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INTRODUCTION AND HYPOTHESIS: The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy. METHODS: This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening. RESULTS: Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups. CONCLUSIONS: In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.
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Background Perineal lacerations are feared complications of vaginal delivery, especially the severe types (third- and fourth-degree tears). World Health Organization (WHO) recommended restrictive episiotomy practice after alarming literature linked the increase in severe tears with routine episiotomy. Therefore, this study aimed to measure the association between episiotomy and the incidence of third- and fourth-degree perineal tears and infections in women who underwent episiotomy versus those who did not at a tertiary care center implementing the restrictive episiotomy policy in Jeddah, Saudi Arabia. Methods This retrospective cohort study was conducted in the Department of Obstetrics and Gynecology at King Abdulaziz Medical City (KAMC), Western Region, between May 2016 and May 2018, targeting all pregnant women who underwent normal spontaneous vaginal delivery. The nonprobability convenient sampling technique was used for women who underwent episiotomy. Women without episiotomy (control group) were randomly selected in a 1:1 ratio. The prevalence (incidence) of episiotomy and its association with severe perineal tears were measured. Statistical data were analyzed using SPSS version 27 (IBM Corp., Armonk, NY). A p-value of less than 0.05 was considered significant. Result A total of 7436 deliveries were recorded. At KAMC, episiotomy had a prevalence of 10% and was more common in primipara. The incidence of third-degree tears was 3.3% in the episiotomy group and 0.8% in the control group (odds ratio, 4.1; p = 0.03). None had fourth-degree tears. Furthermore, the infection rate was not significantly different between the two groups (0.1% vs. 0.1%). Using Firth's logistic regression model, primipara emerged as an independent significant risk factor (OR, 3.5 [1.1-11.2]; p = 0.035) while the trend toward increased risk for tear development in the episiotomy group became statistically insignificant (OR, 2.3 [0.7-8.0]; p = 0.19). A post hoc examination to observe the association between episiotomy exposure and BMI using a stepwise logistic regression model showed that parity and age were independent risk factors for episiotomy, with OR values of 2.2 (1.6-3.2) and 0.9 (0.88-0.94), respectively (p < 0.001). The BMI became insignificant, with an OR of 1.0 (0.7-1.4) (p = 0.96). Conclusion The development of severe perineal tears in a center with a restrictive episiotomy policy is rare. Parity has emerged as an independent risk factor for severe perineal tears. Prospective multicenter research with a larger sample size is recommended to validate this study's findings further and investigate other obstetric measures to reduce severe tears in primi mothers.
