https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)60462-0.pdf

Pelvic organ prolapse

Background
Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear.

Objectives
The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008).

Selection criteria
Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy.

Data collection and analysis
The two review authors independently assessed trial quality and extracted the data.

Main results
We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison.

Authors' conclusions
Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

/pdf/episiotomy-for-vaginal-birth-4mxfdb9j0o.pdf

Episiotomy for vaginal birth

Epidemiology and natural history of pelvic floor dysfunction

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(06)67925-7.pdf

Urinary incontinence in women

Women's sexual health after childbirth

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation

Objective To compare the outcomes of the current practice of liberally or routinely employing episiotomy to prevent perineal tears and pelvic floor relaxation (control group) to a policy of restricting episiotomy use to specific fetal and maternal indications (experimental group). Design A randomized controlled trial (RCT). Setting Three university hospitals in Montreal. Subjects Seven hundred three low-risk women enrolled at 30 to 34 weeks of gestation were randomized late in labor to the designated trial arm, by parity, and followed up to 3 months postpartum. Main outcome measures Antepartum and postpartum information on perineal trauma and pain, pelvic floor symptoms (urinary incontinence), and sexual activity was collected through the use of standard questionnaires; pelvic floor function was measured by electromyographic (EMG) perineometry. Results Restricting episiotomy use in primiparous women was associated with similar sutured perineal trauma to the liberal or routine approach. Multiparous women in the restricted episiotomy group more often gave birth with an intact perineum (31% compared with 19%, odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.09 to 3.16). All but one 3rd/4th-degree perineal tear was associated with median episiotomy (46 of 47 in primiparous women and 6 of 6 among multiparous women). No difference between trial groups was found in postpartum perineal pain, antepartum and 3-month postpartum EMG perineometry, and urinary and pelvic floor symptoms. Conclusions We found no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation. Virtually all severe perineal trauma was associated with median episiotomy. Restriction of episiotomy use among multiparous women resulted in significantly more intact perineums and less perineal suturing.

Does episiotomy prevent perineal trauma and pelvic floor relaxation

Determinants of vaginal-perineal integrity and pelvic floor functioning in childbirth

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Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation

Does episiotomy prevent perineal trauma and pelvic floor relaxation

Does episiotomy prevent perineal trauma and pelvic floor relaxation

Determinants of vaginal-perineal integrity and pelvic floor functioning in childbirth