Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation

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Objective: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears.

Study Design: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied.

Results: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently.

Conclusion: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

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    Supported by the National Health Research and Development Program of the Health Services and Promotion Branch of Health and Welfare Canada 6605-2731-4 and the Fonds de Recherche du Departement d'Obstetrique et Gynecologie de l'Hôpital Ste. Justine, Lady Davis Institute for Medical Research of the Sir Mortimer B. Davis Jewish General Hospital, McGill University Faculty of Medicine (Dean's Fund), the ELDEE Foundation, the CLSC Côte des Neiges, and Departement de Santé Communautaire de l'Hôpital Ste. Justine, Montreal, Quebec, Canada.

    a

    From the Department of Family Medicine, McGill University, Montreal, Quebec, Canada

    b

    Department of Sociology and Psychiatry, McGill University, Montreal, Quebec, Canada

    c

    Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada

    d

    Department of Family Medicine, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada

    e

    Department of Obstetrics and Gynecology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada

    f

    Department of Sociology and Psychiatry, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada

    g

    Institute of Community and Family Psychiatry, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada

    h

    Lady Davis Institute for Medical Research, Montreal, Canada

    i

    CLSC Côte des Neiges, Canada

    j

    the Departement de Santé Communautaire, Canada

    k

    Department of Obstetrics and Gynaecology, l'Université de Montréal, Montreal, Quebec, Canada

    l

    Hôpital Ste. Justine, l'Université de Montréal, Montreal, Quebec, Canada

    m

    the Department of Obstetrics and Gynaecology, St. Mary's Hospital, South Shore Regional Hospital, Bridgewater, Nova Scotia

    n

    Fisherman's Memorial Hospital, Canada

    o

    the Department of Family Practice, University of British Columbia, and the Department of Family Practice, British Columbia's Women's Hospital and Health Centre Society, Vancouver, British Columbia

    p

    the Arkansas Children's Hospital, Little Rock, Arkansas

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