Question:
When is episiotomy needed and what is the safest technique?
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Answer:
A 2009 Cochrane systematic review1 (Evidence level 1a) found that:
“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.”
The NICE guideline on Intrapartum Care2 (Evidence level 1a) makes the following recommendations:
“A routine episiotomy should not be carried out during spontaneous vaginal birth.
“Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60% at the time of the episiotomy.
“An episiotomy should be performed if there is a clinical need such as instrumental birth or suspected fetal compromise.”
A 2007 Cochrane review3 (Evidence level 1a) found that continuous sutures are preferable, especially if they are used for all layers:
“The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain is even greater.”
However, a recent randomised trial4 (Evidence level 1b) found that “skin adhesive is faster than subcuticular sutures, and associated with a similar incidence of complications and pain in the first 30 days”.
References:
1. 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.
2. 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. http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
3. Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000947. DOI: 10.1002/14651858.CD000947.pub2.
4. Mota R, Costa F, Amaral A, Oliveira F, Santos CC, Ayres-De-Campos D. Skin adhesive versus subcuticular suture for perineal skin repair after episiotomy--a randomized controlled trial. Acta obstetricia et gynecologica Scandinavica, 2009 v.88(6): 660-666.
Search date: 13 November 2009
Evidence levels
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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