Episiotomy and Perineal Tears Presumed to be Imminent: A Randomized, Controlled Trial

Several randomized, controlled trials have suggested that routine episiotomy should be avoided to lower the risk of injuring the posterior perineum, place fewer sutures, and minimize complications of healing. Restricted use of episiotomy, however, has been associated with more anterior perineal trauma. The present prospective, randomized, controlled trial compared the use of episiotomy only for fetal indications (group A, the restrictive group) with a policy of also doing an episiotomy when a tear appeared to be imminent (group B, the liberal group). Participants were 146 primiparous women with uncompleted singleton pregnancies past 34 weeks gestation. The final study group included 109 women who vaginally delivered a live, full-term infant. Forty-nine of these women were in group A and 60 in group B. A tear was considered imminent when the perineum was extremely thin and pale and the head was visible during a contraction to a diameter of approximately 4 to 5 cm. Episiotomy was done in 41% of the restrictive policy group and 77% of the liberal policy group (Table 1). The perineum was intact in 29% and 10% of these groups, respectively. Group A women had more minor perineal trauma (39% vs. 13%). There were no significant group differences in rates of third-degree tears or anterior perineal trauma. Nevertheless, 5 of 7 third-degree tears occurred in the liberal policy group. Women following the restrictive policy had significantly lower pain scores. There were no differences in mean time to hospital discharge or pre- or postnatal maternal hemoglobin levels. Neonatal outcomes also were comparable in the 2 groups. These findings strongly suggest that when a mediolateral episiotomy is done because of a presumed imminent tear, perineal pain results but there is no apparent benefit for the mother or child.TABLE I: Perineal outcome