The current study was performed to compare complications following routine and restrictive episiotomy among primigavida patients in Isfahan. The findings demonstrated that the rate of episiotomy indication was low in the restrictive group. In addition, the rate of maternal short-term complications, such as perineum laceration and pain severity, was less in restrictive episiotomy group than the routine group. However, neonatal complications in neonates with estimated birth weight (EBW) < 4000 g was similar in the two groups, i.e. neonatal complication rate was not higher in the restrictive group. The results of this study indicated primigavida patients to have optimum chance of retaining an intact perineum if episiotomy is carried out only when considered to be essential. Our findings were in accordance with a few studies that have compared restrictive and routine episiotomy. In a similar study in Tehran, Moini et al. reported the total rate of severe perineal tears in routine episiotomy to be significantly higher than restrictive episiotomy. They concluded that routine episiotomy is associated with an increased risk of severe perineal tears and subsequent complications especially pain, dyspareunia, and incontinence.10
In this study, we did not study the long-term complications of episiotomy which is considered as the limitation of the present study. According to the results of Argentine Episiotomy Trial Collaborative Group, the main outcome measure was severe perineal trauma. Severe perineal trauma was uncommon in both groups but was slightly less frequent in the restrictive group (1.2% vs. 1.5%). Anterior perineal trauma was commoner in the restrictive group but posterior perineal surgical repair, perineal pain, healing complications, and dehiscence were all less frequent in the restrictive group. Finally, they concluded that routine episiotomy should be abandoned and that episiotomy rates above 30% were not recommended.11
In another study in Colombia by Rodriguez et al., the outcome of selective vs. routine episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women was investigated and the rate of third- or fourth-degree perineal lacerations was 14.3% and 6.8% in selective and routine episiotomy, respectively. They concluded that elective episiotomy is useful in reducing perineal lacerations specially the risk of third-degree lacerations.20
On the other hand, Murphy et al. performed a multicenter pilot randomized controlled trial in Ireland to investigate the primary (third or fourth degree laceration) and secondary (postpartum hemorrhage (PPH), neonatal trauma and pelvic floor symptoms) outcomes of routine versus restrictive use of episiotomy. In contrast to our results, they did not indicate any significant difference in both primary and secondary outcomes between two mentioned methods.21
Danecker et al. found that restrictive protocols could reduce episiotomy by 36%. In their study, 29% had intact perineum following restrictive method.16
In some European countries, these protocols were more efficient than the United States during the last 18 years.1,22
In Sweden, episiotomy rate is reported to be less than 9% since 2002.22
In our study, clinically indicated episiotomy was detected only in 7.5% of deliveries. This rate was lower than that recommended by Argentine Episiotomy Trial Collaborative Group.11
Randomized controlled trials (RCTs) comparing restrictive use of episiotomy and routine use of episiotomy during spontaneous vaginal birth have suggested significant benefits in adopting a restrictive policy, specifically a reduction in posterior perineal tears.2
In this study, the mean length of perineal posterior laceration was significantly lower in restrictive episiotomy group. Similar to the study performed by Morhe et al.,23
in less than half of our cases, perineum was intact following restrictive method.
Expectedly, performing episiotomy only in indicated cases will lead to less severe, if any, lacerations. After establishing several protocols to limit routine episiotomy, 3rd
grade perineal lacerations have been decreased in the United States (from 42% in 1980 to 15% in 1998).1
The obtained data from our study and another study in Iran10
indicate similar results.
Nager et al. reported a significant increase in the length of perineal posterior laceration following episiotomy in primiparous women. They also found that episiotomy and forceps play a significant role in increasing posterior laceration length.19
Episiotomy evidently reduces the risk of anterior perineal tears.1
Therefore, avoiding episiotomy would increase the rate of anterior laceration. It should be mentioned that anterior lacerations are less severe and have fewer complications than posterior lacerations in midline episiotomy.24,25
Dannecker et al. showed that implementing episiotomy indications could decline its rate to 30%. Although in their study anterior lacerations became more prevalent when episiotomy was avoided, this group consisted of more cases with intact perineum.16
In this study however, the rate of anterior laceration was not significantly different between the two studied groups. Carroli and Mignini2
and the Argentine Episiotomy Trial Collaborative Group11
demonstrated anterior laceration to be higher in restrictive episiotomy.
Although some studies reported decreased post-delivery pain and dyspareunia using restrictive episiotomy, others disagreed.13,14
In another study using antenatal dilators, less pain was experienced after delivery as a result of routine episiotomy avoidance.3
Similar to Moini et al.,10
we found that compared to routine episiotomy, restrictive episiotomy would result in less severe pain immediately, 24 and 48 hours after vaginal delivery. In contrast, Carroli and Mignini did not observe differences in most pain measures between the two studied groups.2
Based on a randomized controlled trial performed in Germany by Dannecker et al., it can be concluded that restrictive episiotomy has no effects on Apgar scores, at neither the first nor the fifth minute.16
Moini et al. reported similar results.10
The discrepancy observed between the current study and mentioned research may be due to geographical and ethnical variations.
Unfortunately, our study only assessed early complications. Therefore, further studies with larger sample sizes are necessary to sort indications on episiotomy in different gravid women by importance. Up to now, no study has been conducted on late complications of second deliveries in cases with or without the history of previous episiotomy. We recommend obstetricians to develop a standard or guideline for performing episiotomies. In addition, patients need to be followed for long-term morbidities such as pelvic organ prolapse.