The Maternal factors and short term outcomes associated with episiotomy during vaginal delivery at Women and Newborn Hospital , Lusaka, Zambia

Abstract

Background: An episiotomy is a surgically planned incision on the posterior vaginal wall   and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to   the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy.

Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies.

Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p<0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p<0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670).

Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.