The impact of super-selective episiotomy on maternal short-term morbidity

The impact of super-selective episiotomy on maternal short-term morbidity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of super-selective episiotomy on maternal short-term morbidity Ammar Al Naimi, Gazal Radner, Lukas Jennewein, Dörthe Brüggmann, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2894336/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Our aim is to investigate the risk of short-term maternal morbidity caused by super-selective clinical use of episiotomies (rate of below 0.02). A secondary aim is to compare our risk of severe perineal tears to the state-wide risk. Methods: This is a retrospective cohort study investigating the effect of super-selective episiotomy on the risk of severe perineal tears and blood loss. Results: The study included 10992 women who delivered between 2008-2018. Episiotomies were performed in 171 cases (1.56%), 3 of which (1.75%) experienced severe perineal tears compared to 156 (1.44%) in the control cohort. The adjusted odds ratio of severe perineal tears was 0.99 (0.95 CI 0.30, 3.26 p-value 0.98). Multivariate linear regression showed that episiotomies increased blood loss by 77.47 ml (0.95 CI 34.34, 120.59 p-value <0.0001). Episiotomies were performed in 23% (0.95 CI 0.228, 0.23) of vaginal deliveries in the state of Hessen with a risk of severe perineal tears of 0.0143 (0.95 CI 0.0139, 0.0147) compared to 0.0145 (0.95 CI 0.0123, 0.0168) in our entire cohort. Conclusion: Institutionally implemented super-selective use of episiotomy does not increase the risk of higher-grade perineal tears but leads to increased blood loss. Therefore, episiotomies potentially increase maternal morbidity. episiotomy perineal tears instrumental delivery What does this study add to clinical work The super-selective use of episiotomy affects maternal morbidity by increasing blood loss, but it does not increase the risk of higher-grade perineal tears. Introduction An episiotomy is a surgical procedure to enlarge the vaginal orifice by incising the perineum during the second stage of labor [ 1 , 2 ]. There are three major types of episiotomies. These include median, medio-lateral and lateral episiotomy [ 3 , 4 ]. Episiotomies are believed to be beneficial in the prevention of extensive perineal lacerations, allowing easy repair and expediting delivery of the baby [ 5 , 6 , 7 ]. Nevertheless, definitive evidence for defined episiotomy criteria or proving a clear benefit in reducing maternal and neonatal morbidity is missing [ 8 ]. On the contrary, there is an association between episiotomies and severe bleeding, extension into severe perineal tears, infection, hematoma, and wound dehiscence. Moreover, long-term episiotomy complications include scar tissue formation, dyspareunia, anorectal incontinence and severe tears in future childbirth [ 9 ]. Promoted by the World Health Organization (WHO) recommendations to refrain from routine episiotomies, the worldwide episiotomy rate has been declining for decades. This has led to implementing a selective, indication-based episiotomy with a rate below 0.1 [ 10 , 11 ]. Episiotomy rates have dropped in many countries and they range from 0.037 in Denmark [ 12 ], to around 0.1 in the Unites States [ 13 ] and up to 0.2 in France [ 14 ]. Nevertheless, health care givers in some regions such as Cyprus still perform routine episiotomies with a rate of 0.75, and nulliparous women are especially prone to experience this surgical intervention [ 12 , 2 ]. Two Cochrane reviews reported lower rates of perineal trauma with selective, rather than routine use of episiotomies, whereas short- and long-term adverse outcomes for both the mothers and the newborns did not differ [ 1 , 15 ]. Therefore, the International Federation of Gynecology and Obstetrics (FIGO) has published a statement against routine episiotomies, with the authors emphasizing that the procedure should not be “withheld in all circumstances” [ 16 ]. The National Institute of Health Care Excellence (NICE) recommends the use of episiotomy in vaginal operative deliveries, while the American College of Obstetricians and Gynecologists (ACOG) advises against its routine practice [ 17 , 18 ]. This highlights the conflicting views regarding the practice of episiotomies and more evidence is required to address whether episiotomies protect from severe perineal tears [ 19 ]. The main aim of this work is to investigate the risk of short-term maternal morbidity, represented by severe perineal tears and bleeding in a cohort where a policy of super-selective episiotomy is advocated. According to this policy, episiotomies are performed at a rate below 0.02 strictly due to high risk of hypoxia when the perineum clearly hinders the delivery. Furthermore, we aim to compare the risk of severe perineal tears in this collective cohort to the population of the state of Hessen where the selective policy is followed. Material and methods This is a retrospective cohort study that includes all term vaginal singleton deliveries over a decade at the obstetrical unit of the Goethe-University Hospital of Frankfurt, which is a tertiary referral center. The study was approved by the local Ethics Committee (reference number 20–840) and patient-specific consent was not required. The obstetrical medical records at our department are routinely and prospectively documented in an electronic database (GeDoWin®, Saatmann GmbH, Worms). This was utilized to identify eligible deliveries between January 1st, 2008 and December 31st, 2018. The inclusion criteria were singletons, completed 37 gestational weeks, cephalic or breech presentation, spontaneous, manually assisted and vaginal operative deliveries. Births with fetal abnormalities, small for gestational age, a prior cesarean section, gestational diabetes or other maternal co-morbidities were intentionally included. The exclusion criteria were multiplets and prematurity. The vaginal operative deliveries in our cohort include forceps deliveries and vacuum extractions. Forceps are used to guide the fetal head when delivery fails to progress or when there is a need to accelerate the second stage of labor [ 20 , 21 ]. Our team mainly applies the Kielland forceps, which could additionally be used to overcome asynclitism [ 22 ]. Vacuum extraction is used in term deliveries to avoid fetal distress and resolve failure to progress, as well as when preclusion of voluntary maternal expulsive efforts is advised [ 23 ] [ 24 ]. Manual assistance is limited to breech presentation where it might be indicated to support the necessary rotation of the shoulders, the delivery of the arms, or to increase deflection of the fetal head [ 25 ]. Our deliveries are managed by a midwife and an obstetrician. All types of perineal tears are confirmed by the senior obstetrician to avoid misclassification. Episiotomies in the exposed group (EPI) were performed according to our super-selective policy only when the fetal head was crowning, fetal bradycardia present and the perineum is clearly hindering the delivery. Maternal and neonatal demographic variables such as age, weight, height, body mass index (BMI), gravidity, parity, gestational age, and the incidence of gestational diabetes were acquired for both the exposed and the non-exposed (NoEPI) groups. Further covariates included the presentation of the fetus, the duration of the stages of labor, the use of epidural analgesia, the type of episiotomy and induction of labor. Our database contained no missing data. The primary outcome of this study is the occurrence of severe perineal lacerations (third- and fourth-degree tears) as a binomial variable. Additionally, maternal blood loss is a continuous secondary outcome that surrogates for maternal morbidity. For further comparative analysis, the reference data of Hessian hospitals, which adopt a selective episiotomy policy, were provided by the “ Perinatalerhebung Hessen ” database (a standardized state-wide database collecting perinatal outcome data). Statistical analysis is conducted with Stata ® (ver. 16.1, Texas, USA) using Pearson’s chi-square test, two-sample t-test, univariate and multivariate logistic and linear regression. A p-value of 0.05 was considered as a cut-off for statistical significance. Results Between 2008 and 2018, 10992 vaginal deliveries met our inclusion criteria. Practitioners performed an episiotomy in 171 (1.55%) deliveries. Overall, there were 7951 (72.3%) spontaneous vaginal deliveries, 2163 (19.6%) forceps deliveries, 19 (0.17%) vacuum extractions and 859 (7.8%) manually assisted deliveries. The median type of episiotomies accounted for 60.23%, the medio-lateral type for 37.42% and the lateral type for 2.34% of the episiotomies. Table 1 summarizes the descriptive statistics of both cohorts. Table 1 The descriptive statistics and demographic characteristics of the study cohorts. EPI: episiotomy cohort; NoEPI: control cohort; SD: standard deviation. EPI frequency (%) or mean ± SD NoEPI frequency (%) or mean ± SD p-value Total number of observations 171 (1.55%) 10821 (98.5%) < 0.0001 Maternal age in years 32 ± 4.6 32 ± 5.0 0.869 Gestation age in days 280 ± 8.0 279 ± 7.8 0.300 Birth weight in grams 3410 ± 446 3391 ± 451 0.57 Maternal BMI (kg/m2) 22.2 ± 3.4 23.7 ± 4.8 < 0.0001 Nulliparity 136 (79.5%) 5315 (49.1%) < 0.0001 Induction of labor 30 (17.5%) 1617 (14.9%) 0.34 Duration of labor in minutes 457 ± 310 364 ± 318 < 0.0001 Gestational diabetes 9 (5.3%) 844 (7.8%) 0.21 Epidural analgesia 97 (57%) 4426 (40.9%) < 0.0001 Mode of delivery Spontaneous delivery 7880 (72.82%) 71 (41.52%) < 0.0001 Forceps 2092 (19.33%) 71 (41.52%) < 0.0001 Vacuum extraction 17 (0.16%) 2 (1.17%) 0.001 Manual extraction 832 (7.69%) 27 (15.79%) < 0.0001 Fetal presentation Regular cephalic 9605 (88.76%) 135 (78.95%) < 0.0001 Irregular cephalic 320 (2.96%) 9 (5.26%) 0.047 Breech 896 (8.28%) 27 (15.79%) < 0.0001 There was no statistically significant difference between the exposed (EPI) and non-exposed (NoEPI) cohorts for maternal age (32 ± 4.6 vs 32 ± 5.0 years), gestational age (280 ± 8.0 vs 279 ± 7.8 days), birth weight (3410 ± 446 vs 3391 ± 451 grams), induction of labor (17.5% vs 14.9%) and gestational diabetes (5.3% vs 7.8%) respectively. The Body Mass Index (BMI) was lower in the EPI group compared to the NoEPI group (22.2 ± 3.4 vs 23.7 ± 4.8). The total duration of labor (first and second stage) was significantly longer in the EPI group (457 ± 310 vs 364 ± 318 minutes). Further, patients who experienced an episiotomy were more likely to be nulliparous and have an epidural analgesia. Cephalic presentation was the most common fetal position in both cohorts, but proportionally more regular cephalic presentation were observed in the noEPI group than the EPI group (88.76% vs 78.95% respectively). The irregular cephalic positions were almost twice as likely in the EPI than the NoEPI group (5.26% vs 2.96%). Similarly, breech presentation was about twice as likely in the EPI than the NoEPI group (15.79% vs 8.28%). This indicates that the episiotomy was positively associated with irregular presentations and positions. Episiotomy was performed in 0.89% of all spontaneous deliveries and 3.28% of patients with a vaginal operative delivery. In the EPI group, 58.5% of births ended in a vaginal operative delivery. This rate is significantly higher compared to 27.2% in the NoEPI group. In our study population, practitioners performed 2163 forceps deliveries; 2092 cases without an episiotomy (96.72%), 71 cases with an episiotomy (3.28%). As for the primary outcome, the noEPI cohort included 6003 (44.48%) with no tears, 4662 (43.08%) with mild (first- and second-degree), and 156 (1.44%) with severe perineal tears. The EPI cohort included 142 (83.04%) without tears, 26 (15.2%) with mild tears, and 3 (1.45%) with severe perineal tears. There is an association between having no perineal tears at all and episiotomy with a p-value of < 0.0001. Unadjusted logistic regression showed that the odds ratio of severe perineal tears in the EPI cohort compared to the noEPI cohort was 1.22 (0.95 CI 0.39, 3.87 with 0.73 p-value). Multivariate logistic regression, while adjusting for statistically significant demographic differences, showed that the odds ratio of severe perineal tears in the EPI cohort compared to the noEPI cohort was 0.99 (0.95 CI 0.30, 3.26 with 0.98 p-value). The results of the multivariate logistic regression are shown in Table 2 . Table 2 The results of multivariate logistic regression for the risk of third- and fourth-degree perineal tears among the EPI compared to the NoEPI cohorts. Severe perineal tears Odds ratio 0.95 confidence interval p-value Performing episiotomy 0.99 0.30, 3.26 0.98 Maternal BMI 0.99 0.94, 1.04 0.76 Nulliparity 3.2 1.68, 6.09 < 0.0001 Duration of labor in minutes 0.99 0.99, 1.01 0.148 Epidural analgesia 0.97 0.58, 1.64 0.93 Mode of delivery Spontaneous delivery omitted Forceps 8.82 4.86, 16.02 0.93 Vacuum extraction 1 . . Manual extraction 3.28 1.44, 7.48 0.93 Fetal presentation Regular cephalic omitted Irregular cephalic 1.35 0.59, 3.03 0.47 Breech 1 . . Blood loss was 268 ± 180 ml in the NoEPI group and 344 ± 284 in the EPI group. Simple linear regression showed that episiotomy led to an increase in blood loss of 75.88 ml (0.95 CI 46.75, 105 ml with a p-value < 0.0001). This effect remained statistically significant after adjusting for possible confounders in a multivariate linear regression as shown in Table 3 . Table 3 The results of multivariate linear regression for the effect of episiotomy on blood loss. Blood loss Regression coefficient 0.95 confidence interval p-value Performing episiotomy 77.47 34.34, 120.59 < 0.0001 Maternal BMI 0.62 -0.535, 1.77 0.29 Nulliparity 17.24 4.97, 29.50 0.006 Duration of labor in minutes 0.04 0.02, 0.06 < 0.0001 Epidural analgesia -6.68 -20.14, 6.78 0.33 Mode of delivery Spontaneous delivery omited Forceps 64.77 49.83, 79.7 < 0.0001 Vacuum extraction 95.57 -79.31, 270.45 0.284 Manual extraction 17.01 -1.52, 35.54 0.072 Fetal presentation Regular cephalic omited Irregular cephalic 18.79 -11, 48.59 0.216 Breech 0 . . Intercept 243.57 214.22, 272.91 < 0.0001 From 2008 to 2018, 373.250 vaginal births were documented in the state of Hessen. As a result of a regional selective episiotomy policy, an average of 23% (0.95 CI 0.228, 0.23) of patients received an episiotomy while giving birth. This was significantly more than the 1.5% (0.95 CI 0.0128, 0.0175) for patients in our center. Regarding the primary outcome of interest, the average rate of severe perineal tears was 0.0143 (0.95 CI 0.0139, 0.0147) in Hessen versus 0.0145 (0.95 CI 0.0123, 0.0168) in our center [ 26 ]. Discussion The benefit of episiotomies for preventing higher grade perineal lacerations remains controversial [ 7 , 19 ]. Although Cochrane analyses of different practices involving routine versus selective episiotomy have been published and have shown that performing fewer episiotomies during spontaneous vaginal delivery reduces the risk of higher-degree perineal trauma by 30% [ 15 , 27 ], this contradicts several current recommendations that promote the protective role of episiotomy against higher graded tears [ 28 , 17 ]. Additionally, the findings of the Cochrane analyses suggest that a further reduction of severe perineal trauma can be achieved when episiotomies are entirely avoided, with few exceptions remaining. The likelihood of episiotomy in our study was 1.55% and episiotomies did not affect the risk of severe perineal tears. Nevertheless, they were associated with a trend for a higher risk of high degree perineal tears (0.0175) compared to the NoEPI group (0.0144), even though not statistically significant. This finding is consistent with nationwide data for 2014 where the percentage of episiotomy at 22.7% among 469258 vaginal births increased the risk of higher-grade perineal tears from 0.0104 to 0.0253 [ 29 ]. Therefore, our study shows that episiotomies do not protect mothers from higher-degree perineal tears and consequently they do not improve maternal morbidity. On the contrary, they might be a cause of increased morbidity even if not statistically significant. Most studies in current literature compare two different clinical practice protocols regarding the primary outcome of advanced perineal tears. Numerous studies compare routine to selective episiotomy use or to a cohort where episiotomies are almost completely avoided. Two randomized controlled trials focused on the implementation of a “non-episiotomy” protocol compared to “selective episiotomy” practice with the aim of limiting the episiotomies in clinical practice to an absolute minimum [ 5 , 30 ]. While our study shares the same core idea with these trials, the episiotomy rate of both randomized trials was much higher than ours (around 20%) which was justified by non-compliance of practitioners to the non-episiotomy practice [ 5 ]. While these studies showed limited success towards their main goal, our study, although not a randomized controlled trial, is able to compare our “super-selective” episiotomy (1.55%) protocol to a “selective” (23%) protocol followed by the rest of the state-wide hospitals [ 26 ]. Therefore, this study is especially successful in comparing cohorts with fundementaly different episiotomy rates. Regarding the primary outcome of interest, the rate of severe perineal lacerations was not significantly increased in our patients, which indicates that this super-selective policy does not endanger women by increasing short-term morbidity. An important limitation of our study is the lack of long-term follow-up to assess additional morbidity. Turmo et al. showed that 12.8% of women develop chronic pain after episiotomies [ 31 ], and others studies showed that sex life could also be negatively affected due to higher rates of dyspareunia and insufficient lubrication [ 32 ]. The episiotomy ratio was higher (3.28%) during vaginal operative deliveries, specifically forceps, compared to spontaneous delivery (0.89%). Operative deliveries increase the likelihood of practitioners’ non-adherence to the super-selective episiotomy approach. This is probably caused by following the NICE/RCOG guidelines [ 17 , 33 ]. However, it is unclear whether episiotomies during vaginal operative deliveries truly protect from severe perineal tears. De Leeuw et al. showed a higher risk for third degree perineal tears during vaginal operative deliveries and subsequently recommended the use of mediolateral episiotomy to reduce that risk [ 34 ]. Dandolu et al. on the other hand showed a significantly higher risk for perineal laceration during vaginal operative deliveries when an episiotomy was performed [ 35 ]. Similarly, Kudish et al. demonstrated an increased risk of anal sphincter injuries with the use of episiotomies during operative vaginal deliveries and recommended the avoidance of this combination [ 36 ]. Ecker et al. examined the effect of reducing the use of routine episiotomy for vaginal operative deliveries on the risk of high grade perineal tears and demonstrated an unchanged risk for third-degree lacerations with a decrease in the risk of fourth-degree lacerations [ 37 ]. In our department, forceps are removed before the fetal head passes the perineum as standard protocol in order to prevent perineal tears. Episiotomy increases blood loss by around 77 ml even after adjusting for all available confounders. This finding is expected as it had been observed in other studies [ 38 ]. However, this statistically significant increase is not necessarily clinically significant and might not increase maternal morbidity. In conclusion, this study has shown that there is no increase in short-term maternal morbidity when episiotomies are used within a super-selective clinical approach. Regardless of this, the risk of severe perineal lacerations is low and we do not support the assumption that episiotomies prevent severe tears. Thus our findings provide evidence for adopting a super-selective clinical approach to episiotomies. They highlight the need to reevaluate episiotomy indications in obstetrical centers with the goal of reducing associated perineal trauma. This approach will protect women by reducing short- and eventually long-term morbidity. Our work has several weaknesses such as including mainly primigravids in the EPI group, which is not surprising. Nulliparous women are six times as likely to have an episiotomy [ 2 ]. Another shortcoming is that our data didn’t allow investigation of the effect of episiotomy type on perineal tears, and studies reported that the outcomes in lateral and mediolateral episiotomies differ [ 39 , 40 ]. Finally, this is a retrospective cohort study and information bias, and unknown confounders remain a concern. Future randomized controlled trials with strict adherence to super-selective episiotomy use are necessary to further investigate maternal morbidity. Although our findings indicate a potential for episiotomies to increase maternal morbidity, we wish to emphasize that an episiotomy should not be “withheld in all circumstances” [ 16 ]. Rather, each indication should be critically considered and weighed against the possible drawbacks for mother and fetus. Declarations Acknowledgements: we would like to thank all our patients and colleagues who made this project possible. This study is part of a doctoral thesis for the first author. Author contributions: Gazal Radner: project development, conduct, manuscript writing Lukas Jennewein: data analysis Dörthe Brüggmann: project development Frank Louwen: design, project development Ammar Al Naimi: data analysis, manuscript writing Funding: t he authors declare that no funds, grants, or other support were received during the preparation of this manuscript Conflict of interest: T he authors have no relevant financial or non-financial interests to disclose. Ethics approval: the study was approved by the local Ethics Committee (reference number 20-840) and patient-specific informed consent was not required. References Carroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database Syst Rev 1–53. https://doi.org/10.1002/14651858.CD000081.pub2 Beyene F, Nigussie AA, Limenih SK, Tesfu AA, Wudineh KG (2020) Factors associated with episiotomy practices in Bahirdar City, Ethiopia: A cross-sectional study. Risk Manag Healthc Policy 13:2281–2289. https://doi.org/10.2147/RMHP.S277657 Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Øian P (2012) Episiotomy characteristics and risks for obstetric anal sphincter injuries: A case-control study. BJOG An Int J Obstet Gynaecol 119:724–730. https://doi.org/10.1111/j.1471-0528.2012.03293.x Räisänen S, Vehviläinen-Julkunen K, Heinonen S (2010) Need for and consequences of episiotomy in vaginal birth: A critical approach. Midwifery 26:348–356. https://doi.org/10.1016/j.midw.2008.07.007 Sagi-Dain L, Bahous R, Caspin O, Kreinin-Bleicher I, Gonen R, Sagi S (2018) No episiotomy versus selective lateral/mediolateral episiotomy (EPITRIAL): an interim analysis. Int Urogynecol J 29:415–423. https://doi.org/10.1007/s00192-017-3480-7 Sagi-Dain L, Sagi S (2016) Indications for episiotomy performance - a cross-sectional survey and review of the literature. J Obstet Gynaecol J Inst Obstet Gynaecol 36:361–365. https://doi.org/10.3109/01443615.2015.1065233 Sangkomkamhang U, Kongwattanakul K, Kietpeerakool C, Thinkhamrop J, Wannasiri P, Khunpradit S et al (2020) Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial. BJOG An Int J Obstet Gynaecol 127:397–403. https://doi.org/10.1111/1471-0528.15982 Bansal RK, Tan WM, Ecker JL, Bishop JT, Kilpatrick SJ (1996) Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment. Am J Obstet Gynecol 175:897–901. https://doi.org/10.1016/S0002-9378(96)80021-4 Gün İ, Doğan B, Özdamar Ö (2016) Long- and short-term complications of episiotomy. Turkish J Obstet Gynecol 13:144–148. https://doi.org/10.4274/tjod.00087 APPROPRIATE TECHNOLOGY FOR BIRTH, Lancet (1985) ;326:436–7. https://doi.org/10.1016/S0140-6736(85)92750-3 World Health Organization. Maternal and Newborn Health/Safe Motherhood Unit. Les soins liés à un accouchement normal: guide pratique : rapport d’ un groupe de travail technique 1997 Blondel B, Alexander S, Bjarnadóttir RI, Gissler M, Langhoff-Roos J, Novak-Antolič Ž et al (2016) Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand 95:746–754. https://doi.org/10.1111/aogs.12894 Kozhimannil KB, Karaca-Mandic P, Blauer-Peterson CJ, Shah NT, Snowden JM (2017) Uptake and Utilization of Practice Guidelines in Hospitals in the United States: the Case of Routine Episiotomy. Jt Comm J Qual Patient Saf 43:41–48. https://doi.org/10.1016/j.jcjq.2016.10.002 Goueslard K, Cottenet J, Roussot A, Clesse C, Sagot P, Quantin C (2018) How did episiotomy rates change from 2007 to 2014? Population-based study in France. BMC Pregnancy Childbirth 18:1–10. https://doi.org/10.1186/s12884-018-1747-8 Jiang H, Qian X, Carroli G, Garner P, OF FINDINGS FOR THE MAIN COMPARISON Selective versus routine use of episiotomy for vaginal birth (Review) SUMMARY.Cochrane Database Syst Rev2017:77. https://doi.org/10.1002/14651858.CD000081.pub3. Nassar AH, Visser GHA, Ayres-de-Campos D, Rane A, Gupta S (2019) FIGO Statement: Restrictive use rather than routine use of episiotomy. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 146:17–19. https://doi.org/10.1002/ijgo.12843 NİCE NI for H and CE (2017) ACOG Practice Bulletin No (2015) 154: Operative Vaginal Delivery. Obstet Gynecol. https://doi.org/10.1097/AOG.0000000000001147 Thacker SB, Banta HD (1983) Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860–1980. Obstet Gynecol Surv 38:322–338 Vayssire C, Beucher G, Dupuis O, Feraud O, Simon-Toulza C, Sentilhes L et al (2011) Instrumental delivery: Clinical practice guidelines from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol 159:43–48. https://doi.org/10.1016/j.ejogrb.2011.06.043 Patel RR, Murphy DJ (2004) Forceps delivery in modern obstetric practice. Br Med J 328:1302–1305. https://doi.org/10.1136/bmj.328.7451.1302 Nash Z, Nathan B, Mascarenhas L (2015) Kielland’s forceps. from controversy to consensus? Acta Obstet Gynecol Scand 94:8–12. https://doi.org/10.1111/aogs.12511 Putta LV, Spencer JP (2000) Assisted vaginal delivery using vacuum extractor. Am Fam Physician 62:1316–1320 Vacca A (1999) The trouble with vacuum extraction. Curr Obstet Gynaecol 9:41–45. https://doi.org/https://doi.org/10.1016/S0957-5847(99)90072-0 Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ et al (2019) The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term – A FRABAT prospective cohort study. PLoS ONE 14:1–13. https://doi.org/10.1371/journal.pone.0225546 Gmbh G (2014) Geburtshilfe Jahresauswertung 2014:1–100 Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp JJ, Lohr KN (2005) Outcomes of routine episiotomy: a systematic review. JAMA 293:2141–2148. https://doi.org/10.1001/jama.293.17.2141 De Leeuw JW, De Wit C, Kuijken JPJA, Bruinse HW (2008) Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG An Int J Obstet Gynaecol 115:104–108. https://doi.org/10.1111/j.1471-0528.2007.01554.x AQUA-Institut. Bundesauswertung zum Erfassungsjahr 2014 -Geburtshilfe. 2015:1–117 Amorim M, Coutinho M, Melo IC, Katz I (2017) Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprod Health 14:55. https://doi.org/10.1186/s12978-017-0315-4 Turmo M, Echevarria M, Rubio P, Almeida C (2015) Development of chronic pain after episiotomy. Rev Española Anestesiol y Reanim (English Ed 62:436–442. https://doi.org/10.1016/j.redare.2015.03.002 Ejegård H, Ryding EL, Sjögren B (2008) Sexuality after delivery with episiotomy: A long-term follow-up. Gynecol Obstet Invest 66:1–7. https://doi.org/10.1159/000113464 Pandit B (2013) The Management of Third- and Fourth-Degree Perineal Tears. Man Vaginal Surg 119–119. https://doi.org/10.5005/jp/books/12041_14 De Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HCS (2001) Risk factors for third degree perineal ruptures during delivery. Br J Obstet Gynaecol. https://doi.org/10.1016/S0306-5456(00)00090-5 Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E Risk factors for obstetrical anal sphincter lacerations.Int Urogynecol J 2005. https://doi.org/10.1007/s00192-005-1297-2 Kudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger M, Hendrix SL et al (2006) Operative vaginal delivery and midline episiotomy: A bad combination for the perineum. Am J Obstet Gynecol 195:749–754. https://doi.org/10.1016/j.ajog.2006.06.078 Ecker JL, Tan WM, Bansal RK, Bishop JT, Kilpatrick SJ (1997) Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population. Am J Obstet Gynecol 176:411–414. https://doi.org/10.1016/S0002-9378(97)70507-6 Baksu B, Davas I, Akyol A, Ozgul J, Ezen F (2008) Effect of timing of episiotomy repair on peripartum blood loss. Gynecol Obstet Invest 65:169–173. https://doi.org/10.1159/000111138 Rusavy Z, Karbanova J, Kalis V (2016) Timing of episiotomy and outcome of a non-instrumental vaginal delivery. Acta Obstet Gynecol Scand 95:190–196. https://doi.org/10.1111/aogs.12814 Sagi-Dain L, Sagi S (2015) The correct episiotomy: does it exist? A cross-sectional survey of four public Israeli hospitals and review of the literature. Int Urogynecol J 26:1213–1219. https://doi.org/10.1007/s00192-015-2680-2 Supplementary Files Conflictofintereststatement.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2894336","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":205515516,"identity":"90decff0-dad8-472c-af8e-7e94cb7511b0","order_by":0,"name":"Ammar Al Naimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIie3Pv6rCMBTH8SNCXYJuolTaV0hxEBH0VVIu2MWCY0HBLHbq7CQ+gyA4FwI6XMFV6R1uF+eCi26e2NX4Z3PId2vgw+8UQKf74hoABQ4sACjjV/z/BiE52QEYkrD86RXBCmFO4BmpzH7dcwBd0iqJ6TJdCNuoihRX/qyegtQSf1XfwQ9pR254cNfCCc0+RXJqKg9L/GWdQ5HQOCfMMJkkwo0UwsaVK4cJofsUyVwSL5NkoiI08de4Igg9yBUuyeC+wlSHOUjanG6R4ArbePgvg2HMqHCi+DGx8LAjD0YW3Xun42XcsSumt8qyQNglrvr/+3lvvOh0Op3ug25fC1/toWxFMgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5345-4688","institution":"Buergerhospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ammar","middleName":"Al","lastName":"Naimi","suffix":""},{"id":205515517,"identity":"c22969f7-e468-491c-a91f-ba87c102d846","order_by":1,"name":"Gazal Radner","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gazal","middleName":"","lastName":"Radner","suffix":""},{"id":205515518,"identity":"2f608372-917f-4071-9e75-2dfbb53d4950","order_by":2,"name":"Lukas Jennewein","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lukas","middleName":"","lastName":"Jennewein","suffix":""},{"id":205515519,"identity":"c629f50a-8788-499d-8d1b-b40006fa44d2","order_by":3,"name":"Dörthe Brüggmann","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dörthe","middleName":"","lastName":"Brüggmann","suffix":""},{"id":205515520,"identity":"8e5373af-8219-4bbd-bd78-2131624b8c24","order_by":4,"name":"Frank Louwen","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Louwen","suffix":""}],"badges":[],"createdAt":"2023-05-04 13:37:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2894336/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2894336/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":39878269,"identity":"66ad9fde-4c52-4cc7-b547-ede28cf462fa","added_by":"auto","created_at":"2023-07-11 20:24:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":290338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2894336/v1/7b76c15b-3f9e-49e2-ab5a-1a6050ae0b17.pdf"},{"id":37882884,"identity":"3fcf1b53-6f53-4813-9662-ce6118ce06e2","added_by":"auto","created_at":"2023-06-02 04:19:01","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":12745,"visible":true,"origin":"","legend":"","description":"","filename":"Conflictofintereststatement.docx","url":"https://assets-eu.researchsquare.com/files/rs-2894336/v1/04e403834675f43737d1cf54.docx"}],"financialInterests":"","formattedTitle":"The impact of super-selective episiotomy on maternal short-term morbidity","fulltext":[{"header":"What does this study add to clinical work","content":"\u003cp\u003eThe super-selective use of episiotomy affects maternal morbidity by increasing blood loss, but it does not increase the risk of higher-grade perineal tears.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAn episiotomy is a surgical procedure to enlarge the vaginal orifice by incising the perineum during the second stage of labor [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. There are three major types of episiotomies. These include median, medio-lateral and lateral episiotomy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Episiotomies are believed to be beneficial in the prevention of extensive perineal lacerations, allowing easy repair and expediting delivery of the baby [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Nevertheless, definitive evidence for defined episiotomy criteria or proving a clear benefit in reducing maternal and neonatal morbidity is missing [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the contrary, there is an association between episiotomies and severe bleeding, extension into severe perineal tears, infection, hematoma, and wound dehiscence. Moreover, long-term episiotomy complications include scar tissue formation, dyspareunia, anorectal incontinence and severe tears in future childbirth [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePromoted by the World Health Organization (WHO) recommendations to refrain from routine episiotomies, the worldwide episiotomy rate has been declining for decades. This has led to implementing a selective, indication-based episiotomy with a rate below 0.1 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Episiotomy rates have dropped in many countries and they range from 0.037 in Denmark [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], to around 0.1 in the Unites States [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and up to 0.2 in France [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Nevertheless, health care givers in some regions such as Cyprus still perform routine episiotomies with a rate of 0.75, and nulliparous women are especially prone to experience this surgical intervention [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo Cochrane reviews reported lower rates of perineal trauma with selective, rather than routine use of episiotomies, whereas short- and long-term adverse outcomes for both the mothers and the newborns did not differ [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, the International Federation of Gynecology and Obstetrics (FIGO) has published a statement against routine episiotomies, with the authors emphasizing that the procedure should not be \u0026ldquo;withheld in all circumstances\u0026rdquo; [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The National Institute of Health Care Excellence (NICE) recommends the use of episiotomy in vaginal operative deliveries, while the American College of Obstetricians and Gynecologists (ACOG) advises against its routine practice [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This highlights the conflicting views regarding the practice of episiotomies and more evidence is required to address whether episiotomies protect from severe perineal tears [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main aim of this work is to investigate the risk of short-term maternal morbidity, represented by severe perineal tears and bleeding in a cohort where a policy of super-selective episiotomy is advocated. According to this policy, episiotomies are performed at a rate below 0.02 strictly due to high risk of hypoxia when the perineum clearly hinders the delivery. Furthermore, we aim to compare the risk of severe perineal tears in this collective cohort to the population of the state of Hessen where the selective policy is followed.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis is a retrospective cohort study that includes all term vaginal singleton deliveries over a decade at the obstetrical unit of the Goethe-University Hospital of Frankfurt, which is a tertiary referral center. The study was approved by the local Ethics Committee (reference number 20\u0026ndash;840) and patient-specific consent was not required.\u003c/p\u003e \u003cp\u003eThe obstetrical medical records at our department are routinely and prospectively documented in an electronic database (GeDoWin\u0026reg;, Saatmann GmbH, Worms). This was utilized to identify eligible deliveries between January 1st, 2008 and December 31st, 2018. The inclusion criteria were singletons, completed 37 gestational weeks, cephalic or breech presentation, spontaneous, manually assisted and vaginal operative deliveries. Births with fetal abnormalities, small for gestational age, a prior cesarean section, gestational diabetes or other maternal co-morbidities were intentionally included. The exclusion criteria were multiplets and prematurity.\u003c/p\u003e \u003cp\u003eThe vaginal operative deliveries in our cohort include forceps deliveries and vacuum extractions. Forceps are used to guide the fetal head when delivery fails to progress or when there is a need to accelerate the second stage of labor [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our team mainly applies the Kielland forceps, which could additionally be used to overcome asynclitism [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Vacuum extraction is used in term deliveries to avoid fetal distress and resolve failure to progress, as well as when preclusion of voluntary maternal expulsive efforts is advised [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Manual assistance is limited to breech presentation where it might be indicated to support the necessary rotation of the shoulders, the delivery of the arms, or to increase deflection of the fetal head [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur deliveries are managed by a midwife and an obstetrician. All types of perineal tears are confirmed by the senior obstetrician to avoid misclassification. Episiotomies in the exposed group (EPI) were performed according to our super-selective policy only when the fetal head was crowning, fetal bradycardia present and the perineum is clearly hindering the delivery. Maternal and neonatal demographic variables such as age, weight, height, body mass index (BMI), gravidity, parity, gestational age, and the incidence of gestational diabetes were acquired for both the exposed and the non-exposed (NoEPI) groups. Further covariates included the presentation of the fetus, the duration of the stages of labor, the use of epidural analgesia, the type of episiotomy and induction of labor. Our database contained no missing data.\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe primary outcome\u003c/b\u003e of this study is the occurrence of severe perineal lacerations (third- and fourth-degree tears) as a binomial variable. Additionally, maternal blood loss is a continuous \u003cb\u003esecondary outcome\u003c/b\u003e that surrogates for maternal morbidity. For further comparative analysis, the reference data of Hessian hospitals, which adopt a selective episiotomy policy, were provided by the \u0026ldquo;\u003cem\u003ePerinatalerhebung Hessen\u003c/em\u003e\u0026rdquo; database (a standardized state-wide database collecting perinatal outcome data).\u003c/p\u003e \u003cp\u003eStatistical analysis is conducted with Stata\u003csup\u003e\u0026reg;\u003c/sup\u003e (ver. 16.1, Texas, USA) using Pearson\u0026rsquo;s chi-square test, two-sample t-test, univariate and multivariate logistic and linear regression. A p-value of 0.05 was considered as a cut-off for statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2008 and 2018, 10992 vaginal deliveries met our inclusion criteria. Practitioners performed an episiotomy in 171 (1.55%) deliveries. Overall, there were 7951 (72.3%) spontaneous vaginal deliveries, 2163 (19.6%) forceps deliveries, 19 (0.17%) vacuum extractions and 859 (7.8%) manually assisted deliveries. The median type of episiotomies accounted for 60.23%, the medio-lateral type for 37.42% and the lateral type for 2.34% of the episiotomies. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the descriptive statistics of both cohorts.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe descriptive statistics and demographic characteristics of the study cohorts. EPI: episiotomy cohort; NoEPI: control cohort; SD: standard deviation.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEPI\u003c/p\u003e\n\u003cp\u003efrequency (%) or\u003c/p\u003e\n\u003cp\u003emean \u0026plusmn; SD\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNoEPI\u003c/p\u003e\n\u003cp\u003efrequency (%) or\u003c/p\u003e\n\u003cp\u003emean \u0026plusmn; SD\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal number of observations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e171 (1.55%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10821 (98.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaternal age in years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 \u0026plusmn; 4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 \u0026plusmn; 5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.869\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGestation age in days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e280 \u0026plusmn; 8.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e279 \u0026plusmn; 7.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.300\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBirth weight in grams\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3410 \u0026plusmn; 446\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3391 \u0026plusmn; 451\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.57\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaternal BMI (kg/m2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.2 \u0026plusmn; 3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.7 \u0026plusmn; 4.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNulliparity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e136 (79.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5315 (49.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInduction of labor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (17.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1617 (14.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.34\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDuration of labor in minutes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e457 \u0026plusmn; 310\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e364 \u0026plusmn; 318\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGestational diabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (5.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e844 (7.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.21\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEpidural analgesia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97 (57%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4426 (40.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpontaneous delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7880 (72.82%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71 (41.52%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eForceps\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2092 (19.33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71 (41.52%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVacuum extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (0.16%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (1.17%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eManual extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e832 (7.69%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (15.79%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFetal presentation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRegular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9605 (88.76%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135 (78.95%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIrregular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e320 (2.96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (5.26%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.047\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBreech\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e896 (8.28%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (15.79%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between the exposed (EPI) and non-exposed (NoEPI) cohorts for maternal age (32 \u0026plusmn; 4.6 vs 32 \u0026plusmn; 5.0 years), gestational age (280 \u0026plusmn; 8.0 vs 279 \u0026plusmn; 7.8 days), birth weight (3410 \u0026plusmn; 446 vs 3391 \u0026plusmn; 451 grams), induction of labor (17.5% vs 14.9%) and gestational diabetes (5.3% vs 7.8%) respectively. The Body Mass Index (BMI) was lower in the EPI group compared to the NoEPI group (22.2 \u0026plusmn; 3.4 vs 23.7 \u0026plusmn; 4.8). The total duration of labor (first and second stage) was significantly longer in the EPI group (457 \u0026plusmn; 310 vs 364 \u0026plusmn; 318 minutes). Further, patients who experienced an episiotomy were more likely to be nulliparous and have an epidural analgesia.\u003c/p\u003e\n\u003cp\u003eCephalic presentation was the most common fetal position in both cohorts, but proportionally more regular cephalic presentation were observed in the noEPI group than the EPI group (88.76% vs 78.95% respectively). The irregular cephalic positions were almost twice as likely in the EPI than the NoEPI group (5.26% vs 2.96%). Similarly, breech presentation was about twice as likely in the EPI than the NoEPI group (15.79% vs 8.28%). This indicates that the episiotomy was positively associated with irregular presentations and positions.\u003c/p\u003e\n\u003cp\u003eEpisiotomy was performed in 0.89% of all spontaneous deliveries and 3.28% of patients with a vaginal operative delivery. In the EPI group, 58.5% of births ended in a vaginal operative delivery. This rate is significantly higher compared to 27.2% in the NoEPI group. In our study population, practitioners performed 2163 forceps deliveries; 2092 cases without an episiotomy (96.72%), 71 cases with an episiotomy (3.28%).\u003c/p\u003e\n\u003cp\u003eAs for the primary outcome, the noEPI cohort included 6003 (44.48%) with no tears, 4662 (43.08%) with mild (first- and second-degree), and 156 (1.44%) with severe perineal tears. The EPI cohort included 142 (83.04%) without tears, 26 (15.2%) with mild tears, and 3 (1.45%) with severe perineal tears. There is an association between having no perineal tears at all and episiotomy with a p-value of \u0026lt;\u0026thinsp;0.0001.\u003c/p\u003e\n\u003cp\u003eUnadjusted logistic regression showed that the odds ratio of severe perineal tears in the EPI cohort compared to the noEPI cohort was 1.22 (0.95 CI 0.39, 3.87 with 0.73 p-value). Multivariate logistic regression, while adjusting for statistically significant demographic differences, showed that the odds ratio of severe perineal tears in the EPI cohort compared to the noEPI cohort was 0.99 (0.95 CI 0.30, 3.26 with 0.98 p-value). The results of the multivariate logistic regression are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe results of multivariate logistic regression for the risk of third- and fourth-degree perineal tears among the EPI compared to the NoEPI cohorts.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSevere perineal tears\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOdds ratio\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e0.95 confidence interval\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerforming episiotomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.30, 3.26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.98\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaternal BMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94, 1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNulliparity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.68, 6.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDuration of labor in minutes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.99, 1.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.148\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEpidural analgesia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.58, 1.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpontaneous delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eomitted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eForceps\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.86, 16.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVacuum extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eManual extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.44, 7.48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFetal presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eomitted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIrregular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.59, 3.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.47\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBreech\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBlood loss was 268 \u0026plusmn; 180 ml in the NoEPI group and 344 \u0026plusmn; 284 in the EPI group. Simple linear regression showed that episiotomy led to an increase in blood loss of 75.88 ml (0.95 CI 46.75, 105 ml with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). This effect remained statistically significant after adjusting for possible confounders in a multivariate linear regression as shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe results of multivariate linear regression for the effect of episiotomy on blood loss.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBlood loss\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRegression coefficient\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e0.95 confidence interval\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerforming episiotomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34.34, 120.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaternal BMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.535, 1.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNulliparity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.97, 29.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDuration of labor in minutes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.02, 0.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEpidural analgesia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-6.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-20.14, 6.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.33\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpontaneous delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eomited\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eForceps\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e49.83, 79.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVacuum extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-79.31, 270.45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.284\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eManual extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-1.52, 35.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.072\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFetal presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eomited\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIrregular cephalic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-11, 48.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.216\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBreech\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntercept\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e243.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e214.22, 272.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom 2008 to 2018, 373.250 vaginal births were documented in the state of Hessen. As a result of a regional selective episiotomy policy, an average of 23% (0.95 CI 0.228, 0.23) of patients received an episiotomy while giving birth. This was significantly more than the 1.5% (0.95 CI 0.0128, 0.0175) for patients in our center. Regarding the primary outcome of interest, the average rate of severe perineal tears was 0.0143 (0.95 CI 0.0139, 0.0147) in Hessen versus 0.0145 (0.95 CI 0.0123, 0.0168) in our center [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe benefit of episiotomies for preventing higher grade perineal lacerations remains controversial [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although Cochrane analyses of different practices involving routine versus selective episiotomy have been published and have shown that performing fewer episiotomies during spontaneous vaginal delivery reduces the risk of higher-degree perineal trauma by 30% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], this contradicts several current recommendations that promote the protective role of episiotomy against higher graded tears [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, the findings of the Cochrane analyses suggest that a further reduction of severe perineal trauma can be achieved when episiotomies are entirely avoided, with few exceptions remaining. The likelihood of episiotomy in our study was 1.55% and episiotomies did not affect the risk of severe perineal tears. Nevertheless, they were associated with a trend for a higher risk of high degree perineal tears (0.0175) compared to the NoEPI group (0.0144), even though not statistically significant. This finding is consistent with nationwide data for 2014 where the percentage of episiotomy at 22.7% among 469258 vaginal births increased the risk of higher-grade perineal tears from 0.0104 to 0.0253 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, our study shows that episiotomies do not protect mothers from higher-degree perineal tears and consequently they do not improve maternal morbidity. On the contrary, they might be a cause of increased morbidity even if not statistically significant.\u003c/p\u003e \u003cp\u003eMost studies in current literature compare two different clinical practice protocols regarding the primary outcome of advanced perineal tears. Numerous studies compare routine to selective episiotomy use or to a cohort where episiotomies are almost completely avoided. Two randomized controlled trials focused on the implementation of a \u0026ldquo;non-episiotomy\u0026rdquo; protocol compared to \u0026ldquo;selective episiotomy\u0026rdquo; practice with the aim of limiting the episiotomies in clinical practice to an absolute minimum [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. While our study shares the same core idea with these trials, the episiotomy rate of both randomized trials was much higher than ours (around 20%) which was justified by non-compliance of practitioners to the non-episiotomy practice [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While these studies showed limited success towards their main goal, our study, although not a randomized controlled trial, is able to compare our \u0026ldquo;super-selective\u0026rdquo; episiotomy (1.55%) protocol to a \u0026ldquo;selective\u0026rdquo; (23%) protocol followed by the rest of the state-wide hospitals [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Therefore, this study is especially successful in comparing cohorts with fundementaly different episiotomy rates.\u003c/p\u003e \u003cp\u003eRegarding the primary outcome of interest, the rate of severe perineal lacerations was not significantly increased in our patients, which indicates that this super-selective policy does not endanger women by increasing short-term morbidity. An important limitation of our study is the lack of long-term follow-up to assess additional morbidity. Turmo et al. showed that 12.8% of women develop chronic pain after episiotomies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and others studies showed that sex life could also be negatively affected due to higher rates of dyspareunia and insufficient lubrication [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The episiotomy ratio was higher (3.28%) during vaginal operative deliveries, specifically forceps, compared to spontaneous delivery (0.89%). Operative deliveries increase the likelihood of practitioners\u0026rsquo; non-adherence to the super-selective episiotomy approach. This is probably caused by following the NICE/RCOG guidelines [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, it is unclear whether episiotomies during vaginal operative deliveries truly protect from severe perineal tears. De Leeuw et al. showed a higher risk for third degree perineal tears during vaginal operative deliveries and subsequently recommended the use of mediolateral episiotomy to reduce that risk [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Dandolu et al. on the other hand showed a significantly higher risk for perineal laceration during vaginal operative deliveries when an episiotomy was performed [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Similarly, Kudish et al. demonstrated an increased risk of anal sphincter injuries with the use of episiotomies during operative vaginal deliveries and recommended the avoidance of this combination [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Ecker et al. examined the effect of reducing the use of routine episiotomy for vaginal operative deliveries on the risk of high grade perineal tears and demonstrated an unchanged risk for third-degree lacerations with a decrease in the risk of fourth-degree lacerations [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In our department, forceps are removed before the fetal head passes the perineum as standard protocol in order to prevent perineal tears.\u003c/p\u003e \u003cp\u003eEpisiotomy increases blood loss by around 77 ml even after adjusting for all available confounders. This finding is expected as it had been observed in other studies [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, this statistically significant increase is not necessarily clinically significant and might not increase maternal morbidity.\u003c/p\u003e \u003cp\u003eIn conclusion, this study has shown that there is no increase in short-term maternal morbidity when episiotomies are used within a super-selective clinical approach. Regardless of this, the risk of severe perineal lacerations is low and we do not support the assumption that episiotomies prevent severe tears. Thus our findings provide evidence for adopting a super-selective clinical approach to episiotomies. They highlight the need to reevaluate episiotomy indications in obstetrical centers with the goal of reducing associated perineal trauma. This approach will protect women by reducing short- and eventually long-term morbidity. Our work has several weaknesses such as including mainly primigravids in the EPI group, which is not surprising. Nulliparous women are six times as likely to have an episiotomy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Another shortcoming is that our data didn\u0026rsquo;t allow investigation of the effect of episiotomy type on perineal tears, and studies reported that the outcomes in lateral and mediolateral episiotomies differ [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Finally, this is a retrospective cohort study and information bias, and unknown confounders remain a concern.\u003c/p\u003e \u003cp\u003eFuture randomized controlled trials with strict adherence to super-selective episiotomy use are necessary to further investigate maternal morbidity. Although our findings indicate a potential for episiotomies to increase maternal morbidity, we wish to emphasize that an episiotomy should not be \u0026ldquo;withheld in all circumstances\u0026rdquo; [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Rather, each indication should be critically considered and weighed against the possible drawbacks for mother and fetus.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003ewe would like to thank all our patients and colleagues who made this project possible. This study is part of a doctoral thesis for the first author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGazal Radner: project development, conduct, manuscript writing\u003c/p\u003e\n\u003cp\u003eLukas Jennewein: data analysis\u003c/p\u003e\n\u003cp\u003eD\u0026ouml;rthe Br\u0026uuml;ggmann: project development\u003c/p\u003e\n\u003cp\u003eFrank Louwen: design, project development\u003c/p\u003e\n\u003cp\u003eAmmar Al Naimi:\u003csup\u003e\u0026nbsp;\u003c/sup\u003edata analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e t\u003cem\u003ehe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eT\u003cem\u003ehe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e the study was approved by the local Ethics Committee (reference number\u0026nbsp;20-840)\u0026nbsp;and patient-specific informed consent was not required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database Syst Rev 1\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD000081.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD000081.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeyene F, Nigussie AA, Limenih SK, Tesfu AA, Wudineh KG (2020) Factors associated with episiotomy practices in Bahirdar City, Ethiopia: A cross-sectional study. Risk Manag Healthc Policy 13:2281\u0026ndash;2289. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/RMHP.S277657\u003c/span\u003e\u003cspan address=\"10.2147/RMHP.S277657\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, \u0026Oslash;ian P (2012) Episiotomy characteristics and risks for obstetric anal sphincter injuries: A case-control study. BJOG An Int J Obstet Gynaecol 119:724\u0026ndash;730. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1471-0528.2012.03293.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.2012.03293.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026auml;is\u0026auml;nen S, Vehvil\u0026auml;inen-Julkunen K, Heinonen S (2010) Need for and consequences of episiotomy in vaginal birth: A critical approach. Midwifery 26:348\u0026ndash;356. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.midw.2008.07.007\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2008.07.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagi-Dain L, Bahous R, Caspin O, Kreinin-Bleicher I, Gonen R, Sagi S (2018) No episiotomy versus selective lateral/mediolateral episiotomy (EPITRIAL): an interim analysis. Int Urogynecol J 29:415\u0026ndash;423. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00192-017-3480-7\u003c/span\u003e\u003cspan address=\"10.1007/s00192-017-3480-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagi-Dain L, Sagi S (2016) Indications for episiotomy performance - a cross-sectional survey and review of the literature. J Obstet Gynaecol J Inst Obstet Gynaecol 36:361\u0026ndash;365. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/01443615.2015.1065233\u003c/span\u003e\u003cspan address=\"10.3109/01443615.2015.1065233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSangkomkamhang U, Kongwattanakul K, Kietpeerakool C, Thinkhamrop J, Wannasiri P, Khunpradit S et al (2020) Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial. BJOG An Int J Obstet Gynaecol 127:397\u0026ndash;403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1471-0528.15982\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.15982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBansal RK, Tan WM, Ecker JL, Bishop JT, Kilpatrick SJ (1996) Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment. Am J Obstet Gynecol 175:897\u0026ndash;901. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0002-9378(96)80021-4\u003c/span\u003e\u003cspan address=\"10.1016/S0002-9378(96)80021-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;n İ, Doğan B, \u0026Ouml;zdamar \u0026Ouml; (2016) Long- and short-term complications of episiotomy. Turkish J Obstet Gynecol 13:144\u0026ndash;148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4274/tjod.00087\u003c/span\u003e\u003cspan address=\"10.4274/tjod.00087\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAPPROPRIATE TECHNOLOGY FOR BIRTH, Lancet (1985) ;326:436\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(85)92750-3\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(85)92750-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Maternal and Newborn Health/Safe Motherhood Unit. Les soins li\u0026eacute;s \u0026agrave; un accouchement normal: guide pratique : rapport d\u0026rsquo; un groupe de travail technique 1997\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlondel B, Alexander S, Bjarnad\u0026oacute;ttir RI, Gissler M, Langhoff-Roos J, Novak-Antolič Ž et al (2016) Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand 95:746\u0026ndash;754. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/aogs.12894\u003c/span\u003e\u003cspan address=\"10.1111/aogs.12894\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKozhimannil KB, Karaca-Mandic P, Blauer-Peterson CJ, Shah NT, Snowden JM (2017) Uptake and Utilization of Practice Guidelines in Hospitals in the United States: the Case of Routine Episiotomy. Jt Comm J Qual Patient Saf 43:41\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jcjq.2016.10.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jcjq.2016.10.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoueslard K, Cottenet J, Roussot A, Clesse C, Sagot P, Quantin C (2018) How did episiotomy rates change from 2007 to 2014? Population-based study in France. BMC Pregnancy Childbirth 18:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-018-1747-8\u003c/span\u003e\u003cspan address=\"10.1186/s12884-018-1747-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang H, Qian X, Carroli G, Garner P, OF FINDINGS FOR THE MAIN COMPARISON Selective versus routine use of episiotomy for vaginal birth (Review) SUMMARY.Cochrane Database Syst Rev2017:77. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD000081.pub3.\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD000081.pub3.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.cochranelibrary.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNassar AH, Visser GHA, Ayres-de-Campos D, Rane A, Gupta S (2019) FIGO Statement: Restrictive use rather than routine use of episiotomy. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 146:17\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ijgo.12843\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.12843\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNİCE NI for H and CE (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eACOG Practice Bulletin No (2015) 154: Operative Vaginal Delivery. Obstet Gynecol. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/AOG.0000000000001147\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000001147\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThacker SB, Banta HD (1983) Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860\u0026ndash;1980. Obstet Gynecol Surv 38:322\u0026ndash;338\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVayssire C, Beucher G, Dupuis O, Feraud O, Simon-Toulza C, Sentilhes L et al (2011) Instrumental delivery: Clinical practice guidelines from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol 159:43\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejogrb.2011.06.043\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2011.06.043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel RR, Murphy DJ (2004) Forceps delivery in modern obstetric practice. Br Med J 328:1302\u0026ndash;1305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.328.7451.1302\u003c/span\u003e\u003cspan address=\"10.1136/bmj.328.7451.1302\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNash Z, Nathan B, Mascarenhas L (2015) Kielland\u0026rsquo;s forceps. from controversy to consensus? Acta Obstet Gynecol Scand 94:8\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/aogs.12511\u003c/span\u003e\u003cspan address=\"10.1111/aogs.12511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePutta LV, Spencer JP (2000) Assisted vaginal delivery using vacuum extractor. Am Fam Physician 62:1316\u0026ndash;1320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVacca A (1999) The trouble with vacuum extraction. Curr Obstet Gynaecol 9:41\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/S0957-5847(99)90072-0\u003c/span\u003e\u003cspan address=\"10.1016/S0957-5847(99)90072-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJennewein L, Allert R, M\u0026ouml;llmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ et al (2019) The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term \u0026ndash; A FRABAT prospective cohort study. PLoS ONE 14:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0225546\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0225546\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGmbh G (2014) Geburtshilfe Jahresauswertung 2014:1\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp JJ, Lohr KN (2005) Outcomes of routine episiotomy: a systematic review. JAMA 293:2141\u0026ndash;2148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.293.17.2141\u003c/span\u003e\u003cspan address=\"10.1001/jama.293.17.2141\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Leeuw JW, De Wit C, Kuijken JPJA, Bruinse HW (2008) Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG An Int J Obstet Gynaecol 115:104\u0026ndash;108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1471-0528.2007.01554.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.2007.01554.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAQUA-Institut. Bundesauswertung zum Erfassungsjahr 2014 -Geburtshilfe. 2015:1\u0026ndash;117\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmorim M, Coutinho M, Melo IC, Katz I (2017) Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprod Health 14:55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12978-017-0315-4\u003c/span\u003e\u003cspan address=\"10.1186/s12978-017-0315-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurmo M, Echevarria M, Rubio P, Almeida C (2015) Development of chronic pain after episiotomy. Rev Espa\u0026ntilde;ola Anestesiol y Reanim (English Ed 62:436\u0026ndash;442. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.redare.2015.03.002\u003c/span\u003e\u003cspan address=\"10.1016/j.redare.2015.03.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEjeg\u0026aring;rd H, Ryding EL, Sj\u0026ouml;gren B (2008) Sexuality after delivery with episiotomy: A long-term follow-up. Gynecol Obstet Invest 66:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000113464\u003c/span\u003e\u003cspan address=\"10.1159/000113464\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandit B (2013) The Management of Third- and Fourth-Degree Perineal Tears. Man Vaginal Surg 119\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5005/jp/books/12041_14\u003c/span\u003e\u003cspan address=\"10.5005/jp/books/12041_14\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HCS (2001) Risk factors for third degree perineal ruptures during delivery. Br J Obstet Gynaecol. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0306-5456(00)00090-5\u003c/span\u003e\u003cspan address=\"10.1016/S0306-5456(00)00090-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E Risk factors for obstetrical anal sphincter lacerations.Int Urogynecol J 2005. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00192-005-1297-2\u003c/span\u003e\u003cspan address=\"10.1007/s00192-005-1297-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger M, Hendrix SL et al (2006) Operative vaginal delivery and midline episiotomy: A bad combination for the perineum. Am J Obstet Gynecol 195:749\u0026ndash;754. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajog.2006.06.078\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2006.06.078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEcker JL, Tan WM, Bansal RK, Bishop JT, Kilpatrick SJ (1997) Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population. Am J Obstet Gynecol 176:411\u0026ndash;414. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0002-9378(97)70507-6\u003c/span\u003e\u003cspan address=\"10.1016/S0002-9378(97)70507-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaksu B, Davas I, Akyol A, Ozgul J, Ezen F (2008) Effect of timing of episiotomy repair on peripartum blood loss. Gynecol Obstet Invest 65:169\u0026ndash;173. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000111138\u003c/span\u003e\u003cspan address=\"10.1159/000111138\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRusavy Z, Karbanova J, Kalis V (2016) Timing of episiotomy and outcome of a non-instrumental vaginal delivery. Acta Obstet Gynecol Scand 95:190\u0026ndash;196. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/aogs.12814\u003c/span\u003e\u003cspan address=\"10.1111/aogs.12814\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagi-Dain L, Sagi S (2015) The correct episiotomy: does it exist? A cross-sectional survey of four public Israeli hospitals and review of the literature. Int Urogynecol J 26:1213\u0026ndash;1219. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00192-015-2680-2\u003c/span\u003e\u003cspan address=\"10.1007/s00192-015-2680-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"episiotomy, perineal tears, instrumental delivery","lastPublishedDoi":"10.21203/rs.3.rs-2894336/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2894336/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eOur aim is to investigate the risk of short-term maternal morbidity caused by super-selective clinical use of episiotomies (rate of below 0.02). A secondary aim is to compare our risk of severe perineal tears to the state-wide risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis is\u003cstrong\u003e \u003c/strong\u003ea retrospective cohort study investigating the effect of super-selective episiotomy on the risk of severe perineal tears and blood loss.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study included 10992 women who delivered between 2008-2018. Episiotomies were performed in 171 cases (1.56%), 3 of which (1.75%) experienced severe perineal tears compared to 156 (1.44%) in the control cohort. The adjusted odds ratio of severe perineal tears was 0.99 (0.95 CI 0.30, 3.26 p-value 0.98). Multivariate linear regression showed that episiotomies increased blood loss by 77.47 ml (0.95 CI 34.34, 120.59 p-value \u0026lt;0.0001). Episiotomies were performed in 23% (0.95 CI 0.228, 0.23) of vaginal deliveries in the state of Hessen with a risk of severe perineal tears of 0.0143 (0.95 CI 0.0139, 0.0147) compared to 0.0145 (0.95 CI 0.0123, 0.0168) in our entire cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Institutionally implemented super-selective use of episiotomy does not increase the risk of higher-grade perineal tears but leads to increased blood loss. Therefore, episiotomies potentially increase maternal morbidity.\u003c/p\u003e","manuscriptTitle":"The impact of super-selective episiotomy on maternal short-term morbidity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-02 04:18:57","doi":"10.21203/rs.3.rs-2894336/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8bf014f0-21e2-48a7-b246-e5e0b13d18fb","owner":[],"postedDate":"June 2nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-07-11T20:23:54+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-02 04:18:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2894336","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2894336","identity":"rs-2894336","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}