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Cochrane Database of Systematic Reviews

Selective versus routine use of episiotomy for vaginal birth

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DOI:
https://doi.org/10.1002/14651858.CD000081.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 08 February 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2017 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
  2. This is an open access article under the terms of the Creative Commons Attribution‐Non‐Commercial Licence, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

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Authors

  • Hong Jiang

    Correspondence to: Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai, China

    [email protected]

    [email protected]

  • Xu Qian

    Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai, China

  • Guillermo Carroli

    Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina

  • Paul Garner

    Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK

Contributions of authors

Hong Jiang and Xu Qian screened all the searches, assessed risk of bias, and extracted data from included studies. Hong Jiang and Xu Qian drafted the review. Paul Garner provided critical comments on the revised protocol sections, helped structure the review, assess, summarise and synthesise the data, helped write the review, conducted the GRADE assessment. Guillermo Carroli provided critical comments on the review. All authors reviewed and agreed the final version of the review.

Sources of support

Internal sources

  • Centro Rosarino de Estudios Perinatales, Rosario, Argentina.

  • Liverpool School of Tropical Medicine, UK.

  • School of Public Health, Fudan University, China.

External sources

  • UK Aid (grant 5242), UK.

  • UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.

Declarations of interest

Hong Jiang received support from the Effective Health care Research Consortium, funded by UK aid from the UK government for the benefit of developing countries (Grant: 5242) ‐ this award was paid to Hong Jiang's institution and was used to support the preparation of this review.

Xu Qian received support from the Effective Health care Research Consortium, funded by UK aid from the UK government for the benefit of developing countries (Grant: 5242) ‐ this award was paid to Xu Qian's institution and was used to support the preparation of this review.

Guillermo Carroli is the principal investigator on a large trial included in this review. Risk of bias assessment, data extraction were carried out by authors independent of GC. PG provided oversight on expression of data from this trial and interpretation of its findings with regard to this potential conflict of interest.

Paul Garner is the Director of the Effective Health Care Research Programme Consortium, a DFID funded research programme that aims to increase the number of decisions in low and middle income countries based on reliable evidence.

Acknowledgements

Authors are thankful to Katrina W Tsang, Luciano Mignini, Qin Liu and Chunyi Gu for their consultancy and technical support during the review writing.

This review is supported by the Effective Health Care Research Consortium, funded by UK aid from the UK Government for the benefit of developing countries (Grant: 5242).

As part of the pre‐publication editorial process, this review has been commented on by two peers (an editor and referee who is external to the editorial team), members of Cochrane Pregnancy and Childbirth's international panel of consumers, and the Group's Statistical Adviser.

This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2017 Feb 08

Selective versus routine use of episiotomy for vaginal birth

Review

Hong Jiang, Xu Qian, Guillermo Carroli, Paul Garner

https://doi.org/10.1002/14651858.CD000081.pub3

2009 Jan 21

Episiotomy for vaginal birth

Review

Guillermo Carroli, Luciano Mignini

https://doi.org/10.1002/14651858.CD000081.pub2

1999 Jul 26

Episiotomy for vaginal birth

Review

Guillermo Carroli, Jose Belizan

https://doi.org/10.1002/14651858.CD000081

Differences between protocol and review

We removed Objective 2 of the protocol, "to compare midline and mediolateral episiotomy" since we found it inappropriate to include this objective in the course of writing the review, as the topic 'selective versus routine episiotomy for vaginal birth' and which procedure is used are two different topics. We did look in a subgroup analysis for evidence of a difference in effects depending on the procedure, but there was no obvious pattern. We think it better to carry out another independent review to make this comparison, although we did not find eligible studies comparing these two surgical procedures.

In the protocol, the primary outcome was described as "Severe perineal trauma including, severe vaginal trauma, or severe perineal and vaginal trauma (third‐ or fourth‐degree trauma, irrespective of allocated group, as defined in the background)". We noted during the review that it was a little ambiguous as to where this actually included vaginal trauma, so we altered the descriptor slightly to make this explicit.

In the protocol we included "first or second degree perineal trauma". This outcome is uninformative as it excludes women with severe trauma. The outcome, "any trauma" is also uninformative as the control group expects women to receive an episiotomy, which is in effect "second degree trauma" but would not be reported as such. We therefore dropped this outcome.

Since the previous version of this review, we have changed the title from 'Episiotomy for vaginal birth' to 'Selective versus routine use of episiotomy for vaginal birth' for clarity about the scope of the review.

Since only one trial reported perineal pain measured by visual analogue scale, we also reported pain at different time points by any measure of interest. We think this would be informative for clinical practice.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

The rationale commonly used to justify routine episiotomy
Figures and Tables -
Figure 1

The rationale commonly used to justify routine episiotomy

Study flow diagram
Figures and Tables -
Figure 2

Study flow diagram

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figures and Tables -
Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Funnel plot of comparison: 1 Restrictive versus routine episiotomy (planned non‐instrumental), outcome: 1.1 Severe perineal/vaginal trauma
Figures and Tables -
Figure 5

Funnel plot of comparison: 1 Restrictive versus routine episiotomy (planned non‐instrumental), outcome: 1.1 Severe perineal/vaginal trauma

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 1 Severe perineal/vaginal trauma.
Figures and Tables -
Analysis 1.1

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 1 Severe perineal/vaginal trauma.

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 2 Severe perineal/vaginal trauma (grouped by trial implementation success).
Figures and Tables -
Analysis 1.2

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 2 Severe perineal/vaginal trauma (grouped by trial implementation success).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 3 Blood loss at delivery (mL).
Figures and Tables -
Analysis 1.3

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 3 Blood loss at delivery (mL).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 4 Newborn Apgar score < 7 at 5 minutes.
Figures and Tables -
Analysis 1.4

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 4 Newborn Apgar score < 7 at 5 minutes.

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 5 Perineal infection.
Figures and Tables -
Analysis 1.5

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 5 Perineal infection.

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 6 Moderate or severe pain (visual analogue scale).
Figures and Tables -
Analysis 1.6

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 6 Moderate or severe pain (visual analogue scale).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 7 Dyspareunia long term (≥ 6 m).
Figures and Tables -
Analysis 1.7

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 7 Dyspareunia long term (≥ 6 m).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 8 Genital prolapse long term (≥ 6 m).
Figures and Tables -
Analysis 1.8

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 8 Genital prolapse long term (≥ 6 m).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 9 Urinary incontinence long term (≥ 6 m).
Figures and Tables -
Analysis 1.9

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 9 Urinary incontinence long term (≥ 6 m).

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 10 Need for perineal suturing.
Figures and Tables -
Analysis 1.10

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 10 Need for perineal suturing.

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 11 Admission to special care baby unit.
Figures and Tables -
Analysis 1.11

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 11 Admission to special care baby unit.

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 12 Pain at different time points (any measure).
Figures and Tables -
Analysis 1.12

Comparison 1 Restrictive versus routine episiotomy (where non‐instrumental was intended), Outcome 12 Pain at different time points (any measure).

Comparison 2 Restrictive versus routine episiotomy (non‐instrumental, subgroup by parity), Outcome 1 Severe perineal/vaginal trauma.
Figures and Tables -
Analysis 2.1

Comparison 2 Restrictive versus routine episiotomy (non‐instrumental, subgroup by parity), Outcome 1 Severe perineal/vaginal trauma.

Comparison 3 Restrictive versus routine episiotomy (non‐instrumental, subgroup midline‐midlateral), Outcome 1 Severe vaginal/perineal trauma.
Figures and Tables -
Analysis 3.1

Comparison 3 Restrictive versus routine episiotomy (non‐instrumental, subgroup midline‐midlateral), Outcome 1 Severe vaginal/perineal trauma.

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 1 Severe perineal/vaginal trauma.
Figures and Tables -
Analysis 4.1

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 1 Severe perineal/vaginal trauma.

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 2 Apgar < 7 at 5 minutes.
Figures and Tables -
Analysis 4.2

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 2 Apgar < 7 at 5 minutes.

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 3 Perineal infection.
Figures and Tables -
Analysis 4.3

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 3 Perineal infection.

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 4 Moderate/severe dyspareunia long term (≥ 6 m).
Figures and Tables -
Analysis 4.4

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 4 Moderate/severe dyspareunia long term (≥ 6 m).

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 5 Urinary incontinence long term (≥ 6 m).
Figures and Tables -
Analysis 4.5

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 5 Urinary incontinence long term (≥ 6 m).

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 6 Admission to special care baby unit.
Figures and Tables -
Analysis 4.6

Comparison 4 Restrictive versus routine episiotomy (operative vaginal birth was intended), Outcome 6 Admission to special care baby unit.

Summary of findings for the main comparison. Selective versus routine episiotomy: all vaginal births where operative vaginal delivery was not anticipated

Selective versus routine episiotomy: all vaginal births where operative vaginal delivery was not anticipated

Patient or population: Women in labour where operative delivery was not anticipated. (Women were above 16 years old and between 28 gestational weeks and full term, with a live singleton fetus, without severe medical or psychiatric conditions, and had vaginal birth.)
Setting: Hospitals in high‐, middle‐ and low‐income countries. (Studies were carried out between July 1982 and October 2009, in Argentina, Canada, Columbia, Germany, Ireland, Malaysia, Pakistan, Saudi Arabia, Spain, and the UK. Five studies were carried out in university teaching hospitals, and one of these five studies recruited some participants from a mid‐complexity level hospital. The other six studies were conducted in maternity units with inadequate information to judge the institution's level.)

Intervention: Selective episiotomy (episiotomy rates in the selective group ranged from 8% to 59%).

Comparison: Routine episiotomy (episiotomy rates in the routine group ranged from 61% to 100%; episiotomy rate differences between the groups within trials varied from 21% to 91%).

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with routine episiotomy

Risk with selective episiotomy

Severe perineal/vaginal trauma

3.6 per 100

2.5 per 100
(1.9 to 3.4)

RR 0.70
(0.52 to 0.94)

5375
(8 RCTs)

⊕⊕⊝⊝
low1,2,3

due to imprecision and inconsistency

Selective episiotomy compared to routine may reduce severe perineal/vaginal trauma

Blood loss at delivery

The mean blood loss at delivery was 278 mL

27 mL less (95% CI from 75 mL less to 20 mL more)

336
(2 RCTs)

⊕⊝⊝⊝

very low4,5,6

due to risk of bias, imprecision and inconsistency

We do not know if selective episiotomy compared to routine affects blood loss at delivery

Babies with newborn Apgar score < 7 at 5 minutes

0 per 100

0 per 100

no events

501
(2 RCTs)

⊕⊕⊕⊝

moderate7,8

Due to imprecision

Both selective episiotomy and routine probably has little or no effect on Apgar < 7 at 5 minutes

Perineal infection

2 per 100

2 per 100
(0.9 to 3.6)

RR 0.90
(0.45 to 1.82)

1467
(3 RCTs)

⊕⊕⊝⊝
low9

Due to imprecision

Selective episiotomy compared to routine may result in little or no difference in perineal infection

Women with moderate or severe pain (measured by visual analogue scale)

45.1 per 100

32 per 100
(21.6 to 47.3)

RR 0.71
(0.48 to 1.05)

165
(1 RCT)

⊕⊝⊝⊝
very low10,11,12

Due to imprecision and indirectness

We do not know if selective episiotomy compared to routine results in fewer women with moderate or severe perineal pain

Women with long‐term dyspareunia (≥ 6 months)

12.9 per 100

14.8 per 100
(10.9 to 19.8)

RR 1.14
(0.84 to 1.53)

1107
(3 RCTs)

⊕⊕⊕⊝
moderate13

Due to imprecision

Selective episiotomy compared to routine probably results in little or no difference in women with dyspareunia at > 6 months

Women with long‐term urinary incontinence

(≥ 6 months)

32.2 per 100

31 per 100
(21.5 to 46.3)

RR 0.98
(0.67 to 1.44)

1107
(3 RCTs)

⊕⊕⊝⊝
low13,14

Due to risk of bias and imprecision

Selective episiotomy compared to routine results may have little or no difference in the number of women with urinary incontinence > 6 months

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)

CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Downgraded by 1 for imprecision: confidence intervals range from no important difference to large difference.
2Downgraded by 1 for heterogeneity: there is moderate heterogeneity. Random‐effects model gives confidence intervals that cross 1 (RR 0.67, 95% CI 0.41 to 1.09). However, a subgroup analysis shows that the selective episiotomy has been well implemented (episiotomy rate difference between intervention and control > 30%) there was a more substantial effect (RR 0.55, 95% CI 0.38 to 0.81; 8 trials; n = 4877).
3Funnel plot suggests publication bias with small studies showing that routine episiotomy results in higher perineal trauma.
4Downgraded by 1 for risk of bias: both studies used visual inspection with no specific training, but visual EBL consistently results in underestimation of large volumes and over estimation of large volumes.
5Downgraded by 1 for imprecision: confidence intervals range from no important average loss to an important average loss
6Downgraded by 1 for inconsistency: large, probably clinically important effect in 1 trial and no effect evident in the other trial
7Downgraded by 1 for imprecision as there were no events. Risk difference 0.0 (‐0.01 to 0.01). The risk difference provides confidence intervals indicating we are confident in there being little or no difference, although for rare but important events a larger sample size is required.
8Apgar < 7 at 1 minute was measured in 4 trials, with RR 1.04 (95% CI 0.76 to 1.43), with no detectable heterogeneity.
9Downgraded by 2 for imprecision: few events, and CI included appreciable benefit and harm. (The analysis is under‐powered to detect a difference between groups; the sample size required to half 2% infection rate in the control group to 1% in the intervention group with 90% power at 5% significance would be 6202)
10Downgraded by 2 for imprecision: sample size to lower the 30% pain in the selective episiotomy compared to routine would need a total size of 586 with 90% power at 5% significance level, and wide confidence intervals from substantively fewer to no fewer
11Downgraded by 1 for indirectness: only one trial conducted 32 years ago. Conditions, expectations, and pain relief strategies have changed, and we don't know how representative this trial is.
12Additional trials report on average pain scores in the first 5 days, in a total of 355 women. Pain scores in all 3 trials were similar between the 2 groups (additional table 5).
13Downgraded by 1 for imprecision: confidence intervals have a wide range.
14Downgraded by 1 for risk of bias: 3 trials included, 2 trials, 1 with small sample size and 1 with large sample size had high rate of loss to follow‐up, around 35%, 1 trial with large sample size had low loss to follow‐up, less than 10%.

Figures and Tables -
Summary of findings for the main comparison. Selective versus routine episiotomy: all vaginal births where operative vaginal delivery was not anticipated
Table 1. Included studies: parity, operative vaginal delivery and period of follow‐up

Trial

Primigravidae

Follow‐up

N

per cent (%)

Immediate (< 1 month)

Short‐term (1‐6 months)

Long‐term (≥ 6 months)

Ali 2004

200

100

Discharge & day 7

No data

No data

Belizan 1993

1555/2606

60a

Discharge & day 7

No data

No data

Dannecker 2004

146

100

Discharge

Several months

A mean follow‐up time of 7.3 months (SD 3.4)

Eltorkey 1994

200

100

Delivery only

No data

No data

Harrison 1984

181

100

4 days

6 weeks

No data

House 1986

98/165

59

3 days

3 months

No data

Juste‐Pina 2007

402

100

No data

3 months

3 years

365/402 (91%)

Klein 1992

356/703

51

Discharge

3 months

No data

Murphy 2008b

200

100

Discharge

6 weeks

1 year

Rodriguez 2008

446

100

Delivery only

N

No data

Sleep 1984

420/1000

42

2 & 10 days

3 months

3 years

Sulaiman 2013

209

100

Delivery only

No data

No data

aStratified analysis (primary outcome only)

Figures and Tables -
Table 1. Included studies: parity, operative vaginal delivery and period of follow‐up
Table 2. Episiotomy rates for included studies (non‐operative vaginal delivery anticipated)

Trial

Selective

Routine

Difference (%)

n/N

%

n/N

%

Klein 1992

124/349

36

198/349

57

21

Juste‐Pina 2007

118/200

59

169/202

84

25

Eltorkey 1994

53/100

53

83/100

83

30

Dannecker 2004

20/49

41

46/60

77

36

Sleep 1984

51/498

10

258/502

51

41

House 1986

17/94

18

49/71

69

51

Belizan 1993

391/1298

30

1080/1308

83

53

Sulaiman 2013

39/89

44

82/82

100

56

Ali 2004

32/100

32

100/100

100

68

Rodriguez 2008

54/222

24

223/223

100

76

Harrison 1984

7/92

8

89/89

100

92

Figures and Tables -
Table 2. Episiotomy rates for included studies (non‐operative vaginal delivery anticipated)
Table 3. Operative vaginal delivery rates (OVD) in included studies

Trial

OVD Included

In trial

Total

Included in analysis

Intervention

Control

Belizan 1993

Y

56/2599

Y

24/1302

32/1297

Dannecker 2004

Y

13/109

Y

4/49

9/60

Eltorkey 1994

Y

9/200

Y

4/100

5/100

Harrison 1984

Y

Unknown

Y

4/92

Unknown

House 1986

Y

20/165

Y

10/94

10/71

Juste‐Pina 2007

Unclear

/

/

/

/

Klein 1992

Y

20/703

Y

Unknown

Unknown

Murphy 2008b

ALL

200/200

101/101

99/99

Rodriguez 2008

Y

7/445

Y

3/222

4/223

Sleep 1984

Unknown

/

/

/

/

Ali 2004

Unknown

/

/

/

/

Sulaiman 2013

Unclear

/

/

/

/

Figures and Tables -
Table 3. Operative vaginal delivery rates (OVD) in included studies
Table 4. Trial primary outcomes, and outcomes closest to review primary outcome

Trial

Primary outcome

Outcome related to review primary outcome

Description

Match?

Belizan 1993

Severe perineal trauma

Same

"Extension through the anal sphincter and/or the anal or rectal mucosa (3rd or 4th degree lacerations)"

Matches

Ali 2004

Severe perineal trauma

Same

Severe perineal trauma (3rd and 4th degree tear)

Matches

Dannecker 2004

Not specified

Severe perineal trauma

"extension through the anal sphincter or rectal mucosa"

Matches

Eltorkey 1994

Not specified

Third‐degree tear

"complete tear including the anal sphincter"

Matches

Harrison 1984

Not specified

Third‐degree tear

"a complete tear including the anal sphincter, usually extending 2 cm or more up the anal canal"

Matches

House 1986

Not specified

Third‐degree tear

"one in which the anal sphincter was involved"

Matches

Juste‐Pina 2007

Not specified

Serious case of perineal trauma

"third or fourth degree tear"

Matches

Klein 1992

Not specified

Third‐ or fourth‐degree tear

As stated

Matches

Murphy 2008ba

Third‐/fourth‐degree tear

Same

Extensive perineal tearing involving the anal sphincter

Matches

Rodriguez 2008

Severe laceration to perineal tissues

Same

Third‐degree laceration when the extent of the lesion including the external anal sphincter totally or partially and 4th degree laceration when the rectal mucosa was involved

Matches

Sleep 1984

Not known

Severe maternal trauma

Extension through the anal sphincter or to the rectal mucosa or to the upper 3rd of the vagina

Matches

Sulaiman 2013

Obstetrical anal sphincter injuries

3rd/4th degree

No further details given

Matches

aMurphy included only women where operative delivery was anticipated and this is described and analysed separately.

Figures and Tables -
Table 4. Trial primary outcomes, and outcomes closest to review primary outcome
Table 5. Pain assessed using visual analogue scale (3 trials)

Trial

Parity

Time assessed

Outcome

Selective n/N (%)

Routine n/N (%)

House 1986

All parities

day 3

Moderate and severe pain (defined by score categories)

30/94 (32%)

32/71 (45%)

Klein 1992

Primigravida

day 2

Average score

Score 1.4, SD 0.8 (N 150)

Score 1.3, SD 0.7 (N 156)

Klein 1992

Multigravida

day 2

Average score

Score 0.9, SD 0.8 (N 156)

Score 0.9, SD 0.7 (N 145)

Dannecker 2004

Primigravida

1‐5 days

Average score

Score 51, SD 25, 22 (N 49)

Score 69, SD 23, 31 (N 60)

Figures and Tables -
Table 5. Pain assessed using visual analogue scale (3 trials)
Table 6. Dyspareunia in included studies (4 trials)

Trial

Parameter measured

Collection

Selective

n/N (%)

Routine

n/N (%)

Dannecker 2004

Pain during sex in the last 4 weeks

Questionnaire. Follow up average time of 7.3 months in about 65% of those randomised.

6/29 (21%)

13/39 (33%)

Juste‐Pina 2007

Dyspareunia at 3 months; and pain with coitus at 3 years postpartum

Telephone survey 3 months postpartum and interview by telephone at 3 years postpartum. Loss to follow up was 6% in the selective, 5% in the routine group at 3 months; and 8% in the selective, 11% in the routine group at 3 years postpartum.

3 months postpartum: 42/189 (22%)

3 years postpartum: 20/185 (11%)

3 months postpartum:67/192 (35%)

3 years postpartum: 15/180 (8%)

Klein 1992

Not reported

Collected but not reported

NA

NA

Sleep 1984

Reported dyspareunia at 3 months postpartum

Self administered postal questionnaire. Follow up rate 66% in selective, and 69% in routine at 3 years postpartum.

3 months postpartum:

87/394 (22%)

3 years postpartum: 52/329 (16%)

3 months postpartum: 74/411 (18%)

3 years postpartum: 45/345 (13%)

Figures and Tables -
Table 6. Dyspareunia in included studies (4 trials)
Table 7. Urinary incontinence in included studies (4 trials)

Trial

Parameter measured

Collection

Selective

n/N (%)

Routine

n/N (%)

Dannecker 2004

Urinary incontinence was considered as present whenever a participant gave an answer other than 'never' when replying to "How often do you leak urine involuntarily?"

Questionnaire. Follow‐up average time of 7.3 months in about 65% of those randomised

13/27 (48%)

11/41 (27%)

Juste‐Pina 2007

Urinary incontinence at 3 years postpartum

Telephone survey 3 years postpartum. Loss to follow‐up was 8% in the selective, 11% in the routine group at 3 years postpartum

34/180 (19%)

49/185 (26%)

Klein 1992

Urinary incontinence at 3 months

Questions employing a 4‐point scale

57/337 (17%)

60/337 (18%)

Sleep 1984

Reported urinary incontinence at 3 months after delivery; Reported incontinence of urine at 3 years postpartum

Standardised postal questionnaire administered by mothers at 3 months and 3 years postpartum. Follow‐up rate 62% in selective, and 67% in routine at 3 months postpartum; follow‐up rate 66% in selective, and 69% in routine at 3 years postpartum

3 months postpartum: 83/438 (19%)

3 years postpartum: 112/329 (34%)

3 months postpartum: 87/457 (19%)

3 years postpartum:

124/345 (36%)

Figures and Tables -
Table 7. Urinary incontinence in included studies (4 trials)
Comparison 1. Restrictive versus routine episiotomy (where non‐instrumental was intended)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Severe perineal/vaginal trauma Show forest plot

11

6177

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

2 Severe perineal/vaginal trauma (grouped by trial implementation success) Show forest plot

11

6177

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

2.1 Difference in episiotomy rate < 30%

3

1300

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.63, 1.69]

2.2 Difference in episiotomy rate 30% +

8

4877

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.38, 0.81]

3 Blood loss at delivery (mL) Show forest plot

2

336

Mean Difference (IV, Random, 95% CI)

‐27.16 [‐74.80, 20.49]

4 Newborn Apgar score < 7 at 5 minutes Show forest plot

2

511

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.01, 0.01]

5 Perineal infection Show forest plot

3

1467

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.45, 1.82]

6 Moderate or severe pain (visual analogue scale) Show forest plot

1

165

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.48, 1.05]

7 Dyspareunia long term (≥ 6 m) Show forest plot

3

1107

Risk Ratio (M‐H, Fixed, 95% CI)

1.14 [0.84, 1.53]

8 Genital prolapse long term (≥ 6 m) Show forest plot

1

365

Risk Ratio (M‐H, Fixed, 95% CI)

0.30 [0.06, 1.41]

9 Urinary incontinence long term (≥ 6 m) Show forest plot

3

1107

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.67, 1.44]

10 Need for perineal suturing Show forest plot

6

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

11 Admission to special care baby unit Show forest plot

5

2471

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.56, 1.07]

12 Pain at different time points (any measure) Show forest plot

4

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

12.1 Any perineal pain at discharge

2

2587

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.25, 2.86]

12.2 Any pain at 10 days

1

885

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.78, 1.27]

12.3 Moderate‐severe pain in first 10 days

3

1127

Risk Ratio (M‐H, Random, 95% CI)

1.14 [0.61, 2.12]

12.4 Severe or moderate pain at 3 months postpartum

1

895

Risk Ratio (M‐H, Random, 95% CI)

1.51 [0.65, 3.49]

Figures and Tables -
Comparison 1. Restrictive versus routine episiotomy (where non‐instrumental was intended)
Comparison 2. Restrictive versus routine episiotomy (non‐instrumental, subgroup by parity)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Severe perineal/vaginal trauma Show forest plot

11

6177

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

1.1 Primiparae

11

4137

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.50, 0.93]

1.2 Multiparae

4

2040

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.35, 2.01]

Figures and Tables -
Comparison 2. Restrictive versus routine episiotomy (non‐instrumental, subgroup by parity)
Comparison 3. Restrictive versus routine episiotomy (non‐instrumental, subgroup midline‐midlateral)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Severe vaginal/perineal trauma Show forest plot

10

5977

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

1.1 Midline

2

1143

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.51, 1.07]

1.2 Mediolateral

8

4834

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.37, 1.04]

Figures and Tables -
Comparison 3. Restrictive versus routine episiotomy (non‐instrumental, subgroup midline‐midlateral)
Comparison 4. Restrictive versus routine episiotomy (operative vaginal birth was intended)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Severe perineal/vaginal trauma Show forest plot

1

175

Risk Ratio (M‐H, Fixed, 95% CI)

1.30 [0.55, 3.07]

2 Apgar < 7 at 5 minutes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3 Perineal infection Show forest plot

1

175

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.04, 5.11]

4 Moderate/severe dyspareunia long term (≥ 6 m) Show forest plot

1

108

Risk Ratio (M‐H, Fixed, 95% CI)

3.71 [0.43, 32.16]

5 Urinary incontinence long term (≥ 6 m) Show forest plot

1

108

Risk Ratio (M‐H, Fixed, 95% CI)

0.46 [0.09, 2.43]

6 Admission to special care baby unit Show forest plot

1

175

Risk Ratio (M‐H, Fixed, 95% CI)

2.13 [0.68, 6.64]

Figures and Tables -
Comparison 4. Restrictive versus routine episiotomy (operative vaginal birth was intended)