A study of the morbidity associated with episiotomy Deepal S. Weerasekera1* and Surani G. Udugama 1 The Ceylon journal of Medical Science '2002; 45:77-81 Abstract Objective: To review the indications and the morbidity associated with episiotomy. Methods: Study was carried out in 450 consecu­ tive women who had episiotomies at delivery during the period from 01-03-2002 to 01-09-2002 at University Unit, Colombo South Teaching Hos­ pital. Women were interviewed within 24 hours of delivery and 6 weeks later. Data were collected using an interviewer administered questionnaire. Results: Out of a total of 876 mothers 51.4% had episiotomies at delivery and in 87% the indication was prevention of a possible perineal laceration. In 8% of women episiotomy was sutured later than 30 minutes from the time of performing. Although 10 ml of 1% lignocaine was infiltrated before performing and suturing the episiotomy, 80% of women complained of moderate to severe pain while performing the incision and 73% complained of moderate to severe pain during suturing. When seen six weeks later, 5% of patients complained of perineal pain and only 0.4 % had dyspareunia. Conclusion: Although episiotomy is generally considered to be a harmless procedure it causes moderate to severe pain in a majority of women. Adequate local analgesia, use of less-reactive suture material, emphasis on immediate sutur­ ing and post-partum analgesics may contribute to reduce the pain suffered by women following episiotomy. Introduction Episiotomy is the most commonly performed operative procedure in women (1). It is an incision in the perineum which enlarges the introitus and is used primarily to avoid perineal tears, and also at times, to expedite delivery. Many studies have questioned the benefit of routine episiotomy in primigravidae (2): This study was performed to assess the indications and morbidity associated with episiotomy. Methods A prospective observational study was conducted using the study population of all the women who had an episiotomy during delivery from 01-03-2002 to 01-09-2002 at the University Unit, Colombo South Teaching Hospital, Kalubowila. The study sample consisted of 450 consecutive mothers, who had an episiotomy performed at delivery during the study period. In all subjects perineum was infiltrated with 10ml of 1% ligno­ caine before episiotomy and when suturing was performed. All episiotomies were sutured using 1 /0 catgut threaded on a needle. Vaginal mucosa was sutured with a continuous layer of sutures starting from the apex. Perineal muscle was sutured with interrupted sutures and skin was sutured with mattress stitches. No routine anal­ gesics were given after suturing. The women were interviewed initially 24 hours after delivery and subsequently 6 weeks post partum. Pain was assessed using a visual analogue scale. The data were collected using an interviewer administered questionnaire. Results A total of 876 women delivered during this period and 51.4% had episiotomies. Out of the total of 450 mothers 232 (51.6%) were primiparus and 218 (48.4%) were multiparus. Out of the 450 1. University Unit, Department of Obstetrics and Gynaecology, Colombo South Teaching Hospital, Kalubowila. * Author for correspondence 78 Deepal S. Weerasekera and Surani G. Udugama women 172 (38.2%) had experienced previous episiotomy, 423 (94%) had term vaginal deliver­ ies and 27 (6.0%) had preterm vaginal deliveries. The mean age of the sample was 27.2 years (SD-5.87) and 44 (9.8%) mothers were below 20 years, 273 (60.7%) were between 20 to 29 years, 121 (26.9%) were between 30 to 39 years and 12 (2.7%) were over 40 years of age. Indications for episiotomy are shown in Table 1. In all women a medio-lateral episiotomy was performed as this was the policy of this obstetric unit. Time taken to suture the episiotomy is shown in Table 2. Discomfort experienced by women while per­ forming the episiotomy and during suturing are shown in Table 3. Post-parturm assessment was done 6 weeks later and Table 4 shows the complications seen at that time. Table 5 shows the complications seen 6 weeks later in women in whom the episiotomy was sutured within 30 minutes and in whom the episiotomy was sutured after a delay of more than 30 minutes. Table 1. Indications for episiotomy Indication No. of women (n=450) % To prevent perineal laceration 391 86.9 Instrumental Delivery Forceps 16 3.6 Vacuum 12 2.7 To expedite second stage 23 5.1 Fetal conditions 8 1.8 Table 2. Time taken to suture the episiotomy Time taken to suture No. of women % episiotomy (n=450) Within 15 minutes 306 68.0 Between 15 to 30 minutes 106 23.6 > 30 minutes 38 8.4 The Ceylon Journal of Medical Science A study of the morbidity associated with episiotomy 79 Table 3. Discomfort experienced while performing and suturing the episiotomy Discomfort (assessed by patient) During incision (n = 450) % During suturing (n = 450) % Mild (only a discomfort but no pain) 89 19.9 123 27.3 Moderate (bearable) 285 63.4 301 66.9 Severe (unbearable) 76 16.9 26 5.7 Table 4. Complications seen 6 weeks post partum Complication No. of women (n=450) % Infected episiotomy 5 1.1 Post partum perineal pain 21 4.7 Wound dehiscence 8 1.8 Excessive granulation tissue 1 0.2 Dyspareunia 2 0.4 Table 5. Complications within 6 weeks post partum in relation to time taken to suture the episiotomy Complications within 6 weeks post partum Time taken to suture the episiotomy < 30 min. > 30 min. (n = 412) (n = 38) P-value Infected episiotomy 3 2 0.081 Post partum perineal pain 17 4 0.165 Wound dehiscence 6 . 2 0.290 Excessive granulation tissue 1 0 1.000 Dyspareunia 1 1 0.399 Differences not statistically significant. Vol. 45 No. 2, December 2002 80 Deepal S. Weerasekera and Surani G. Udugama The Ceylon Journal of Medical Science Discussion Although it is commonly considered that per­ forming an episiotomy is a harmless procedure it can lead to an increase in maternal blood loss, increase the average depth of posterior perineal injury, risk of improper wound healing, and sig­ nificant amount of pain in the first few post­ partum days (2). As shown in this study women experienced considerable amount of discomfort during performing and suturing the episiotomy. Of the 450 mothers 80% experienced moderate to severe pain during episiotomy and 73% while suturing the episiotomy inspite of perineal infil­ tration with lignocaine in all women. Only 5% com­ plained of post-partum perineal pain when seen 6 weeks later. Although certain studies have shown that medio-lateral episiotomy can cause more pain and impaired wound healing when compaired to median episiotomy (3), the policy of the Obstetric Unit was to perform medio-lateral episiotomies, as extension to third degree perineal tear was less likely in this type. Catgut was used for suturing the episiotomy as this was the material available for suturing in government hospitals. It has been shown in other studies that use of less-reactive suture material such as Polyglycolic acid (Vicryl- Ethicon) sutures can reduce the pain and risk of infection, and lead to good wound healing (4). Despite the fact that this study was done in a well staffed university unit in a Teaching Hospital, where a separate house officer was assigned to the labour room on a rostered basis, in 8% of women the suturing of the episiotomy was delayed beyond 30 minutes. Unusually by heavy work load on admission days and lack of supervision during night time may have contributed towards this. The situation in Provincial and Base hospitals can be worse. When assessed 6 weeks later there was no significant difference in complications in women where the episiotomy was sutured within 30 minutes of performing and in women where the delay was more than 30 minutes. In 87% of women the indication for an episiotomy was to prevent perineal lacerations. In this study all episiotomies were sutured using interrupted skin sutures. Other studies have shown that con­ tinuous repair techniques are better than inter­ rupted suture methods in terms of postpartum pain (5). Training doctors to suture episiotomies using continuous suture technique may help in this regard. A previous study has shown that epi­ siotomy is associated with a decrease in perineal lacerations of first or second degree but a four­ fold increase in the incidence of third degree lac­ erations (6). Two other similar studies have shown that episiotomy can prevent anterior perineal lac­ erations but fail to prevent perineal damage and its sequelae (2) and that third degree lacerations were not significantly more frequent in deliveries without episiotomy (7). In our study we did not have any women where the episiotomy was ex­ tended into a third degree perineal laceration. When assessed 6 weeks post partum only 0.4% complained of dyspareunia. This figure is very low when compared to 50% and 30% reported in various other studies (8,9). Under reporting of this complication by Sri Lankan women due to shyness may be a possible explanation. Proper justification of performing episiotomies, adequate local infiltration before performing and during suturing, availability of less-reactive suture material, emphasis on immediate suturing and prescription of analgesics during the post-partum period may contribite towards reducing discom­ fort suffered by women due to episiotomy. References 1. Reading A.E., Sledmere C M . , Cox D.N., Campbel l S. How women view post- epi siotomy pain. British Medical Journal 1982; 284:243-246. 2. WooIIey R. J. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Obstetrics and Gynaecological Survey 1995; 50:806-820. 3. Wenderlein J.M., Merkle E. Complaints caused by episiotomy: Study of 413 women with spontaneous complication-free labor. Geburtshilfe Frauenheilkd 1983; 43:625-628. A study of the morbidity associated with episiotomy 4. HirschHA Episiotomy and its complications. Z Geburtshilfe Neonatol 1997; 201 Suppl 1:55-62. 5. Christine Kettle, Robert K Hills, Peter Jones, Louisa Darby, Richard Gray, Richard Johanson. Continuous versus interrupted perineal repair with standard or rapidly ab­ sorbed sutures after spontaneous vaginal birth: a randomized controlled trial. Lancet 2002; 359:2217-2223. 6. Wilcox L.S. , Strobino D.M., Baruffi G., Dellinger W.S. Jr. Episiotomy and its role in the incidence of perineal lacerations in a ma­ ternity center and a tertiary hospital obstet- 81 rics service. American Journal of Obstetrics and Gynecology 1989; 160:1047-1052. 7. Buekens P., Bernard N., Blondel B., Grandjean H., Huisjes H., Kaminski M., Lagasse R., Van Eijk E., Wollast E. Episiotomy and prevention of complete and complicated tears. Journal of Gynaecology and Obstetrics Biological Repro­ duction (Paris) 1987; 6:513-517. 8. Goetsch M.F. Postpartum dyspareunia: An unexplored problem. Journal of Reproduc­ tive Medicine 2000; 45:964. 9. Wenderlein J.M., Merkle E. Complaints caused by episiotomy: Geburtshilfe Frauenheilkd 1983;43:625-628. Vol. 45 No. 2, December 2002