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Acknowledgment This study was made possible by a grant from the Qatar National Research Fund. The contents of the publication are solely the responsibility of the authors and do not necessarily represent the ofcial views of the Qatar National Research Fund. References
[1] World Health Organization. Care in normal birth: a practical guide. WHO/FRH/ MSM/96.24. Geneva: World Health Organization; 1996.
[2] Larsson PG, Platz-Christensen JJ, Bergman B, Wallstersson G. Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynecol Obstet Invest 1991;31(4):2136. [3] Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 1999;2 CD000081.
0020-7292/$ see front matter 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.09.018
Episiotomy and third- and fourth-degree perineal tears in primiparous Iranian women
Ashraf Moini a,b,, Rita Emadi Allah Yari a, Bita Eslami a
a b
Department of Gynecology and Obstetrics, Roointan-Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran Department of Endocrinology and Female Infertility, Royan Institute, Tehran, Iran
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Article history: Received 13 August 2008 Received in revised form 26 October 2008 Accepted 28 October 2008 Keywords: Episiotomy Fourth-degree tear Iran Primiparous Third-degree tear
From April 2007 until March 2008, 283 primiparous women with a full term singleton pregnancy and no underlying problems participated in this randomized clinical trial at the Arash Hospital, in Tehran, Iran. Informed consent was provided by all participants. Exclusion criteria were noncephalic and cephalic presentations except occiput anterior and fetal macrosomia. Using Epi Info software (CDC, Atlanta, GA, USA) and the total rate of severe perineal tears in the two groups, the power of the study was more than 90%. P b 0.05 was considered signicant.
Table 1 Comparison of perineal tears, 1- and 5-minute APGAR scores, and short- and long-term complications in both groupsa Variables Group 1 Episiotomy (n = 146) Group 2 No episiotomy (n = 137) 64 26 3 0 (43.8) (17.8) (2) (0) P value
Episiotomy is perhaps the most frequently performed operative procedure during childbirth to facilitate delivery and prevention of perineal and rectal trauma. There is no evidence that routine or prophylactic episiotomy reduces the risk of severe perineal tears. Restrictive episiotomy policies appear to have a number of benets, such as fewer posterior perineal tears, less suturing, and fewer complications [1]. However, some studies have reported that episiotomy protects against the occurrence of third-degree laceration and decreased the likelihood of it occurring [2,3]. Unpublished data from our hospital suggest that the recent rate of episiotomy in primiparous women is about 39%, which is higher than evidence-based recommendations for optimal patient care. The main aim of the present study was to compare the rate of third- and fourth-degree perineal tears in two groups of women who did (group 1) and did not (group 2) undergo episiotomy.
Corresponding author. Department of Gynecology and Obstetrics, Roointan-Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran. Tel.: +98 21 77883283; fax: +98 21 77883196. E-mail address: hosp_arash@tums.ac.ir (A. Moini).
Perineal tears 1st degree 0 (0) 2nd degree 119 (86.9)b 3rd degree 16 (11.7) 4th degree 2 (1.5) 1-minute APGAR score b7 3 (2.19) 78 20 (14.60) 9 114 (83.21) 5-minute APGAR score b7 1 (0.73) 78 3 (2.19) 910 133 (97.08) Short-term complications Pain 137 (100) Inammation 47 (34.31) Edema 44 (32.12) Long-term complications Perineal Pain 121 (88.32) Dyspareunia 124 (90.51) Inammation 31 (22.63) Incontinence 18 (13.14) Repair 5 (3.65)
a b
b 0.0001
1 (0.68) 13 (8.9) 132 (90.41) 0 (0) 1 (0.68) 145 (99.31) 21 (14.38) 6 (4.11) 7 (4.79) 29 21 10 1 0 (19.86) (14.38) (6.85) (0.68) (0)
0.05
0.51
b 0.0001
b 0.05
Values are given as number (percentage). Episiotomy was considered as a second-degree tear.
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BRIEF COMMUNICATIONS
The mean age of the women in both groups was not signicantly different (23.25 5 vs 24.22 4.41 years, P = 0.09). Average body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) was higher in the women who did not undergo episiotomy (group 2) compared with those who did have the procedure (28.45 2.48 vs 27.63 1.87, P = 0.002). Average head circumference was also higher in group 2 (34.98 1.54 vs 34.54 1.73 cm, P = 0.025). Average birth weight was similar in both groups (3238.91 399.99 vs 3158.22 345.81 g, P = 0.07). The total rate of severe perineal tears in group 1 was signicantly higher than in group 2 (18 cases [13.14%] vs 3 cases [2.05%], P = 0.0007). The 1-minute APGAR score was signicantly different between the two groups (P = 0.05), but there was no difference at 5 minutes (P = 0.51). Short-term (after delivery) and long-term (after 68 weeks) complications were more common in group 1 (Table 1). The episiotomy odds ratio of 6.75 (95% CI, 3.9323.95; P = 0.0006) was the only identied risk factor. Other variables (maternal age and BMI, birth weight and head circumference) had no signicant effect on perineal tears.
The present study demonstrated that routine episiotomy is associated with an increased risk of third- and fourth-degree tears and subsequent complications especially pain, dyspareunia, and incontinence. The study is consistent with others [1,4] and supports the recommendation that routine episiotomy should be abandoned in obstetric centers in Iran. References
[1] Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2000(2): CD000081. [2] Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98(2):22530. [3] De Leeuw JW, Vierhout ME, Struijk PC, Hop WC, Wallenburg HC. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 2001;80(9):8304. [4] Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 2000;320(722):8690.
0020-7292/$ see front matter 2008 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2008.10.025
Department of Obstetrics and Gynecology, School of Medicine, University of Uruguay, Montevideo, Uruguay Bacteriology and Virology Department, School of Medicine, University of Uruguay, Montevideo, Uruguay
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Article history: Received 28 September 2008 Received in revised form 19 October 2008 Accepted 23 October 2008 Keywords: Colonization Group B streptococcus Pregnant women Uruguay
Pregnant women admitted to the Pereira Rossell Hospital, the largest public maternity unit in Uruguay, were asked to participate in the study. Inclusion criteria were pregnant women in labor or admitted for elective cesarean delivery; gestational age between 32 and 41 weeks; and signed consent forms. If a woman had been tested for GBS during prenatal care and the culture was positive, she received treatment after the study sample had been obtained. Exclusion criteria were pregnant women who had received antibiotics within 1 week before being admitted to hospital and women who declined to participate. During a 2-month period in 2008, a total of 300 pregnant women were selected at random from a total of 846 women eligible women admitted to the hospital. The random allocation scheme was derived from a computer-generated list of numbers using sealed envelopes
Group B streptococcus (GBS) is one of the most common causes of neonatal sepsis. In the United States, 5%10% of neonatal deaths are caused by this organism [1]. Early-onset GBS disease is dened as an infection occurring in the rst week of life and accounts for approximately 70% of all GBS diseases in the rst 3 months of life [2]. Sepsis develops in approximately 1% of neonates born to colonized women. It has been estimated that between 10%30% of pregnant women are colonized by GBS. These gures have been reported mainly from high-income countries, with few studies from Latin America [1]. The objective of the present study was to determine the prevalence of GBS colonization in pregnant women using the method recommended by the Centers for Disease Control and Prevention (CDC) [2].
Table 1 Comparison of characteristics between the hospital population and the study sample a Characteristics Maternal age, y b 20 2034 35 Parity Nulliparous 1 Preterm birth, wk b 37 b 35 Cesarean delivery rate
a b c
Hospital population (n = 8185) 1981 (24.2) 5346 (65.3) 858 (10.5) 3469 (42.4) 4716 (57.6) 1284 (15.7) 659 (8.1) 1760 (21.5)
Study sample (n = 300) 84 (28.0) 190 (63.3) 26 (8.7) 119 (39.7) 181 (60.3) 46 (15.3) 15 (5.0) 65 (21.7)
P value
0.336
0.346
Corresponding author. Echevarriarza 3320 Apt. 701, CP11300, Montevideo, Uruguay. Tel./fax: +598 27065758. E-mail address: csosa@tulane.edu (C.G. Sosa).
Values are given as number (percentage). Total hospital population available for 2007. Using the 2 test.