible benefits and risks of the use of restrictive episiotomy versus routine episiotomy during delivery (Carroli) found that:
"The restrictive use of episiotomy shows a lower risk of clinically relevant morbidities including severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), posterior perineal trauma (RR 0.88, 95% 0.84 to 0.92), need for suturing perineal trauma (RR 0.71, 95% CI 0.61 to 0.81), and healing complications at seven days (RR 0.69, 95% CI 0.56 to 0.85). No difference is shown in the incidence of major outcomes such as severe vaginal and perineal trauma nor in pain, dyspareunia or urinary incontinence."
(Evidence level 1a)
The following guidelines on the use of episiotomy or prevention of third and fourth degree tears were identified:
- The Royal College of Midwives Midwifery Practice Guideline "Care of the perineum":
"Episiotomy is strongly associated with a higher frequency of serious trauma (third and fourth degree lacerations)"
- Map of Medicine. Management of the second stage of labour
"Episiotomy does not protect against third- or fourth-degree tears"
- RCOG green-top guideline on the management of third and fourth degree perineal tears:
Can obstetric anal sphincter injury be predicted and prevented?
Clinicians need to be aware of the risk factors for obstetric anal sphincter injury but also recognise that known risk factors do not readily allow its prediction or prevention.
Studies are required to investigate the effect of interventions to prevent third-degree tears in women with risk factors.
- NICE guideline on Intrapartum care
A routine episiotomy should not be carried out during spontaneous vaginal birth.
An episiotomy should be performed if there is a clinical need such as instrumental birth or suspected fetal compromise.
(Evidence level IV)
- Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2. Abstract and full text (restricted in some countries). Full text available to Fellows, Members and Trainees.
- Map of Medicine. Management of the second stage of labour. 2011
- National Collaborating Centre for Women’s and Children’s Health. Intrapartum Care: care of healthy women and their babies during childbirth. London: RCOG Press, 2007
- Royal College of Midwives. Care of the perineum. Midwifery Practice guideline. RCM, 2008
- RCOG. The management of third- and fourth-degree perineal tears. Green-top guideline 29. London: RCOG, 2007
Search date: March 2012
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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