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Bibliographical entry (without author) :

Avoiding episiotomy is the best strategy to prevent OASIS: response to the article ‘Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case–control study’ - BJOG: An International Journal of Obstetrics & Gynaecology - Vol. 119, 9 - ISBN: 1471-0528 - p.1148-1148

Author(s) :

Knobel, R; Takemoto, Mls; Jones, Rh; Amorim, Mmr

Year of publication :

2012

URL(s) :

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-…
https://doi.org/10.1111/j.1471-0528.2012.03391.x

Résumé (français)  :

Abstract (English)  :

Sir,

We have read with interest the article by Stedenfeldt et al.1 published in the last edition of BJOG. However, some points need to be addressed. The conclusion seemed to suggest that increased episiotomy length and depth should be adopted for preventing severe perineal injuries, including obstetric anal sphincter injuries (OASIS).

The study findings differ markedly from those reported in randomised trials already summarised in a recent Cochrane Systematic Review,2 which observed a reduction in the risk of severe perineal trauma among women under a restrictive episiotomy policy (RR 0.67 versus routine episiotomy, 95% CI 0.49–0.91).

The Cochrane Review states that the restrictive use of episiotomy seems to improve maternal outcomes without increasing adverse perinatal ones. Moreover, a women-centered, less interventionist model of care for childbearing women has been discussed and gradually implemented worldwide. Within this process, protecting perineal integrity emerges as a major concern, as it is impossible to achieve it when an episiotomy is performed, regardless of its angle, length, or depth. Several studies have investigated antenatal and intrapartum perineal protection strategies,3,4 and thus we understand that any study aiming to identify predictive factors for perineal trauma should mandatorily include these techniques, particularly those addressing OASIS.

This was a case–control study that enrolled women receiving an episiotomy with or without OASIS. The lack of an adequate control group is an obvious bias of this approach because it is expected that a lower risk of OASIS would be found in women NOT receiving episiotomy. Case–control studies are more prone to bias by nature, but the inclusion of women who had not undergone an episiotomy would at least allow for the comparison of OASIS risk for each modality of episiotomy versus no episiotomy.

Additionally, the small sample could overestimate the risk and increase the probability of random error or selection bias (i.e. if women without OASIS more often declined to participate in the study). Furthermore, it is reasonable to argue that the accuracy of episiotomy angle, length and depth assessment would be more reliable if it was conducted immediately after birth, not years later. Another limitation is the lack of control for several potential confounding factors in the multivariate analysis: birth position, fundal pressure, guided pushing, perineal techniques, etc.

Although some of these limitations have been disclosed by the authors, we are deeply concerned about the possible misuse of their findings to justify a return to the systematic use of episiotomy. In fact, the abstract has been released in the media and, without an accurate critical appraisal of the full article, readers may interpret that the problem is not the episiotomy per se, but an insufficient length or depth, which is a conclusion that cannot be derived from this study.

Sumário (português)  :

Resumen (español)  :

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Keywords :

➡ episiotomy

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Import 02/08/2014 — 02 Aug 2014