While nearly 70% of women had an episiotomy during their first childbirth in the early 2000s, the National College of Obstetrician Gynecologists of France (CNGOF) published recommendations in 2005 aimed at restricting this practice, taken up by the High Authority of health in 2018. Twenty years later, this change of gear has it had an effect on the incidence of a rare but serious complication of childbirth, which episiotomy aims to prevent: obstetric lesions of the anal sphincters (Losa)*?
A Franco-Swiss study, supported by several French health authorities, looked into the subject. By analyzing the national perinatal surveys of Public Health France from 2010, 2016 and 2021, the authors confirm a drop in the prevalence of episiotomies, without this leading to an increase in the occurrence of Losa.
Episiotomy is a source of severe maternal complications: postpartum hemorrhage, urinary retention, infection, dyspareunia, anxiety and post-traumatic stress syndrome. Thus, the study published in Plos Medicine demonstrates an increase in the benefit provided by the change in medical strategy, avoiding unnecessary episiotomies, without increasing the risk of complications.
Episiotomies in multiple pregnancies divided by 16
The researchers analyzed the medical records of 29,750 women who had given birth vaginally in order to identify episiotomies and Losa. In 2010, the prevalence of episiotomies for vaginal deliveries was 25.8%. It decreased significantly, reaching 20.1% in 2016 then 8.3% in 2021 (adjusted risk ratio aRR: 0.33). Between 2010 and 2021, the prevalence of Losa has not significantly changed.
-The study looked at seven subgroups defined according to the obstetric context. The greatest drop in the prevalence of episiotomies was found in multiparous women with a singleton in cephalic presentation at 37 weeks of gestation (SA) or more with spontaneous delivery (aRR: 0.20) as well as in multiple pregnancies (aRR: 0.06, i.e. a division by 16). For nulliparous women with a singleton in cephalic presentation at 37 weeks or more and a forceps delivery, the reduction was less (aRR: 0.67).
Only one group saw the prevalence of Losa increase, from 2.6% in 2010 to 9.6% in 2021 (aRR: 3.69) while the episiotomy rate was divided by more than half (from 78 .8% to 31.7%): nulliparous women with a singleton at term, in cephalic position and delivery by spatulas. The researchers call for further research on the specific risks of subgroups (notably nulliparous women with instrumental extraction), in order to possibly review the supervision of episiotomy practices.
* The French National Society of Colo-Proctology estimated in 2022 the overall prevalence of Losa between 0.5 and 7% after vaginal delivery; 0.8% in France.
