Prevalence and Factors Associated With Episiotomy in Shahroud City, Northeast of Iran

Episiotomy is the most common incision of perineal muscles in the second stage of labor to widen the vaginal opening (1). The prevalence of episiotomy varies from 9.7% in Sweden to 100% in Taiwan (2). In the United States, episiotomy was routinely performed on nearly all primipara until the end of 1970s and declined to 39% by 1997 (3). In developing countries including Asian ones like India, the prevalence of episiotomy was 90% (4). In 2009, the prevalence of episiotomy in Iran was reported 88.7% and 97.3% in studies by Khani et al in Sari town and Shojae et al in Tehran, respectively (5,6). Various researchers have suggested advantages of episiotomy as follows: avoiding potential intracranial damage to infant, improving Apgar score, avoiding severe and irregular perineal tear, easier restoration of episiotomy incision compared to other incisions, preventing relaxation of pelvic floor muscles and incidence of cystocele and rectocele. However, these advantages have not been supported by solid evidence and with the exception of reduced anterior perineal tear, the rest have not been proven or rejected (3). A study showed that perineal tear were only observed in women that had not undergone episiotomy, which suggests episiotomy prevents unwanted tear (7). Like other surgical incisions, episiotomy runs the risk of short-term complications such as pain, bleeding and maternal infection and long-term complications such as painful intercourse and complications due to urinary incontinence (8). In a systematic, meta-analysis review study, LaCross et al found a significant relationship between perineal damage due to episiotomy and third or fourth degree tear and postpartum fecal incontinency and emphasized reduction of perineal trauma during vaginal childbirth for reducing fecal incontinency (9). In a study in Turkey, episiotomy was reported responsible for painful intercourse and adverse effects on women’s sex life, but not for fecal incontinency (10). A systematic review study by Cochrane library on eight randomized clinical trials on 5000 women revealed that episiotomy should not be routinely performed because it is unnecessary and likely to cause damage. It was also found that routine episiotomy was associated with further loss of blood during childbirth, perineal pain, increased risk of severe perineal tear, needing more stitches and greater complications at wound site and no proven clear benefits for mother or infant (8). Routine episiotomy is an unnecessary intervention in childbirth, with uncertain benefits. Thus, to reduce unnecessary childbirth interventions, physiological manageAbstract Objectives: Episiotomy is the most common surgical incision in midwifery. Given its questionable benefits, the present study aimed to determine the frequency of episiotomy and its associated factors in women with vaginal childbirth. Materials and Methods: This descriptive cross-sectional study was conducted on a population consisting of all women that had vaginal childbirth over a six-month period (from October 2014 to April 2015) in Fatemieh Teaching hospital in Shahroud city. Participants were selected by census. Data were collected using a researcher-made questionnaire consisting of four parts, whose validity and reliability had been confirmed. Data were analyzed in SPSS 21 using descriptive statistics and chi-square, t test and logistic regression analysis. Results: Of the 978 cases of vaginal childbirth, 406 (41.5%) had undergone episiotomy. Mean age of participating women was 27.32±5.14 years. Episiotomy was found to have significant relationships with mother’s age, parity, first and fifth minute Apgar scores, duration of the second stage of labor, birth spacing, use of oxytocin, vacuum deliveries and use of analgesics (P < 0.05). Overall, prevalence of intact perinea was 34.7%. In the final logistic regression analysis, among significant variables and variables with P<0.1 in univariate analysis, parity, use of oxytocin, first minute Apgar score and infant’s head circumference with P < 0.0001 and birth spacing with P = 0.043 were considered predictors of episiotomy. Conclusion: The overall rate of episiotomy in this study was 41.5%, which is much higher than the standards set by the World Health Organization (WHO). Further research is required to provide appropriate solutions to reduce episiotomy.