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Evaluation of the incision angle of mediolateral episiotomy at 60 degrees
International Journal of Gynecology and Obstetrics 112 (2011) 220–224
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Evaluation of the incision angle of mediolateral episiotomy at 60 degrees Vladimir Kalis a,⁎, Jana Landsmanova a, Barbora Bednarova a, Jaroslava Karbanova a, Katariina Laine b, Zdenek Rokyta a a b
Department of Obstetrics and Gynecology, University Hospital, Faculty of Medicine, Charles University, Pilsen, Czech Republic Department of Obstetrics, Oslo University Hospital, Oslo, Norway
a r t i c l e
i n f o
Article history: Received 23 June 2010 Received in revised form 21 September 2010 Accepted 29 September 2010 Keywords: Definition Mediolateral episiotomy Perineum Surgery Vaginal birth
a b s t r a c t Objective: To study the angle of mediolateral episiotomy at the time of cut, after primary repair, and 6 months postpartum; and the incidence and severity of perineal pain and anal incontinence 6 months after delivery. Methods: The study group comprised 60 consecutively recruited primiparous women who required episiotomy during delivery assisted by 2 obstetricians. The incision angle of episiotomy (defined as 60°) was measured before cutting, after primary repair, and after 6 months. At follow-up, perineal pain was evaluated by a verbal rating score; anal incontinence was assessed by St Mark's score. Results: The angles differed significantly among the incision (60°), repair (45°), and 6-month (48°) measurements (P b 0.001). There was a poor correlation between the suture angle and the angle measured at 6 months postpartum. No severe perineal tear was diagnosed in the cohort. At 6 months postpartum, only 1 woman reported mild symptoms of de novo anal incontinence, whereas 7 women reported perineal pain related to episiotomy. Conclusion: An incision angle of mediolateral episiotomy of 60° resulted in a low incidence of anal sphincter tearing, anal incontinence and perineal pain. A randomized controlled trial is needed to assess the outcome when different angles of episiotomy are used. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Episiotomy can be defined by the following variables: the location of the beginning of the cut, the incision angle and the length. It has not been common practice to assess the accuracy with which an episiotomy complies with its surgical description, and the optimal angle for the incision of mediolateral episiotomy has not previously been reported or quantified. Eogan et al. [1] measured the mean angle of episiotomy and found that it was significantly smaller in cases with third degree tears (30°) than in controls (38°). A European survey [2] found that the definition of mediolateral episiotomy differs widely. In addition, inter-individual differences in practical execution have been found among doctors and midwives in clinical practice [3,4]. Tincello et al. [4] calculated from standard texts that an incision angle of 40–60° fulfilled the criteria for the definition of mediolateral episiotomy. When mediolateral episiotomy was performed at an incision angle of 40° at the time of crowning, however, the median angle between the episiotomy and the midline was 20° after repair
⁎ Corresponding author. Department of Obstetrics and Gynecology, University Hospital, Faculty of Medicine, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic. Tel.: + 420 377105212; fax: + 420 377105290. E-mail address: [email protected] (V. Kalis).
[5]. Considering the findings of Eogan et al. [1] and Kalis et al. [5], anal sphincter injury seems to occur more often if the lower limit of 40° as a definition of mediolateral episiotomy is applied. The primary aims of the present study were to compare the 60° incision angle for mediolateral episiotomy with the suture angle after its repair, to evaluate whether the suture angle of episiotomy corresponds to the scar angle of episiotomy measured 6 months postpartum, and also to assess whether a simple line drawn on the perineum at the time of episiotomy reflects the same deformation of the perineum during vaginal delivery and whether this technique could be used in future research to mimic episiotomy without the actual cut. The secondary aims were to determine the incidence of obstetric anal sphincter injuries, and the frequency of perineal pain and anal incontinence at 6 months postpartum, and to evaluate the applicability of the scar evaluation scale [6] to the present cohort. 2. Materials and methods During the study period (December 1, 2008, to September 30, 2009), 2226 women gave birth vaginally at University Hospital Pilsen, and episiotomy was performed in 934 (42%) of these women. Two obstetricians were responsible for and assisted in deliveries by 195 women during the study period, and mediolateral episiotomy was performed in 93 (48%) of these women. Of the 195 women, 131 (67%) were primiparas, of whom 75 (57%) required an episiotomy and were potentially eligible for the study.
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.09.015
V. Kalis et al. / International Journal of Gynecology and Obstetrics 112 (2011) 220–224
The exclusion criteria were multiparity, instrumental delivery, breech, twins, premature delivery and inability to understand Czech. Three women did not consent to the measurement. Three of the neonates were at a gestational age of less than 37 weeks. Four women were unable to read or understand the informed consent in Czech. Five women had an episiotomy because of fetal distress, and for technical reasons (emergency or episiotomy incised prior to the fetal head crowning the perineum) the measurements were not performed. These 15 women were excluded. The remaining 60 women signed a detailed informed consent form and were included in the present trial. The study was approved by the local ethics committee. The following data were recorded: maternal age, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), duration of the second stage of labor, use of epidural, fetal distress, shoulder dystocia, birth weight, the length of episiotomy, the suture angle of episiotomy after primary repair, the scar angle at 6 months postpartum, the angle of the line drawn on the left side, incidence of tearing in continuation of the episiotomy, and the shortest distance between the incision and the outer edge of the anal epithelium. The suture angle of episiotomy after primary repair was defined as the angle formed by the midline and the line of epidermal suturing. The angle of the line on the left side was defined in the same way and was measured at the same time as the suture angle. The scar angle was defined as the angle formed by the midline and the line of the episiotomy scar. All measurements were performed in the lithotomy position with legs flexed at the hip joints at an angle of 90–120°. All variables were measured via a protractor and a tape measure. Gentian-violet in 1% aqueous solution was used to mark the lines. The top point of the angles was defined by the fourchette, and lines were drawn at 60° from the midline. Local infiltration anesthesia was used when cutting the episiotomy. The episiotomy was cut on the right side with scissors when the fetal head crowned the perineum. The line drawn on the left side was left intact (Fig. 1). To improve the precision of the diagnostics of obstetric perineal trauma, a rectal examination was made (visual inspection combined with palpation) by performing a pill-rolling motion between the index finger in the rectum and the thumb over the anal sphincter after every delivery. To standardize the technique used for suturing the episiotomy, 2/0-gauge rapidly absorbed polyglactin 910 was used and every layer (vaginal epithelium, perineal muscles, and skin) was reapproximated with a loose, continuous, non-locking technique [7]. Follow-up was performed 6 months after delivery. All of the women were invited by telephone, and 3 reminders were sent if the
Fig. 1. Angles drawn in the final phase of the second stage of labor.
221
appointment was missed. Perineal pain was evaluated by a verbal rating score [8,9]. This scale of 0–3 (where 0 = no pain and 3 = severe pain) was used to record women's experience of pain in 4 domains: at rest; sitting; moving; and during coitus. Therefore, the total score on the scale ranged from 0 to 12. The incidence and degree of anal incontinence were evaluated by St Mark's score [10], which indicates the type of incontinence (gas, fluid, or solid), its frequency, and additional items (alterations in lifestyle, the need to wear a pad or a plug, use of constipating medications, and the presence of fecal urgency). The total score on the scale ranges from 0 to 24 (where 0 = complete continence and 24 = complete incontinence). Women were asked to report any defecatory problems occurring in the month before completion of the questionnaire. The cosmetic effect of the healed episiotomy scar was evaluated independently by 2 observers using the novel scar evaluation scale (a point scale of 1 to 5, where 5 is the best score) [6], and both scores were noted. In addition, women were asked to use a modified visual analog scale (a point scale of 0 to 100, where 100 is the best score) [11] to evaluate the aesthetic effect of the scar. A small mirror was used to enable each woman to get a clear view of the scar. Lastly, the scar angle of episiotomy was measured. Statistical analysis was done by using the free, open-source statistical software Comprehensive R Archive Network (CRAN), version 2.4.0 (http://cran.r-project.org/) and STATISTICA version 9.0 (StarSoft, Tulsa, Oklahoma, USA). Basic statistical values (such as mean, median, standard deviation, variance, minimum, maximum, quantile, and frequency) were computed for study groups and subgroups. The distribution of variables within groups was compared by nonparametric analysis of variance (2-sample Wilcoxon test). The relations between variables were described by using Spearman and Pearson correlation coefficients, and linear regression. Differences between dependent (paired) data were computed by the nonparametric paired test (signed rank test). P b 0.05 was considered to be statistically significant. To determine interobserver reliability in the measurement of angles of episiotomy, 2 independent researchers measured the same suture angle of 12 women and the scar angle of 28 women. The interobserver results were analyzed by a paired signed rank test and Spearman rank correlation. The interobserver variability was 2.4% for the suture angle, and 2.2% for the scar angle.
3. Results During the duration of the study, 131 nulliparous women with spontaneous vaginal delivery were assisted by 2 observers, 75 mediolateral episiotomies were performed, and 60 women were evaluated after exclusion (Table 1). In 13 women an additional injury was diagnosed: 4 (7%) women had a tear in the perineum in continuation of the episiotomy, and 9 (15%) women had a vaginal tear in continuation of the episiotomy. No anal sphincter injury was detected in the study group. Fetal distress was diagnosed in 12 (20%) women. An epidural was required in, and given to, 2 (3%) women. No delivery was complicated by shoulder dystocia. The median suture angle of the episiotomies originally incised at 60° was 45°. Throughout the cohort, there was a significant difference between the angle of mediolateral episiotomy at the time that the episiotomy was cut and the suture angle after repair (P b 0.001). The median angle of the line on the left side, measured at the same time as the suture angle, was 47°; however, the correlation between this angle and the suture angle of episiotomy was not strong (Fig. 2). In 75% of women this angle was less acute, and in 25% it was more acute, than the suture angle of episiotomy. Two women could not be reached due to changes in contact details and were lost from follow-up. Of the remaining 58 women, 46 (79%) attended the follow-up at 6 months postpartum, underwent a physical examination, and completed the questionnaire at the time
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Table 1 Obstetric variables of 60 women who underwent mediolateral episiotomy. Median (range) Procedure-related characteristics Length of the episiotomy, mm Shortest distance from the anal canal, mm Angle of the episiotomy after repair (on the right side): suture angle, ° Angle of the line drawn on the left side after delivery, ° Angle of the episiotomy after 6 months: scar angle, ° Procedure-independent characteristics Maternal age, y Body mass index a Duration of the 2nd stage of labor, min Birth weight, g a
Mean ± SD
30 (20–45) 30 (15–43)
31.08 ± 5.58 30.59 ± 6.48
45 (32–59)
44.43 ± 4.93
47 (35–60)
46.77 ± 5.05
48 (24–71)
48.11 ± 9.17
27 (19–36) 26.7 (19.7–40.7) 21 (4–115)
27.25 ± 3.91 27.46 ± 3.99 25.63 ± 18.80
3370 (2600–4060)
3317.00 ± 315.28
Calculated as weight in kilograms divided by the square of height in meters.
of appointment. Another 5 (8%) women answered the questionnaire by telephone. In total, 51 (86%) women completed the questionnaire. The median scar angle of episiotomy was 48°. There was a poor correlation between this angle and the suture angle of episiotomy (Fig. 3). Of the obstetric variables measured, none was found to be statistically significant in relation to the suture or scar angle of episiotomy (Table 2). At the time of follow-up, 2 (4%) women registered symptoms of anal incontinence. Only 1 (2%) of these women reported anal incontinence de novo, registering 1 episode of flatal incontinence per month. The other reported mild symptoms of impairment: 2 episodes of leakage of flatus a month, and 1 episode of fecal urgency a month. The remaining 49 women who completed the questionnaire were asymptomatic. Perineal pain related to episiotomy was reported by 7 (14%) women. None of these women referred to pain at rest, or while sitting or moving. The average score of pain during coitus was 0.22. Five women scored their pain during coitus as 1, and 2 women scored this pain as 3. In total, 49 (96%) women had regular coitus. On the novel scar evaluation scale [8], 37 (80%) women were scored as 5, and the other 9 (20%) women were scored as 4. No woman had a total score of less than 4 points. On the modified cosmetic visual analog scale [6,11], the average score of the scar was 91. Only 5 (11%) women gave their subjective cosmetic score as less than 80, and only 1 woman as less than 70.
4. Discussion The results of the present study showed that, when the mediolateral episiotomy was cut at an angle of 60° at the time of crowning, the median angle between the episiotomy scar and the midline was 45° after repair. For technical reasons, the suture or scar angle cannot become part of the definition of mediolateral episiotomy. However, the data presented by Eogan [1] are supported mathematically: a ‘safe’ scar angle (38°) was measured and can serve as a reference. In this study only 3 women had a suture angle more acute than 38° (37° in 2 women; 32° in 1 woman). In agreement with van Dillen et al. [12], there was a poor correlation between the suture and scar angles of episiotomy; however, only 3 (7%) women had a scar angle smaller than 38° (36°, 30°, and 24°). Our hypothesis was that the simple line that is drawn on the perineum (at the same angle as the episiotomy) at the time that the episiotomy is performed might be used instead of the episiotomy itself, and might give the same information on deformation of the perineum. Because of the weak correlation between the angle of this line and the suture angle of episiotomy, however, this technique did not provide the expected data and could not be used to mimic the characteristics of episiotomy. Regarding healing of the episiotomy, on the scar evaluation scale [6] used in the present study only the 2 highest rankings (4 or 5 points on a 5-point scale) were scored across the whole study group. Thus, this parameter did not seem to provide any significant data at 6 months postpartum; however, it might be useful if the follow-up is done sooner after the delivery and on a higher number of women. No anal sphincter tear was detected among the study group; however, 1 anal sphincter tear was diagnosed among the remaining 15 women who were not included in the present study. In that case, there was fetal distress, persistent occipitoposterior presentation, and a neonatal weight of more than 4000 g. Because episiotomy was performed prior to the fetal head crowning the perineum, the woman was excluded from the study. The incidence of anal incontinence 5–9 months after the first vaginal delivery varies between 8% and 26% [13–15]. In the present study, only 1 (2%) woman reported minor symptoms of de novo flatal incontinence. The other (2%) reported a mild increase in the frequency of episodes of flatal incontinence (twice a month) and fecal urgency (once a month). However, this woman also experienced flatal incontinence before giving birth (once a month), a factor that is reported to be predictive for the occurrence of symptoms after delivery [15,16]. Previous studies have demonstrated an increased incidence of dyspareunia after episiotomy. In a study in Germany, dyspareunia
Fig. 2. Comparison between the suture angle of episiotomy and the angle of the line on the left side.
V. Kalis et al. / International Journal of Gynecology and Obstetrics 112 (2011) 220–224
223
Fig. 3. Comparison between the suture angle (after repair) and scar angle of episiotomy (after 6 months).
persisted for longer than 6 months in 11% of primiparous women who had episiotomy or perineal laceration [17]. In a study where median episiotomies (not extending into the anal sphincter) were performed, 24% of women reported some degree of dyspareunia at 6 months [18]. Perineal pain at 6 months after delivery was reported by 14% of the present cohort, a value that is in accordance with other studies [17,18]. This value does not differ from the reported incidence of perineal pain during pregnancy [19]. In the present study, the 2 women with a higher score of perineal pain had a minor skin duplicature that caused narrowing of the introitus and was easy to repair. Another 5 women reported mild entrance pain that was felt only during the initial phase of coitus and then disappeared, or that was due to lack of lubrication. An incision angle of 60° is used by some institutions [2], and a study by Karbanova et al. [20] found that the median incision angle of episiotomy directed toward the ischial tuberosity is 63°, an angle that is clinically identical with the currently evaluated angle of 60°. In a European survey [2], 25% of hospitals placed the direction of episiotomy toward the ischial tuberosity. In the study of Grigoriadis et al. [21], the ischial tuberosity was used as a general reference point. The present pilot study shows that an incision angle of episiotomy of 60° might be proposed as a definition for mediolateral episiotomy in women with spontaneous vaginal delivery. However, a randomized controlled trial is needed to assess whether this angle is optimal in reducing anal sphincter injuries during delivery and postpartum anal incontinence. Further research is also required for cases of instrumental delivery (forceps in particular) and short perineal body length, although it can be assumed that the episiotomy technique should be the same. Such a proposal is also suitable from a technical point of view. During busy daily clinical practice, it is difficult to make a fast incision at an angle that is hard to imagine and visualize. The clinical selection should be made among the angles 0° (median episiotomy), 30°, 45°, 60°, and 90°; however, the angles 0°, 30°, and 45° are currently considered too acute for mediolateral episiotomy.
Table 2 Spearman correlation coefficients and P values of obstetric variables. Variable
Maternal age Body mass index a Duration of the 2nd stage Birth weight Fetal distress Epidural anesthesia a
Spearman coefficient (P value) Suture angle of episiotomy
Scar angle of episiotomy
0.082 (0.54) − 0.036 (0.79) 0.19 (0.14) 0.19 (0.15) 0.03 (0.80) − 0.21 (0.11)
0.14 (0.35) − 0.19 (0.20) 0.00 (0.98) − 0.017 (0.91) − 0.03 (0.86) − 0.13 (0.39)
Calculated as weight in kilograms divided by the square of height in meters.
It might be difficult to make the cut at the desired angle with absolute accuracy. In agreement with Tincello et al. [4], perhaps a segment rather than a simple line is more suitable for defining mediolateral episiotomy. On the basis of the present results, we propose to define mediolateral episiotomy as “an incision of the perineum during the last part of the second stage of labor beginning in the perineal midline but directed laterally at an angle of at least 60° in the direction of ischial tuberosity.” Conflict of interest The authors have no conflicts of interest. References [1] Eogan M, Daly L, O'Connell P, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? Br J Obstet Gynecol 2006;113(2):190–4. [2] Kalis V, Stepan Jr J, Horak M, Roztocil A, Kralickova M, Rokyta Z. Definitions of mediolateral episiotomy in Europe. Int J Gynecol Obstet 2008;100(2):188–9. [3] Andrews V, Thakar R, Sultan AH, Jones PW. Are mediolateral episiotomies actually mediolateral? Br J Obstet Gynecol 2005;112(8):1156–8. [4] Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevic Z. Differences in episiotomy technique between midwives and doctors. Br J Obstet Gynecol 2003;110(12):1041–4. [5] Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z. The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynecol Obstet 2008;103(1):5–8. [6] Singer AJ, Arora B, Dagum A, Valentine S, Hollander JE. Development and validation of a novel scar evaluation scale. Plast Reconstr Surg 2007;120(7):1892–7. [7] Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359(9325): 2217–23. [8] Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27(1):117–26. [9] Corkill A, Lavender T, Walkinshaw SA, Alfirevic Z. Reducing postnatal pain from perineal tears by using lignocaine gel: a double-blind randomized trial. Birth 2001;28(1):22–7. [10] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;44(1):77–80. [11] Quinn JV, Drzewiecki AE, Steill IG, Elmslie TJ. Appearance scales to measure the cosmetic outcomes of healed lacerations. Am J Emerg Med 1995;13(2):229–31. [12] van Dillen J, Spaans M, van Keijsteren W, van Dillen M, Vredevoogd C, van Huizen M, et al. A prospective multicenter audit of labor-room episiotomy and anal sphincter injury assessment in the Netherlands. Int J Gynecol Obstet 2010;108(2): 97–100. [13] Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006;108(4):863–72. [14] Zetterström JP, López A, Anzén B, Dolk A, Norman M, Mellgren A. Anal incontinence after vaginal delivery: a prospective study in primiparous women. Br J Obstet Gynecol 1999;106(4):324–30. [15] Kalis V, Chaloupka P, Turek J, Sucha R, Rokyta Z. Vaginal delivery in primiparas and anal incontinence. Ceská Gynekol 2003;68(5):312–20. [16] van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(3):224–30.
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[17] Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, Dudenhausen JW. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol 2006;124(1):42–6. [18] Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184(5):881–8. [19] Zahumensky J, Zverina J, Sottner O, Zmrhalova B, Driak D, Brtnicka H, et al. Comparison of labor course and women's sexuality in planned and unplanned pregnancy. J Psychosom Obstet Gynecol 2008;29(3):157–63.
[20] Karbanova J, Landsmanova J, Novotny Z. Angle of mediolateral episiotomy using the ischial tuberosity as a reference point. Int J Gynecol Obstet 2009;107(2): 157. [21] Grigoriadis T, Athanasiou S, Zisou A, Antsaklis A. Episiotomy and perineal repair practices among obstetricians in Greece. Int J Gynecol Obstet 2009;106(1):27–9.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Evaluation of the incision angle of mediolateral episiotomy at 60 degrees Vladimir Kalis a,⁎, Jana Landsmanova a, Barbora Bednarova a, Jaroslava Karbanova a, Katariina Laine b, Zdenek Rokyta a a b
Department of Obstetrics and Gynecology, University Hospital, Faculty of Medicine, Charles University, Pilsen, Czech Republic Department of Obstetrics, Oslo University Hospital, Oslo, Norway
a r t i c l e
i n f o
Article history: Received 23 June 2010 Received in revised form 21 September 2010 Accepted 29 September 2010 Keywords: Definition Mediolateral episiotomy Perineum Surgery Vaginal birth
a b s t r a c t Objective: To study the angle of mediolateral episiotomy at the time of cut, after primary repair, and 6 months postpartum; and the incidence and severity of perineal pain and anal incontinence 6 months after delivery. Methods: The study group comprised 60 consecutively recruited primiparous women who required episiotomy during delivery assisted by 2 obstetricians. The incision angle of episiotomy (defined as 60°) was measured before cutting, after primary repair, and after 6 months. At follow-up, perineal pain was evaluated by a verbal rating score; anal incontinence was assessed by St Mark's score. Results: The angles differed significantly among the incision (60°), repair (45°), and 6-month (48°) measurements (P b 0.001). There was a poor correlation between the suture angle and the angle measured at 6 months postpartum. No severe perineal tear was diagnosed in the cohort. At 6 months postpartum, only 1 woman reported mild symptoms of de novo anal incontinence, whereas 7 women reported perineal pain related to episiotomy. Conclusion: An incision angle of mediolateral episiotomy of 60° resulted in a low incidence of anal sphincter tearing, anal incontinence and perineal pain. A randomized controlled trial is needed to assess the outcome when different angles of episiotomy are used. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Episiotomy can be defined by the following variables: the location of the beginning of the cut, the incision angle and the length. It has not been common practice to assess the accuracy with which an episiotomy complies with its surgical description, and the optimal angle for the incision of mediolateral episiotomy has not previously been reported or quantified. Eogan et al. [1] measured the mean angle of episiotomy and found that it was significantly smaller in cases with third degree tears (30°) than in controls (38°). A European survey [2] found that the definition of mediolateral episiotomy differs widely. In addition, inter-individual differences in practical execution have been found among doctors and midwives in clinical practice [3,4]. Tincello et al. [4] calculated from standard texts that an incision angle of 40–60° fulfilled the criteria for the definition of mediolateral episiotomy. When mediolateral episiotomy was performed at an incision angle of 40° at the time of crowning, however, the median angle between the episiotomy and the midline was 20° after repair
⁎ Corresponding author. Department of Obstetrics and Gynecology, University Hospital, Faculty of Medicine, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic. Tel.: + 420 377105212; fax: + 420 377105290. E-mail address: [email protected] (V. Kalis).
[5]. Considering the findings of Eogan et al. [1] and Kalis et al. [5], anal sphincter injury seems to occur more often if the lower limit of 40° as a definition of mediolateral episiotomy is applied. The primary aims of the present study were to compare the 60° incision angle for mediolateral episiotomy with the suture angle after its repair, to evaluate whether the suture angle of episiotomy corresponds to the scar angle of episiotomy measured 6 months postpartum, and also to assess whether a simple line drawn on the perineum at the time of episiotomy reflects the same deformation of the perineum during vaginal delivery and whether this technique could be used in future research to mimic episiotomy without the actual cut. The secondary aims were to determine the incidence of obstetric anal sphincter injuries, and the frequency of perineal pain and anal incontinence at 6 months postpartum, and to evaluate the applicability of the scar evaluation scale [6] to the present cohort. 2. Materials and methods During the study period (December 1, 2008, to September 30, 2009), 2226 women gave birth vaginally at University Hospital Pilsen, and episiotomy was performed in 934 (42%) of these women. Two obstetricians were responsible for and assisted in deliveries by 195 women during the study period, and mediolateral episiotomy was performed in 93 (48%) of these women. Of the 195 women, 131 (67%) were primiparas, of whom 75 (57%) required an episiotomy and were potentially eligible for the study.
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.09.015
V. Kalis et al. / International Journal of Gynecology and Obstetrics 112 (2011) 220–224
The exclusion criteria were multiparity, instrumental delivery, breech, twins, premature delivery and inability to understand Czech. Three women did not consent to the measurement. Three of the neonates were at a gestational age of less than 37 weeks. Four women were unable to read or understand the informed consent in Czech. Five women had an episiotomy because of fetal distress, and for technical reasons (emergency or episiotomy incised prior to the fetal head crowning the perineum) the measurements were not performed. These 15 women were excluded. The remaining 60 women signed a detailed informed consent form and were included in the present trial. The study was approved by the local ethics committee. The following data were recorded: maternal age, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), duration of the second stage of labor, use of epidural, fetal distress, shoulder dystocia, birth weight, the length of episiotomy, the suture angle of episiotomy after primary repair, the scar angle at 6 months postpartum, the angle of the line drawn on the left side, incidence of tearing in continuation of the episiotomy, and the shortest distance between the incision and the outer edge of the anal epithelium. The suture angle of episiotomy after primary repair was defined as the angle formed by the midline and the line of epidermal suturing. The angle of the line on the left side was defined in the same way and was measured at the same time as the suture angle. The scar angle was defined as the angle formed by the midline and the line of the episiotomy scar. All measurements were performed in the lithotomy position with legs flexed at the hip joints at an angle of 90–120°. All variables were measured via a protractor and a tape measure. Gentian-violet in 1% aqueous solution was used to mark the lines. The top point of the angles was defined by the fourchette, and lines were drawn at 60° from the midline. Local infiltration anesthesia was used when cutting the episiotomy. The episiotomy was cut on the right side with scissors when the fetal head crowned the perineum. The line drawn on the left side was left intact (Fig. 1). To improve the precision of the diagnostics of obstetric perineal trauma, a rectal examination was made (visual inspection combined with palpation) by performing a pill-rolling motion between the index finger in the rectum and the thumb over the anal sphincter after every delivery. To standardize the technique used for suturing the episiotomy, 2/0-gauge rapidly absorbed polyglactin 910 was used and every layer (vaginal epithelium, perineal muscles, and skin) was reapproximated with a loose, continuous, non-locking technique [7]. Follow-up was performed 6 months after delivery. All of the women were invited by telephone, and 3 reminders were sent if the
Fig. 1. Angles drawn in the final phase of the second stage of labor.
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appointment was missed. Perineal pain was evaluated by a verbal rating score [8,9]. This scale of 0–3 (where 0 = no pain and 3 = severe pain) was used to record women's experience of pain in 4 domains: at rest; sitting; moving; and during coitus. Therefore, the total score on the scale ranged from 0 to 12. The incidence and degree of anal incontinence were evaluated by St Mark's score [10], which indicates the type of incontinence (gas, fluid, or solid), its frequency, and additional items (alterations in lifestyle, the need to wear a pad or a plug, use of constipating medications, and the presence of fecal urgency). The total score on the scale ranges from 0 to 24 (where 0 = complete continence and 24 = complete incontinence). Women were asked to report any defecatory problems occurring in the month before completion of the questionnaire. The cosmetic effect of the healed episiotomy scar was evaluated independently by 2 observers using the novel scar evaluation scale (a point scale of 1 to 5, where 5 is the best score) [6], and both scores were noted. In addition, women were asked to use a modified visual analog scale (a point scale of 0 to 100, where 100 is the best score) [11] to evaluate the aesthetic effect of the scar. A small mirror was used to enable each woman to get a clear view of the scar. Lastly, the scar angle of episiotomy was measured. Statistical analysis was done by using the free, open-source statistical software Comprehensive R Archive Network (CRAN), version 2.4.0 (http://cran.r-project.org/) and STATISTICA version 9.0 (StarSoft, Tulsa, Oklahoma, USA). Basic statistical values (such as mean, median, standard deviation, variance, minimum, maximum, quantile, and frequency) were computed for study groups and subgroups. The distribution of variables within groups was compared by nonparametric analysis of variance (2-sample Wilcoxon test). The relations between variables were described by using Spearman and Pearson correlation coefficients, and linear regression. Differences between dependent (paired) data were computed by the nonparametric paired test (signed rank test). P b 0.05 was considered to be statistically significant. To determine interobserver reliability in the measurement of angles of episiotomy, 2 independent researchers measured the same suture angle of 12 women and the scar angle of 28 women. The interobserver results were analyzed by a paired signed rank test and Spearman rank correlation. The interobserver variability was 2.4% for the suture angle, and 2.2% for the scar angle.
3. Results During the duration of the study, 131 nulliparous women with spontaneous vaginal delivery were assisted by 2 observers, 75 mediolateral episiotomies were performed, and 60 women were evaluated after exclusion (Table 1). In 13 women an additional injury was diagnosed: 4 (7%) women had a tear in the perineum in continuation of the episiotomy, and 9 (15%) women had a vaginal tear in continuation of the episiotomy. No anal sphincter injury was detected in the study group. Fetal distress was diagnosed in 12 (20%) women. An epidural was required in, and given to, 2 (3%) women. No delivery was complicated by shoulder dystocia. The median suture angle of the episiotomies originally incised at 60° was 45°. Throughout the cohort, there was a significant difference between the angle of mediolateral episiotomy at the time that the episiotomy was cut and the suture angle after repair (P b 0.001). The median angle of the line on the left side, measured at the same time as the suture angle, was 47°; however, the correlation between this angle and the suture angle of episiotomy was not strong (Fig. 2). In 75% of women this angle was less acute, and in 25% it was more acute, than the suture angle of episiotomy. Two women could not be reached due to changes in contact details and were lost from follow-up. Of the remaining 58 women, 46 (79%) attended the follow-up at 6 months postpartum, underwent a physical examination, and completed the questionnaire at the time
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Table 1 Obstetric variables of 60 women who underwent mediolateral episiotomy. Median (range) Procedure-related characteristics Length of the episiotomy, mm Shortest distance from the anal canal, mm Angle of the episiotomy after repair (on the right side): suture angle, ° Angle of the line drawn on the left side after delivery, ° Angle of the episiotomy after 6 months: scar angle, ° Procedure-independent characteristics Maternal age, y Body mass index a Duration of the 2nd stage of labor, min Birth weight, g a
Mean ± SD
30 (20–45) 30 (15–43)
31.08 ± 5.58 30.59 ± 6.48
45 (32–59)
44.43 ± 4.93
47 (35–60)
46.77 ± 5.05
48 (24–71)
48.11 ± 9.17
27 (19–36) 26.7 (19.7–40.7) 21 (4–115)
27.25 ± 3.91 27.46 ± 3.99 25.63 ± 18.80
3370 (2600–4060)
3317.00 ± 315.28
Calculated as weight in kilograms divided by the square of height in meters.
of appointment. Another 5 (8%) women answered the questionnaire by telephone. In total, 51 (86%) women completed the questionnaire. The median scar angle of episiotomy was 48°. There was a poor correlation between this angle and the suture angle of episiotomy (Fig. 3). Of the obstetric variables measured, none was found to be statistically significant in relation to the suture or scar angle of episiotomy (Table 2). At the time of follow-up, 2 (4%) women registered symptoms of anal incontinence. Only 1 (2%) of these women reported anal incontinence de novo, registering 1 episode of flatal incontinence per month. The other reported mild symptoms of impairment: 2 episodes of leakage of flatus a month, and 1 episode of fecal urgency a month. The remaining 49 women who completed the questionnaire were asymptomatic. Perineal pain related to episiotomy was reported by 7 (14%) women. None of these women referred to pain at rest, or while sitting or moving. The average score of pain during coitus was 0.22. Five women scored their pain during coitus as 1, and 2 women scored this pain as 3. In total, 49 (96%) women had regular coitus. On the novel scar evaluation scale [8], 37 (80%) women were scored as 5, and the other 9 (20%) women were scored as 4. No woman had a total score of less than 4 points. On the modified cosmetic visual analog scale [6,11], the average score of the scar was 91. Only 5 (11%) women gave their subjective cosmetic score as less than 80, and only 1 woman as less than 70.
4. Discussion The results of the present study showed that, when the mediolateral episiotomy was cut at an angle of 60° at the time of crowning, the median angle between the episiotomy scar and the midline was 45° after repair. For technical reasons, the suture or scar angle cannot become part of the definition of mediolateral episiotomy. However, the data presented by Eogan [1] are supported mathematically: a ‘safe’ scar angle (38°) was measured and can serve as a reference. In this study only 3 women had a suture angle more acute than 38° (37° in 2 women; 32° in 1 woman). In agreement with van Dillen et al. [12], there was a poor correlation between the suture and scar angles of episiotomy; however, only 3 (7%) women had a scar angle smaller than 38° (36°, 30°, and 24°). Our hypothesis was that the simple line that is drawn on the perineum (at the same angle as the episiotomy) at the time that the episiotomy is performed might be used instead of the episiotomy itself, and might give the same information on deformation of the perineum. Because of the weak correlation between the angle of this line and the suture angle of episiotomy, however, this technique did not provide the expected data and could not be used to mimic the characteristics of episiotomy. Regarding healing of the episiotomy, on the scar evaluation scale [6] used in the present study only the 2 highest rankings (4 or 5 points on a 5-point scale) were scored across the whole study group. Thus, this parameter did not seem to provide any significant data at 6 months postpartum; however, it might be useful if the follow-up is done sooner after the delivery and on a higher number of women. No anal sphincter tear was detected among the study group; however, 1 anal sphincter tear was diagnosed among the remaining 15 women who were not included in the present study. In that case, there was fetal distress, persistent occipitoposterior presentation, and a neonatal weight of more than 4000 g. Because episiotomy was performed prior to the fetal head crowning the perineum, the woman was excluded from the study. The incidence of anal incontinence 5–9 months after the first vaginal delivery varies between 8% and 26% [13–15]. In the present study, only 1 (2%) woman reported minor symptoms of de novo flatal incontinence. The other (2%) reported a mild increase in the frequency of episodes of flatal incontinence (twice a month) and fecal urgency (once a month). However, this woman also experienced flatal incontinence before giving birth (once a month), a factor that is reported to be predictive for the occurrence of symptoms after delivery [15,16]. Previous studies have demonstrated an increased incidence of dyspareunia after episiotomy. In a study in Germany, dyspareunia
Fig. 2. Comparison between the suture angle of episiotomy and the angle of the line on the left side.
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Fig. 3. Comparison between the suture angle (after repair) and scar angle of episiotomy (after 6 months).
persisted for longer than 6 months in 11% of primiparous women who had episiotomy or perineal laceration [17]. In a study where median episiotomies (not extending into the anal sphincter) were performed, 24% of women reported some degree of dyspareunia at 6 months [18]. Perineal pain at 6 months after delivery was reported by 14% of the present cohort, a value that is in accordance with other studies [17,18]. This value does not differ from the reported incidence of perineal pain during pregnancy [19]. In the present study, the 2 women with a higher score of perineal pain had a minor skin duplicature that caused narrowing of the introitus and was easy to repair. Another 5 women reported mild entrance pain that was felt only during the initial phase of coitus and then disappeared, or that was due to lack of lubrication. An incision angle of 60° is used by some institutions [2], and a study by Karbanova et al. [20] found that the median incision angle of episiotomy directed toward the ischial tuberosity is 63°, an angle that is clinically identical with the currently evaluated angle of 60°. In a European survey [2], 25% of hospitals placed the direction of episiotomy toward the ischial tuberosity. In the study of Grigoriadis et al. [21], the ischial tuberosity was used as a general reference point. The present pilot study shows that an incision angle of episiotomy of 60° might be proposed as a definition for mediolateral episiotomy in women with spontaneous vaginal delivery. However, a randomized controlled trial is needed to assess whether this angle is optimal in reducing anal sphincter injuries during delivery and postpartum anal incontinence. Further research is also required for cases of instrumental delivery (forceps in particular) and short perineal body length, although it can be assumed that the episiotomy technique should be the same. Such a proposal is also suitable from a technical point of view. During busy daily clinical practice, it is difficult to make a fast incision at an angle that is hard to imagine and visualize. The clinical selection should be made among the angles 0° (median episiotomy), 30°, 45°, 60°, and 90°; however, the angles 0°, 30°, and 45° are currently considered too acute for mediolateral episiotomy.
Table 2 Spearman correlation coefficients and P values of obstetric variables. Variable
Maternal age Body mass index a Duration of the 2nd stage Birth weight Fetal distress Epidural anesthesia a
Spearman coefficient (P value) Suture angle of episiotomy
Scar angle of episiotomy
0.082 (0.54) − 0.036 (0.79) 0.19 (0.14) 0.19 (0.15) 0.03 (0.80) − 0.21 (0.11)
0.14 (0.35) − 0.19 (0.20) 0.00 (0.98) − 0.017 (0.91) − 0.03 (0.86) − 0.13 (0.39)
Calculated as weight in kilograms divided by the square of height in meters.
It might be difficult to make the cut at the desired angle with absolute accuracy. In agreement with Tincello et al. [4], perhaps a segment rather than a simple line is more suitable for defining mediolateral episiotomy. On the basis of the present results, we propose to define mediolateral episiotomy as “an incision of the perineum during the last part of the second stage of labor beginning in the perineal midline but directed laterally at an angle of at least 60° in the direction of ischial tuberosity.” Conflict of interest The authors have no conflicts of interest. References [1] Eogan M, Daly L, O'Connell P, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? Br J Obstet Gynecol 2006;113(2):190–4. [2] Kalis V, Stepan Jr J, Horak M, Roztocil A, Kralickova M, Rokyta Z. Definitions of mediolateral episiotomy in Europe. Int J Gynecol Obstet 2008;100(2):188–9. [3] Andrews V, Thakar R, Sultan AH, Jones PW. Are mediolateral episiotomies actually mediolateral? Br J Obstet Gynecol 2005;112(8):1156–8. [4] Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevic Z. Differences in episiotomy technique between midwives and doctors. Br J Obstet Gynecol 2003;110(12):1041–4. [5] Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z. The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynecol Obstet 2008;103(1):5–8. [6] Singer AJ, Arora B, Dagum A, Valentine S, Hollander JE. Development and validation of a novel scar evaluation scale. Plast Reconstr Surg 2007;120(7):1892–7. [7] Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359(9325): 2217–23. [8] Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27(1):117–26. [9] Corkill A, Lavender T, Walkinshaw SA, Alfirevic Z. Reducing postnatal pain from perineal tears by using lignocaine gel: a double-blind randomized trial. Birth 2001;28(1):22–7. [10] Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;44(1):77–80. [11] Quinn JV, Drzewiecki AE, Steill IG, Elmslie TJ. Appearance scales to measure the cosmetic outcomes of healed lacerations. Am J Emerg Med 1995;13(2):229–31. [12] van Dillen J, Spaans M, van Keijsteren W, van Dillen M, Vredevoogd C, van Huizen M, et al. A prospective multicenter audit of labor-room episiotomy and anal sphincter injury assessment in the Netherlands. Int J Gynecol Obstet 2010;108(2): 97–100. [13] Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006;108(4):863–72. [14] Zetterström JP, López A, Anzén B, Dolk A, Norman M, Mellgren A. Anal incontinence after vaginal delivery: a prospective study in primiparous women. Br J Obstet Gynecol 1999;106(4):324–30. [15] Kalis V, Chaloupka P, Turek J, Sucha R, Rokyta Z. Vaginal delivery in primiparas and anal incontinence. Ceská Gynekol 2003;68(5):312–20. [16] van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(3):224–30.
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[17] Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, Dudenhausen JW. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol 2006;124(1):42–6. [18] Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184(5):881–8. [19] Zahumensky J, Zverina J, Sottner O, Zmrhalova B, Driak D, Brtnicka H, et al. Comparison of labor course and women's sexuality in planned and unplanned pregnancy. J Psychosom Obstet Gynecol 2008;29(3):157–63.
[20] Karbanova J, Landsmanova J, Novotny Z. Angle of mediolateral episiotomy using the ischial tuberosity as a reference point. Int J Gynecol Obstet 2009;107(2): 157. [21] Grigoriadis T, Athanasiou S, Zisou A, Antsaklis A. Episiotomy and perineal repair practices among obstetricians in Greece. Int J Gynecol Obstet 2009;106(1):27–9.