Imaging Characteristics of Episiotomy Scars on Translabial Ultrasound: An Observational Study.

INTRODUCTION: Episiotomy has been purported to protect the anal sphincter from injury; efficacy is, however, disputed. Correct execution of episiotomy may have substantial implications. We aimed to describe the characteristics of episiotomy scars on translabial ultrasound (TLUS). METHODS: In this retrospective observational study involving women after repair of obstetric anal sphincter injuries, 76 women with a history of episiotomy were analyzed. Episiotomy scars were assessed on tomographic ultrasound in the transverse plane using volumes acquired on pelvic floor muscle contraction. We measured scar length, depth, and angle relative to a vertical reference line. Episiotomy scars were described as 1) ipsilateral if they started on the same side as the direction of the episiotomy, 2) contralateral if on the opposite side, and 3) mediolateral if the scar began in the midline. RESULTS: The mean scar angle was 50.5° (SD 14°; range 14.4°-79.3°) while mean scar length was 14.2 mm (SD 4.5; range 5.7-27.5 mm) and depth was 8.4 mm (SD 2.8, range 3.1-18.2 mm). Sixteen (21%) scars were located mediolateral while 32 (42%) were ipsilateral. In 28 (37%) women, the starting point of the episiotomy was located contralateral to the direction of the episiotomy. CONCLUSION: In this pilot series, the mean angle of episiotomy scars was within the safe zone of 40° to 60°, however, in one-third of cases the cut may have been initially directed toward the sphincter, not away from it. This observation suggests that not all episiotomies are performed optimally.

Which characteristics of the episiotomy and perineum are associated with a lower risk of obstetric anal sphincter injury in instrumental deliveries.

OBJETIVE: Operative vaginal delivery (OVD) is the most important risk fact for obstetric anal sphincter injury (OASI). Knowledge of possible risk factors for their occurrence may therefore reduce the likelihood of faecal incontinence. The aim is to analyse the effect of mediolateral episitomy and perineum characteristics on the occurrence of OASI in OVD. STUDY DESIGN: Case-control study, which included 958 OVD that were reviewed in Pelvic Floor and Puerperium Clinic. The episiotomy and perineum characteristics of those women who experienced OASIs (n = 150) were compared with those who had no evidence of anal sphincter injury (n = 788). RESULTS: In multivariate logistic regression analysis the factors which were independently associated were nulliparity, persistent occipitoposterior position, birthweight >3500 g, an angle of episiotomy <30°, a distance episiotomy-fourchette <5 mm and a distance of perineal body <30 mm. The analysis of subgroups show that only the multiparous women does not benefit from any feature of the episiotomy, and an angle greater than 30° and a distance episiotomy-fourchette >5 mm are associated with a risk reduction of OASI in nulliparous, perineal bodies ≤30 mm and occipitoanterior position. CONCLUSIONS: Two modifiable risk factors at the time of performing the episiotomy, the angle and distance episiotomy-fourchette, have been identified as the risk modification of OASI. It is necessary to achieve an adequate angle to reduce the probability of OASIs in OVD, and in nulliparous women with an anterior position and a distance of perineal body ≤30 mm could benefit from increasing the episiotomy-fourchette distance.

Behavior of perineum during delivery before fetal head expulsion.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to describe perineum deformation during the final part of delivery and suggest a modification of the episiotomy cut to increase accuracy for obtaining a suitable angle (45°) for surgical wound suture. METHODS: This prospective study enrolled 45 primiparous women. The perineum at rest was marked with five lines (0°, 30°, 45°, 60°, 90°), and each line was marked with two dots (point A-B: to 2-3 cm from initial point in fourchette, respectively). Two digital pictures were taken: one with the women at rest and the second during fetal head crowning; displacements were calculated for each point and angle. RESULTS: When the perineum is distending, the initial point of every line in the posterior fourchette moves laterally in introitus (only the 0° line remains at midline). The angle and the distance to points A and B of each line drawn do not change significantly from at rest to crowning. However, comparing original line configuration with an imaginary line from the fourchette to points A and B before expulsion, the angle and the distance is increased statistically significantly. CONCLUSIONS: Perineal distension at the moment of fetal head crowning causes a linear displacement of the perineum, which causes the difference in angle between the incision and episiotomy suture. Therefore, to obtain an episiotomy suture from fourchette with an angle of 45°, theoretically, we would have several angle incision options (between 45° and 60°), with a less acute angle when the introitus cut is closer to the fourchette (45° to 6 mm and ∼60° in the fourchette) and a sharper angle with a longer episiotomy.

Episiotomy preferences, indication, and classification--a survey among Nordic doctors.

INTRODUCTION: Episiotomy performance impacts perineal health and rates of obstetric anal sphincter injuries (OASIS). Our objective was to assess self-reported episiotomy practice and opinions on clinical indication for episiotomy among Nordic physicians and to investigate potential misclassification. MATERIAL AND METHODS: A survey was conducted among doctors attending the 2012 Nordic obstetrical and gynecological conference. Participants were asked to draw an episiotomy on a photo of a perineum with a crowning fetal head similarly to their clinical practice if an episiotomy was clinically indicated, and to name the technique drawn. Differences in outcome measures were compared by country of practice and seniority. RESULTS: The majority of the 297 participants (47%) drew a lateral episiotomy according to our classification by incision point and angle, but as many as 64% of these 138 doctors misclassified this as mediolateral episiotomy. Only 20% drew a mediolateral episiotomy, the great majority classifying it accurately, but 8% misclassified their mediolateral cut as a lateral episiotomy. One-third of episiotomies were nonclassifiable. In general, doctors in Finland, Sweden, and Norway more often favored lateral episiotomies compared with doctors in Denmark and Iceland. There were significant differences between Finnish and Norwegian vs. Danish and Swedish doctors in perception of clinical indications for episiotomy. CONCLUSIONS: The great variation in self-reported episiotomy performance between Nordic physicians and large misclassification rates indicate that educational programs are warranted. Use of uniform classification and appropriate techniques may be crucial to investigate the role of episiotomies in preventing OASIS.

Differences in characteristics of mediolateral episiotomy in proffesionals at the same hospital.

OBJECTIVES: The objective of our study was to compare the theoretical concept of the accoucheur in our institution with regard to the characteristics of the mediolateral episiotomy (MLE), with a crowning head and after a delivery. METHODS: We devised two simple pictorial questionnaires (one with a crowning head and the other in rest after a delivery) in order to explore possible differences in clinical practice between the accoucheurs of our institution with respect to the MLE characteristics. RESULTS: With a crowning head, we found more acute angles when the age of accoucheurs was greater than 35 years old and more than 15 years of experience, but no with the perineum at rest. No difference was found between doctors and midwives, nor between males and females. 28.1% of accoucheurs indicated an acuter episiotomy angle with a crowning head. CONCLUSION: This study confirmed that the individual interpretation of MLE differed widely among professionals at the same hospital. These differences which have been shown could predispose women to a greater risk of anal sphincter injuries. For this reason, there is a need to standardize this practice, to make the technique more homogeneous, particularly in the context of future research into the risks and benefits of episiotomy with respect to major perineal trauma.