- Email: [email protected]
The Value of Routine Episiotomy in Forceps Deliveries
The Value of Routine Episiotomy •
1n Forceps Deliveries
Helen L. Steed, MD Thomas C. Corbett, MD Damon C. Mayes, MSc Department of Obstetrics and Gynaecology University of Alberta
Abstract Objective: to determine the risk of third and fourth degree tears if episiotomy precedes
operative forceps deliveries. Methods: a retrospective analysis was performed, identifying 319 women who had a forceps
delivery. Two hundred and seventy-two women met our inclusion criteria (term, singleton, cephalic presentation, with mid, low or outlet forceps). Patients having forceps deliveries with an episiotomy were compared to those with forceps deliveries and no episiotomy. Maternal age, parity, use of an epidural, gestational age, and birth weight were examined for each group. The incidence of third and fourth degree tears and the odds ratio between the two groups were determined. Results: there were no differences in demographic or clinical variables between the two groups. Compared to the patients without episiotomy (n = 46), patients having forceps deliveries with an episiotomy (n = 226) had a significantly higher incidence of third and fourth degree tears (odds ratio 2.8; 95% confidence interval 1.5-5.6). Conclusion: the routine use of episiotomy is possibly associated with an increased incidence of sphincteric injuries in patients undergoing forceps deliveries. The routine use of episiotomy with forceps delivery should be re-evaluated. Resume Objectif : definir le risque de dechirure du troisieme ou du quatrieme degre lorsqu'une
episiotomie est pratiquee avant un accouchement operatoire avec application de forceps. Methode : on a fait une analyse retrospective et choisi 319 femmes ayant eu un accouche-
ment avec application de forceps en 1994. Deux cent soixante-douze de ces femmes ont satisfait aux criteres de selection (grossesse a terme et unique, presentation cephalique, application de forceps a la partie moyenne ou basse). On a compare les patientes qui avaient eu un accouchement avec episiotomie et application de forceps a celles qui avaient eu une application de forceps sans episiotomie. Pour chaque groupe, on a releve l'age, la parite, le recours a une epidurale, l'age gestationnel et le poids a la naissance. On a determine !'incidence des dechirures du troisieme et du quatrieme degre et le risque relatif entre les deux groupes. Resultats : ii n'y avait aucune difference entre les deux groupes au niveau des variables demographiques ou cliniques. Comparees aux patientes ayant eu une episiotomie (n =46), les patientes qui avaient eu un accouchement aux forceps accompagne d'une episiotomie (n = 226) ont eu une incidence de dechirures du troisieme et du quatrieme degre plus elevee (risque relatif : 2,8 ; IC de 95 % de 1,5 a 5,6). Conclusion: le recours systematique a l'episiotomie peut etre lie a une incidence accrue de blessures sphincteriennes chez les patientes qui ont un accouchement avec application de forceps. II faudrait reevaluer la pratique de l'episiotomie systematique lors des accouchements avec application de forceps.
J Soc
Obstet Gynaecol Can 2000;22(8):583-6
INTRODUCTION
Key Words forceps, episiotomy, sphincteric injury. Received on October 20th, 1999. Revised and accepted on June 26th, 2000.
An episiotomy is a surgical incision made at the time of delivery to enlarge the vaginal introitus for ease of passage of the fetus. The incision is made into the perinea! body and involves perinea! skin, vaginal mucosa, perinea! muscles and connective tissue. There are three types of episiotomies: midline, mediolateral, and J- shaped. Potential advantages of routine episiotomy include substitution of a straight surgical incision for a ragged laceration, 1 reduction
in the duration of second stage labour? and prevention of perineal and rectal trauma and subsequent pelvic floor relaxation. 3 Potential disadvantages of routine episiotomy include increased blood loss1 and increased perineal pain postpartum. 3 In a retrospective review of272 women who had a forceps assisted vaginal delivery, we assessed the incidence of third and fourth degree tears berween women who had an episiotomy and forceps versus those who had forceps delivery alone. MATERIALS AND METHODS
We reviewed the medical records of women delivering live born infants at the Grey Nuns Hospital in Edmonton, Alberta during a 12 month period. Of the 2,807 deliveries during this period, 319 were assisted by the use of forceps. Exclusion criteria included: multiple pregnancy, breech presentation, premature delivery (< 37 weeks gestation), and use of vacuum extraction. All forceps deliveries and perineal repairs were performed by practising obstetricians or senior obstetrics residents. The study population included 272 women who had singleton, cephalic, term, vaginal deliveries assisted with forceps. The primary outcome measure was the incidence of third or fourth degree perineal lacerations. A third degree laceration is defined as including complete disruption of the anal sphincter. A fourth degree laceration includes extension of the tear to involve the rectal mucosa. In addition to the use of episiotomy and the presence and degree of perineal lacerations, data also was collected for each patient regarding potentially confounding factors such as: maternal age, gestational age at delivery, parity, birth weight, use of epidural analgesia, and type of episiotomy. Body mass index measurements were not available in most charts. The women were separated into rwo groups: forceps delivery with an episiotomy and forceps delivery only. STATISTICAL ANALYSIS
Logistic regression analysis was used to assess whether women undergoing forceps delivery who received an episiotomy experienced a higher incidence of third and fourth degree tears relative to patients delivered without episiotomy. Comparisons berween groups with proportional data were analysed using Fisher's exact test (Instat, GraphPad Software, San Diego, CA). RESULTS
The demographic data for both study groups are shown in Table I. The groups were similar for maternal age, gestational age, parity, birth weight, and use of epidural analgesia. Rectal injury was more common in the nulliparous female in both study groups (p
found due to factors noted in Table I. Table II presents the data regarding the occurrence of third and fourth degree perineal tears according to the type of episiotomy and forceps operation. Almost 80 percent of episiotomies were midline. There was a significantly increased risk of damage to the anal sphincter and rectal mucosa with a midline epsiotomy (p<0.0001). The type of forceps delivery was often recorded as a "low-mid" with no distinction according to the currently accepted definitions of the American College of Obstetricians and Gynecologists. 2 To analyse the data, we have categorized forceps deliveries as low, "low-mid" without rotation, and those accompanied by rotation of the fetal head >90 degrees. In all three categories, the incidence of third or TABLE I BASELINE CHARACTERISTICS AND OUTCOMES Characteristic
Episiotomy and Forceps (n = 226)
Age (y) Parity (nullip) Gestational age (weeks) Birthweight (gm) Epidural analgesia
Forceps only (n = 46)
27.8 ± 0.8 147 (65.0%) 39.5 ± 0.0 3460.7 ± 31.1 122 (54.0%)
28.0 ± 0.8 25 (54.4%) 39.4 ± 0.1 3469.6 ± 84.3 27 (58.7%)
13 I (58.0%)*
15(32.6%)
Outcome measure Third or fourth degree tear
Data are presented as mean ± standard error or as n (%). * Significant difference (p
no tear
without episiotomy (n = 46) tear
no tear
Type of episiotomy* Midline (n = 43) 120 (65.6%) 63 (34.4%) Mediolateral (n = 43) 13 (30.2%) 30 (69.8%) type of forceps low 22 (52.4%) 20 (47.6%) 4 (30.8%) 9 low mid so (56.8%) 38 (43.2%) 5 (38.5%) 8 mid with rotation ** 59 (61.5%) 37 (38.5%) 6 (30.0%) 14
-
(69.2%) (61.5%) (70.0%)
Data are presented as n (%).
* Significant differences between the midline and mediolateral episiotomies (p
fourth degree tears was greater in the groups with episiotomy, but this attained statistical significance only in the group with rotation (p<0.0131). DISCUSSION
In most centres, episiotomies are routinely performed with forceps delivery to facilitate use of this instrument. 6 In unassisted vaginal delivery, there is little evidence to support or disprove the claim that episiotomy results in less trauma than perineal tear. 5 Additionally, midline episiotomies have been associated with a higher incidence of rectal injury when compared with mediolateral episiotomy or no episiotomy. 6-8 However, it is not clear whether this correlation also applies to deliveries assisted with obstetrical forceps. Spontaneous vaginal delivery episiotomy rates in our hospital decreased from above 50 percent in the 1980's to 19 percent in the mid 1990's. However, for forceps delivery, the rate is still quite high at 83 percent. Since damage to the anal sphincter may result in long term clinically significant symptoms,9-11 this study evaluated the effectiveness of episiotomy in forceps delivery by determining the incidence of third and fourth degree perineal lacerations. There are many indications for performing an episiotomy: to hasten delivery in the presence of non-reassuring fetal status; to protect a previous vaginal repair; or to facilitate delivery over a "rigid" perineum. However, in many centres, routine episiotomy is performed in all forceps deliveries to facilitate delivery and prevent undue trauma to the perineum. 6 This study demonstrates a significant increase in the incidence of rectal injury with the performance of an episiotomy. After controlling for parity, gestational age, and birth weight, episiotomy increased the risk of third or fourth degree perineal lacerations by an odds ratio of 2.8. Mediolateral episiotomies were less often associated with these serious consequences. However, compared to midline episiotomy, mediolateral incisions may have an increased rate of other negative consequences such as increased pain, less satisfactory cosmetic results, and painful intercourse. 8 Several other studies have established this association of increased tears with episiotomies. Green and Soohoo showed an adjusted risk of rectal injury with a midline episiotomy in spontaneous deliveries increased at an odds ratio of 8.9. 9 In a study of singleton, term deliveries, Buekens et al found that third-degree tears occurred in 1.4 percent of the deliveries with episiotomy, compared to 0.9 percent in those without episiotomy. 11 In a randomized control trial using standard questionnaires on perineal pain, urinary incontinence, and sexual activity postpartum, as well as electromyographic (EMG) perineometry to evaluate pelvic floor function, Klein et al found no evidence that liberal or routine use of episiotomy prevents perineal trauma and pelvic floor relaxation. 12 Thus, episioto-
my may not be a necessary procedure to prevent rectal injury in a large proportion of cases in spontaneous deliveries. This conclusion has resulted in a marked reduction in the routine use of episiotomy in most centres. Although we could find no data in the literature that addressed the benefits of routine episiotomy in deliveries assisted by obstetrical forceps, many obstetricians consider a forceps delivery an indication for an episiotomy. Our findings question this practice and suggest that episiotomy may possibly be over-utilized in patients requiring forceps application for delivery. Several potentially confounding factors could not be evaluated in this retrospective review, including: maternal body mass index, selection criteria for the use of forceps, indication for forceps, urgency of delivery, and the skill of the various obstetricians. The only way to control for these potentially important variables would be a proper randomized control clinical trial. Because damage to the anal sphincter may give rise to serious long term sequelae following vaginal delivery, 4 our outcome of interest was the incidence of third and fourth degree perineal lacerations. In a study by Haadem et al 13 almost half of the women with anal sphincter rupture experienced persistent symptoms such as flatal incontinence, dyspareunia, and perineal pain. Previous studies have shown the association of childbirth using operative assistance with a significant increase in new abnormal defaecatory symptoms and a high incidence of occult anal sphincter defects. 14·15 Resultant trauma may be neurogenic or mechanical. Even after apparently normal healing of a third or fourth degree tear, there may be dehiscence of the external anal sphincter or neural damage to the sensory or motor innervation of the sphincter, resulting in dysfunction. Although intact sensation is important in the continence mechanism, its role remains unclear, since most studies to date have been small and retrospective. 16 Another uncommon but severe long term problem is the development of a rectovaginal fistula, the majority of which occur after instrumental vaginal deliveries.8·17 Finally, and perhaps most importantly, anal sphincter dysfunction following third and fourth degree perineal lacerations may be accompanied by psychological and emotional reactions that can be quite detrimental to social interaction and lead to a degree of social isolation of the postpartum woman.8·11·12 Episiotomy can also lead to other complications including: increased blood loss at delivery, perineal haematomas, severe perineal pain, long term dyspareunia, and the risk of delayed healing, wound breakdown, and infection. 18 Better information is required to evaluate the true short and long term morbidity of rectal sphincter injury. Many women may not reveal their suffering until much later than the usual postpartum follow-up period. It is difficult to assess the prevalence or extent of sphincter dysfunction resulting from perineal trauma occurring at the time of childbirth because of lack of availability or utilization of valid diagnostic tests. Several such
tests are being developed and validated, including: anal manometry, anal mucosal electrosensitivity, and anal endosonography. Endosonography revealed a higher prevalence of sphincter damage than expected from an anorectal physiology test, and thus may have a role in screening patients at risk. 19 Endoanal ultrasound has been recommended in all patients with fecal incontinence to detect occult sphincter defects. 20 Our results reinforce the recommendations ofThacker and Banta3 and Sleep et al, 5 who suggest a more conservative approach to the use of episiotomy even with operative deliveries. The deliberate attempt to avoid performing an episiotomy may decrease the rate of third and fourth degree tears. Further clinically useful information regarding the value of episiotomy in forceps-assisted vaginal deliveries will likely be obtained only from randomized controlled trial comparing use versus non-use of episiotomy.
3.
4.
5. 6. 7. 8. 9. I0.
I I. 12.
REFERENCES: I.
2.
Cunningham FG, MacDonald PC, Gant NF, Levene KJ, Gilstrap LC Ill. Williams Obstetrics. 20th ed. Norwalk, Connecticut: Appleton and Lange, 1997:342-5. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies. 3rd ed. New York, New York: Churchill Livingstone, 1996:374-5.
13. 14. IS.
16. 17.
Managemen t of Twin Pregnancies (Part II)
18. 19.
This issue of the Journal SOGC includes a Self-Directed Learning Module on the Management ofTwin Pregnancies (Part II). This module qualifies for credits under Section 2 of the Maintenance of Certification Programme of the Royal College ofPhysicians and Surgeons of Canada. Don't miss this valuable selfdirected learning module on the management of twin pregnancies (part II). Supported by an unrestricted educational grant from
)A,
WYETH-AYERST
®~W CANADA INC
20.
Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretive review of the English literature, 1860-1980. Obstet Gynecol Surv 1983;38:322-38. Henriksen TB, Mollerbek K, Hedegaard M, Sechar NJ. Episiotomy and perineal lesions in spontaneous vaginal deliveries. Brit J Obstet Gynaecol 1992;99:950-4. Sleep J, Grant A. Garcia J, Elbourne, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J Clin Res 1984;289:587-90. Thorp JM, Bowes WA, Brame RG, Cefalo R. Selected use of midline episiotomy: Effect on perineal trauma. Obstet Gynecol 1987;70:260-2. Gass MS, Dunn C, Stys SJ. Effect of episiotomy on the frequency of vaginal outlet lacerations.J Reprod Med 1986;31 :240-4. Shine P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:765-70. Green JR, Soohoo SL. Factors associated with rectal injury in spontaneous deliveries. Obstet Gynecol 1989;73:732-8. Peen AC, Felt-Bersma RJ, Dekker GA, eta/. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997; I 04(5) : 563-6. Buekens P, Lagasse R, Dramaix M, Wollast E. Episiotomy and third degree tears. Br J Obstet Gynaecol 1985;92:820-3. Klein MC, Gauthier RJ,Jorgensen SH, eta/. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials 1992;Vol.l Doc I0. Haadem K, Dahlstrom JA, Ling L, Ohrlander S.Anal sphincter function after delivery rupture. Obstet Gynecol 1987;70:53-6. Sultan AH, Kamm MA, Hudson CN, et ai.Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329(26): 1905-11. Farnell EK, Berg G, Hallbook 0, eta/. Clinical consequences of anal sphincter rupture during vaginal delivery.J Am Coli Surg 1996; 183(6): 553-8. Cernes H, Bartolo DC, Stirrat GM. Changes in anal canal sensation after childbirth. Br J Surg 1991 ;78:74-7. Tancer ML, Lasser D, Rosenblum N. Rectovaginal fistula or perineal and anal sphincter disruption, or both, after vaginal delivery. Surg Gynecol Obstet 1990; 171 :43-6. Kitzinger S,Walters R. Some women's experiences of episiotomy. London; National Childbirth Trust, 1981. Burnett SJ, Spence-Jones 0, Speakmen DT, Kamm MA. Hudson CN, Bartram Cl. Unsuspected sphincter damage following childbirth revealed by anal endosonography. Br J Radial 1991 ;64:225-7. Reiger NA, Sweeney JL, Hoffman eta!. Investigation of fecal incontinence with endoanal ultrasound. Dis Colon Rectum 1996;39:860-4.
1n Forceps Deliveries
Helen L. Steed, MD Thomas C. Corbett, MD Damon C. Mayes, MSc Department of Obstetrics and Gynaecology University of Alberta
Abstract Objective: to determine the risk of third and fourth degree tears if episiotomy precedes
operative forceps deliveries. Methods: a retrospective analysis was performed, identifying 319 women who had a forceps
delivery. Two hundred and seventy-two women met our inclusion criteria (term, singleton, cephalic presentation, with mid, low or outlet forceps). Patients having forceps deliveries with an episiotomy were compared to those with forceps deliveries and no episiotomy. Maternal age, parity, use of an epidural, gestational age, and birth weight were examined for each group. The incidence of third and fourth degree tears and the odds ratio between the two groups were determined. Results: there were no differences in demographic or clinical variables between the two groups. Compared to the patients without episiotomy (n = 46), patients having forceps deliveries with an episiotomy (n = 226) had a significantly higher incidence of third and fourth degree tears (odds ratio 2.8; 95% confidence interval 1.5-5.6). Conclusion: the routine use of episiotomy is possibly associated with an increased incidence of sphincteric injuries in patients undergoing forceps deliveries. The routine use of episiotomy with forceps delivery should be re-evaluated. Resume Objectif : definir le risque de dechirure du troisieme ou du quatrieme degre lorsqu'une
episiotomie est pratiquee avant un accouchement operatoire avec application de forceps. Methode : on a fait une analyse retrospective et choisi 319 femmes ayant eu un accouche-
ment avec application de forceps en 1994. Deux cent soixante-douze de ces femmes ont satisfait aux criteres de selection (grossesse a terme et unique, presentation cephalique, application de forceps a la partie moyenne ou basse). On a compare les patientes qui avaient eu un accouchement avec episiotomie et application de forceps a celles qui avaient eu une application de forceps sans episiotomie. Pour chaque groupe, on a releve l'age, la parite, le recours a une epidurale, l'age gestationnel et le poids a la naissance. On a determine !'incidence des dechirures du troisieme et du quatrieme degre et le risque relatif entre les deux groupes. Resultats : ii n'y avait aucune difference entre les deux groupes au niveau des variables demographiques ou cliniques. Comparees aux patientes ayant eu une episiotomie (n =46), les patientes qui avaient eu un accouchement aux forceps accompagne d'une episiotomie (n = 226) ont eu une incidence de dechirures du troisieme et du quatrieme degre plus elevee (risque relatif : 2,8 ; IC de 95 % de 1,5 a 5,6). Conclusion: le recours systematique a l'episiotomie peut etre lie a une incidence accrue de blessures sphincteriennes chez les patientes qui ont un accouchement avec application de forceps. II faudrait reevaluer la pratique de l'episiotomie systematique lors des accouchements avec application de forceps.
J Soc
Obstet Gynaecol Can 2000;22(8):583-6
INTRODUCTION
Key Words forceps, episiotomy, sphincteric injury. Received on October 20th, 1999. Revised and accepted on June 26th, 2000.
An episiotomy is a surgical incision made at the time of delivery to enlarge the vaginal introitus for ease of passage of the fetus. The incision is made into the perinea! body and involves perinea! skin, vaginal mucosa, perinea! muscles and connective tissue. There are three types of episiotomies: midline, mediolateral, and J- shaped. Potential advantages of routine episiotomy include substitution of a straight surgical incision for a ragged laceration, 1 reduction
in the duration of second stage labour? and prevention of perineal and rectal trauma and subsequent pelvic floor relaxation. 3 Potential disadvantages of routine episiotomy include increased blood loss1 and increased perineal pain postpartum. 3 In a retrospective review of272 women who had a forceps assisted vaginal delivery, we assessed the incidence of third and fourth degree tears berween women who had an episiotomy and forceps versus those who had forceps delivery alone. MATERIALS AND METHODS
We reviewed the medical records of women delivering live born infants at the Grey Nuns Hospital in Edmonton, Alberta during a 12 month period. Of the 2,807 deliveries during this period, 319 were assisted by the use of forceps. Exclusion criteria included: multiple pregnancy, breech presentation, premature delivery (< 37 weeks gestation), and use of vacuum extraction. All forceps deliveries and perineal repairs were performed by practising obstetricians or senior obstetrics residents. The study population included 272 women who had singleton, cephalic, term, vaginal deliveries assisted with forceps. The primary outcome measure was the incidence of third or fourth degree perineal lacerations. A third degree laceration is defined as including complete disruption of the anal sphincter. A fourth degree laceration includes extension of the tear to involve the rectal mucosa. In addition to the use of episiotomy and the presence and degree of perineal lacerations, data also was collected for each patient regarding potentially confounding factors such as: maternal age, gestational age at delivery, parity, birth weight, use of epidural analgesia, and type of episiotomy. Body mass index measurements were not available in most charts. The women were separated into rwo groups: forceps delivery with an episiotomy and forceps delivery only. STATISTICAL ANALYSIS
Logistic regression analysis was used to assess whether women undergoing forceps delivery who received an episiotomy experienced a higher incidence of third and fourth degree tears relative to patients delivered without episiotomy. Comparisons berween groups with proportional data were analysed using Fisher's exact test (Instat, GraphPad Software, San Diego, CA). RESULTS
The demographic data for both study groups are shown in Table I. The groups were similar for maternal age, gestational age, parity, birth weight, and use of epidural analgesia. Rectal injury was more common in the nulliparous female in both study groups (p
found due to factors noted in Table I. Table II presents the data regarding the occurrence of third and fourth degree perineal tears according to the type of episiotomy and forceps operation. Almost 80 percent of episiotomies were midline. There was a significantly increased risk of damage to the anal sphincter and rectal mucosa with a midline epsiotomy (p<0.0001). The type of forceps delivery was often recorded as a "low-mid" with no distinction according to the currently accepted definitions of the American College of Obstetricians and Gynecologists. 2 To analyse the data, we have categorized forceps deliveries as low, "low-mid" without rotation, and those accompanied by rotation of the fetal head >90 degrees. In all three categories, the incidence of third or TABLE I BASELINE CHARACTERISTICS AND OUTCOMES Characteristic
Episiotomy and Forceps (n = 226)
Age (y) Parity (nullip) Gestational age (weeks) Birthweight (gm) Epidural analgesia
Forceps only (n = 46)
27.8 ± 0.8 147 (65.0%) 39.5 ± 0.0 3460.7 ± 31.1 122 (54.0%)
28.0 ± 0.8 25 (54.4%) 39.4 ± 0.1 3469.6 ± 84.3 27 (58.7%)
13 I (58.0%)*
15(32.6%)
Outcome measure Third or fourth degree tear
Data are presented as mean ± standard error or as n (%). * Significant difference (p
no tear
without episiotomy (n = 46) tear
no tear
Type of episiotomy* Midline (n = 43) 120 (65.6%) 63 (34.4%) Mediolateral (n = 43) 13 (30.2%) 30 (69.8%) type of forceps low 22 (52.4%) 20 (47.6%) 4 (30.8%) 9 low mid so (56.8%) 38 (43.2%) 5 (38.5%) 8 mid with rotation ** 59 (61.5%) 37 (38.5%) 6 (30.0%) 14
-
(69.2%) (61.5%) (70.0%)
Data are presented as n (%).
* Significant differences between the midline and mediolateral episiotomies (p
fourth degree tears was greater in the groups with episiotomy, but this attained statistical significance only in the group with rotation (p<0.0131). DISCUSSION
In most centres, episiotomies are routinely performed with forceps delivery to facilitate use of this instrument. 6 In unassisted vaginal delivery, there is little evidence to support or disprove the claim that episiotomy results in less trauma than perineal tear. 5 Additionally, midline episiotomies have been associated with a higher incidence of rectal injury when compared with mediolateral episiotomy or no episiotomy. 6-8 However, it is not clear whether this correlation also applies to deliveries assisted with obstetrical forceps. Spontaneous vaginal delivery episiotomy rates in our hospital decreased from above 50 percent in the 1980's to 19 percent in the mid 1990's. However, for forceps delivery, the rate is still quite high at 83 percent. Since damage to the anal sphincter may result in long term clinically significant symptoms,9-11 this study evaluated the effectiveness of episiotomy in forceps delivery by determining the incidence of third and fourth degree perineal lacerations. There are many indications for performing an episiotomy: to hasten delivery in the presence of non-reassuring fetal status; to protect a previous vaginal repair; or to facilitate delivery over a "rigid" perineum. However, in many centres, routine episiotomy is performed in all forceps deliveries to facilitate delivery and prevent undue trauma to the perineum. 6 This study demonstrates a significant increase in the incidence of rectal injury with the performance of an episiotomy. After controlling for parity, gestational age, and birth weight, episiotomy increased the risk of third or fourth degree perineal lacerations by an odds ratio of 2.8. Mediolateral episiotomies were less often associated with these serious consequences. However, compared to midline episiotomy, mediolateral incisions may have an increased rate of other negative consequences such as increased pain, less satisfactory cosmetic results, and painful intercourse. 8 Several other studies have established this association of increased tears with episiotomies. Green and Soohoo showed an adjusted risk of rectal injury with a midline episiotomy in spontaneous deliveries increased at an odds ratio of 8.9. 9 In a study of singleton, term deliveries, Buekens et al found that third-degree tears occurred in 1.4 percent of the deliveries with episiotomy, compared to 0.9 percent in those without episiotomy. 11 In a randomized control trial using standard questionnaires on perineal pain, urinary incontinence, and sexual activity postpartum, as well as electromyographic (EMG) perineometry to evaluate pelvic floor function, Klein et al found no evidence that liberal or routine use of episiotomy prevents perineal trauma and pelvic floor relaxation. 12 Thus, episioto-
my may not be a necessary procedure to prevent rectal injury in a large proportion of cases in spontaneous deliveries. This conclusion has resulted in a marked reduction in the routine use of episiotomy in most centres. Although we could find no data in the literature that addressed the benefits of routine episiotomy in deliveries assisted by obstetrical forceps, many obstetricians consider a forceps delivery an indication for an episiotomy. Our findings question this practice and suggest that episiotomy may possibly be over-utilized in patients requiring forceps application for delivery. Several potentially confounding factors could not be evaluated in this retrospective review, including: maternal body mass index, selection criteria for the use of forceps, indication for forceps, urgency of delivery, and the skill of the various obstetricians. The only way to control for these potentially important variables would be a proper randomized control clinical trial. Because damage to the anal sphincter may give rise to serious long term sequelae following vaginal delivery, 4 our outcome of interest was the incidence of third and fourth degree perineal lacerations. In a study by Haadem et al 13 almost half of the women with anal sphincter rupture experienced persistent symptoms such as flatal incontinence, dyspareunia, and perineal pain. Previous studies have shown the association of childbirth using operative assistance with a significant increase in new abnormal defaecatory symptoms and a high incidence of occult anal sphincter defects. 14·15 Resultant trauma may be neurogenic or mechanical. Even after apparently normal healing of a third or fourth degree tear, there may be dehiscence of the external anal sphincter or neural damage to the sensory or motor innervation of the sphincter, resulting in dysfunction. Although intact sensation is important in the continence mechanism, its role remains unclear, since most studies to date have been small and retrospective. 16 Another uncommon but severe long term problem is the development of a rectovaginal fistula, the majority of which occur after instrumental vaginal deliveries.8·17 Finally, and perhaps most importantly, anal sphincter dysfunction following third and fourth degree perineal lacerations may be accompanied by psychological and emotional reactions that can be quite detrimental to social interaction and lead to a degree of social isolation of the postpartum woman.8·11·12 Episiotomy can also lead to other complications including: increased blood loss at delivery, perineal haematomas, severe perineal pain, long term dyspareunia, and the risk of delayed healing, wound breakdown, and infection. 18 Better information is required to evaluate the true short and long term morbidity of rectal sphincter injury. Many women may not reveal their suffering until much later than the usual postpartum follow-up period. It is difficult to assess the prevalence or extent of sphincter dysfunction resulting from perineal trauma occurring at the time of childbirth because of lack of availability or utilization of valid diagnostic tests. Several such
tests are being developed and validated, including: anal manometry, anal mucosal electrosensitivity, and anal endosonography. Endosonography revealed a higher prevalence of sphincter damage than expected from an anorectal physiology test, and thus may have a role in screening patients at risk. 19 Endoanal ultrasound has been recommended in all patients with fecal incontinence to detect occult sphincter defects. 20 Our results reinforce the recommendations ofThacker and Banta3 and Sleep et al, 5 who suggest a more conservative approach to the use of episiotomy even with operative deliveries. The deliberate attempt to avoid performing an episiotomy may decrease the rate of third and fourth degree tears. Further clinically useful information regarding the value of episiotomy in forceps-assisted vaginal deliveries will likely be obtained only from randomized controlled trial comparing use versus non-use of episiotomy.
3.
4.
5. 6. 7. 8. 9. I0.
I I. 12.
REFERENCES: I.
2.
Cunningham FG, MacDonald PC, Gant NF, Levene KJ, Gilstrap LC Ill. Williams Obstetrics. 20th ed. Norwalk, Connecticut: Appleton and Lange, 1997:342-5. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies. 3rd ed. New York, New York: Churchill Livingstone, 1996:374-5.
13. 14. IS.
16. 17.
Managemen t of Twin Pregnancies (Part II)
18. 19.
This issue of the Journal SOGC includes a Self-Directed Learning Module on the Management ofTwin Pregnancies (Part II). This module qualifies for credits under Section 2 of the Maintenance of Certification Programme of the Royal College ofPhysicians and Surgeons of Canada. Don't miss this valuable selfdirected learning module on the management of twin pregnancies (part II). Supported by an unrestricted educational grant from
)A,
WYETH-AYERST
®~W CANADA INC
20.
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