CURRENT TRENDS IN THE UTILITY OF EPISIOTOMY IN A UNIVERSITY HOSPITAL, BENIN CITY, NIGERIA

BACKGROUND: Episiotomies have been performed for several years for various indications. Routine use of episiotomy has gone into disfavor with many obstetricians and midwives in Europe and North America but many studies from Latin America, Asia and Africa continue to document prevalence of 50% or higher. OBJECTIVE: This study sought to examine the current trend in the utilization of episiotomy in our hospital amidst an observation of increasing reports of episiotomy complications. METHODS: The case records of women who delivered vaginally in the University of Benin Teaching Hospital, Benin City from January 2010 to December 2014 were retrospectively studied. Sociodemographic and clinical information were retrieved and analyzed. Results: There were 5,398 women studied, among which 1,975 (36.6%) had episiotomy. Episiotomy was more likely in women younger than 30 years (60%), nulliparas (80.5%) and term pregnancies (94.2%). Midwives administered 82.0% of the episiotomies while consultants were involved in only 1.1%. Spontaneous vaginal delivery was 15.1% less likely to involve episiotomy than forceps, vacuum and breech deliveries together (35.6 vs 50.7%, RR 0.722 95%CI 0.608-0.856; P < 0.001). The 6-week appointment was kept by 40.1% (792) of the patients with 24.1% (191/792) reporting complications. Extension to the perineum


INTRODUCTION
Episiotomy is one of the commonest operations performed on women.Over the years, due to the dynamic nature of obstetric practice, the decision to or not perform an episiotomy has been influenced by various factors.The earliest practitioners, including Sir Fielding Ould recommended it solely for the tight perineum especially in cases where 1 labour seemed prolonged .It was later introduced into the United States of America th in the mid-19 century and recommended for all nulliparous women to avoid perineal 2 trauma .Beyond that era, the application of episiotomy has been swayed toward the prevailing regional practice, the cadre of health provider as well as the experience of individual practitioner.The prevalence of episiotomy varies widely worldwide with figures as low as 1% reported in Sweden and 3 4 80% in Argentina .Otoide et al reported an incidence of 46.6% in the University of Benin Teaching Hospital (UBTH).
Considering that most deliveries are attended by nurses and/or midwives, they are also expected to perform more episiotomies than doctors working in the setting of labour and delivery.In many instances, episiotomies are not promoted by midwives except in situations where they anticipate risk of injury to maternal tissue or the fetus especially with necessitating more manipulations such as vacuum, forceps and assisted breech deliveries, and in many of these cases 4 episiotomy is often utilized .Other lower cadre health workers like community health extension workers (CHEW), community health officers (CHO) and auxiliary nurses and midwives who may not have the proficiency for managing episiotomy are likely to allow more spontaneous distension of the perineum by the fetal head.The corollary is that the episiotomy rate is likely to be lower but this practice is also thought to allow ragged tears should there be any significant risk for perineal injury.Some observers have thus documented the role of provider experience on the utilization of episiotomy, suggesting 6,7 higher rates with increasing experience .It will appear to be the case that established practice is often a reflection of experiential depth, so that clinicians with a wealth of experience are more likely to sustain the practice of routine episiotomy even in the face of current evidence suggesting otherwise.
In the last few decades, opinion on the use of episiotomy has shifted between selective and routine use.

TABLE 1: DEMOGRAPHIC AND CLINICAL PARAMETERS AT DELIVERY
About 60% of women who had episiotomy were younger than 30 years.Nulliparas accounted for the majority (80.5%) of women given episiotomy.The use of episiotomy was rare amongst women who were para 4 and above.Term pregnancies accounted for the majority (94.2%) of patients who required episiotomy at delivery.Pregnancies with normal birth weights were associated with the majority (87.1%) of episiotomy in this group of women.(Table 1) The majority (82.0%) of episiotomy in our series were administered by midwives who often take most of the deliveries in our hospital.Consultants were involved in only 1.1% of the cases while junior residents administered episiotomy in 9.1%, and the senior residents gave the episiotomy for 4.5% of the women.(Fig 1) Among women who had spontaneous vaginal delivery, 35.7% had episiotomy whereas the majority of assisted vaginal deliveries were assisted with episiotomy.Forceps delivery had the highest rate of episiotomy utilization of 62.9%, followed by assisted vaginal breech delivery with 48.6% of women requiring episiotomy, and vacuum deliveries had a frequency of 41.9% episiotomy utilization.Forceps delivery was associated with 27.2% more risk of episiotomy use than spontaneous vertex delivery (62.9% vs 35.7,Chi square 41.748, df=3; P<0.001).(   The reason why episiotomy is applied to most nulliparous women has often been the assumption that the perineum could stretch and tear raggedly because it had "not been previously tested."Certainly, substituting a clean cut for a ragged tear to help minimize the pressure on the fetal head, and probably shorten the last portion of the second stage of labour, appears attractive.Even so, it may be rationalized that allowing first-time mothers earn episiotomy can help drive down the rates among them; and this may possibly reduce the overall incidence of episiotomy considering that the majority of episiotomy currently are done for nulliparas.
In our study, term pregnancies constituted the majority of those who had episiotomy for pain, and urinary incontinence .Episiotomy breakdown in our series occurred in 8.4% of the women, a significant burden for the women who most times had to endure secondary wound repair.The factors associated with wound breakdown have been suggested to be poor attention to asepsis, poor perineal hygiene, which could lead to 16 infection with resultant breakdown.In our study, we did not report the contributing factors to episiotomy breakdown.It will be instructive to examine the determinants of episiotomy outcome in future studies, as empirical data from our facility currently s u g g e s t s t h a t i n d i v i d u a l p a t i e n t characteristics and poor wound care following repair are prominent determinants of episiotomy repair outcome.Clinician cadre-specific breakdown rate could also form a focus for further research.In this study, we reviewed episiotomy utilization including over 5000 women, a sample size that appears large enough to improve the external validity of our findings.Furthermore, we documented the utility of episiotomy in many routine procedures which currently form the bulk of our labour ward activities, highlighting the important place of episiotomy in our practice.While admitting that the incidence of episiotomy can be safely reduced by the approach of selective or indicated use, it has also been brought to the fore that improvements in the utilization of episiotomy also require more focused attention in order to reduce complication rates.The retrospective design of this study has some inherent drawbacks of lack of temporality and inadequate documentation from source of information.Despite these inadequacies, we have been able to add to the body of knowledge regarding the ongoing debate on the continued utility of episiotomy in modern day obstetric practice.In conclusion, the incidence of episiotomy remains high in our hospital.However, many obstetric procedures continue to require the application of episiotomy, hence the need to focus on a more selective approach to episiotomy utilization.We recommend a prospective multicenter study to evaluate the continued role of episiotomy in our practice, and to determine ways to improve the overall outcome.

TABLE 3 : COMPLICATIONS OF EPISIOTOMY Mediolateral
episiotomy was uniformly applied in all the women, as this is the type of episiotomy that is commonly done in our hospital.