Journal of Public Health Medicine

Vol. 20, No. 4, pp. 422-427 Printed in Great Britain

Episiotomy and perineal tears in low-risk UK primigravidae

F. L R. Williams, C. du V. Florey, G. J. Mires and S. A. Ogston

Abstract
Background The aim of the study was to determine the rates and to describe the risk factors for episiotomy and perineal tears in low-risk primigravidae. Method A cross-sectional survey of 101 randomly selected NHS hospitals in the UK was carried out between February 1993 and January 1994. Subjects were 40 consecutive lowrisk primigravidae in each hospital. The main outcome measures were number and reasons for episiotomy, and number and degree of perineal tears. Results A large proportion of women (83 per cent) experienced some form of perineal trauma. Forty per cent of the women had an episiotomy only, 6 per cent an episiotomy and perineal tear, and 37 per cent perineal or other tears without episiotomy. The main reasons for performing an episiotomy were foetal distress (27 percent), impending tear (25 per cent) and delay of the second stage of labour (21 per cent). Fifty-nine per cent of women with a delayed second stage had a spontaneous vaginal delivery and 41 per cent required instrumental assistance. The likelihood of having an episiotomy increased with the duration of the second stage of labour, irrespective of type of delivery. Episiotomy rates varied appreciably throughout regions and hospitals in the United Kingdom, ranging from 26 to 67 per cent. There was also a large regional variation in the rates of perineal trauma; generally, high rates of one outcome were associated with low rates of the other. Compared with white women, women from the Indian sub-continent were almost twice as likely and those from the Orient almost five times as likely to have an episiotomy. Conclusions The magnitude of the geographical variation suggests a lack of uniformity in indications for performing episiotomies and that guidelines for performing episiotomies may need to be reviewed. The rates of episiotomy in women from the Indian sub-continent and Orient were very high compared with those for white women, and this requires clarification and explanation, as they are contrary to rates experienced in these ethnic groups in other countries. Keywords: episiotomy, low-risk primigravidae, ethnicity, geographical variation

and multiparous deliveries in Argentina,1 in over 50 per cent of hospital-based deliveries in the United States,2 and in 30 per cent of deliveries in Sweden. 3 In England and Wales the rates increased from 25 per cent of all deliveries in 1967 to 53 per cent in 1978.4 Recent data derived from the rather patchy returns to the Maternal Hospital Episode Statistics suggest that the multigravid rates in England have fallen to 20 per cent in 1994-1995. 5 Some textbooks of obstetrics comment that episiotomies will be necessary in almost all primigravidae. 6 The procedure is not routinely recommended in the United Kingdom7 and there is controversy about how many should be performed. The Argentine Episiotomy Trial Collaborative Group1 reported that episiotomy rates above 30 per cent cannot be justified for multiparae and above 40 per cent for primigravidae. The supposed maternal benefits of episiotomy include a reduction in third and fourth degree tears, preservation of the muscle of the pelvic floor, and more speedy healing.8 For the infant it is suggested that the procedure minimizes the risk of foetal asphyxia, cranial trauma, cerebral haemorrhage and mental retardation.7 However, there is evidence that the maternal benefits may not be uniformly experienced and there are reports suggesting that episiotomies may result in an increased loss of blood, 9 a higher infection rate, 10 and an increase in third- and fourth-degree lacerations." As part of a study of intrapartum care we have investigated perineal trauma in primigravidae in the United Kingdom. In this paper we report the rates and describe the risk factors for having an episiotomy and the numbers and degree of perineal tears.

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Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY. F. L. R. Williams, Lecturer C. du V. Florey, Professor, Head of Department S. A. Ogston, Lecturer Department of Obstetrics and Gynaecology, University of Dundee. G. J. Mires, Senior Lecturer, Consultant Address correspondence to Dr Williams. Oxford University Press 1998

Introduction
Episiotomy is a commonly performed surgical procedure of childbirth but globally the rates vary considerably. They have been reported to occur in 83 per cent of routine primigravid

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Methods
A sampling frame of all the consultant maternity units in the United Kingdom was obtained from the annual returns to the Royal College of Obstetricians and Gynaecologists. Two hundred and twenty-six hospitals were identified in which 1000 or more births per annum were delivered. Hospitals delivering fewer than 1000 births per annum were excluded so that data collection could be completed in one year. The target sample size was 4040 women. One hundred and one hospitals were randomly selected and invited to take part in the study. Each hospital was asked to collect data on the labour of 40 consecutive eligible primigravidae. Data were collected also about primigravidae who did not meet the entry criteria so that information was available about consecutive primigravidae delivering in each hospital while the study was continuing. Data were collected between February 1993 and January 1994. The women were entered into the study if they were National Health Service patients with an uneventful antenatal period, delivering in hospital after 36 completed weeks of pregnancy and with foetal head presenting. Primigravidae were selected because they start from the same level of maternal experience. The exclusion criteria aimed to exclude women with antenatal complication or a foreseeable intrapartum complication. The exclusion list included, for example, previous surgery on the reproductive tract, severe continuing illness, known substance abuse, antenatal admission over 24 hours, induced labour, and breech or transverse lie. A fuller description of the methods has been published elsewhere.12 Data about the type and degree of tear were collected by midwives using a specifically designed abstraction form. Data were analysed using SPSS for Windows. With episiotomy as the dependent variable, forward stepwise multiple logistic regression was used to estimate the influence of 14 covariates: size of hospital, geographical location, delivery in a teaching or non-teaching hospital, one- or two-parent family, gestational age, the durations of the first, second and third stages of labour, type of delivery, mother's age, ethnic origin and social class, and birth weight and sex of the baby. The analysis was performed twice. In the first, all the covariates were entered stepwise into the model. In the second analysis only the covariates significantly associated with episiotomy (p<0.05) were entered. Using this approach minimized the effect of missing values on the number of observations which could be used. Because of the association between instrumental delivery and the use of episiotomy, the regression analyses were repeated separately for women having a spontaneous vaginal delivery and for those having either forceps or ventouse delivery. The significance of episiotomy adjusted for the 14 covariates was assessed by computing the Wald \2, which is reported by SPSS.13 It is a measure of the overall significance of the variables when considered simultaneously.

Results
Ninety-eight hospitals (97 per cent) participated in the study. Abstraction forms for 3160 women (81 per cent of expected) were completed and returned. Ninety-two hospitals provided information about women excluded from the study. The ratio of included to excluded women was 1.05:1. The mean number of excluded women was 31 per hospital, range 1-89. The most frequently given reason for exclusion were induced labour (42 per cent) and antenatal admission over 24 hours (24 per cent). Episiotomies were performed on 46 per cent of the women (1454/3160); 14 per cent (199/1454) also had perineal or other tears (Table 1). The most frequently given reasons for performing an episiotomy were foetal distress (27 per cent), impending tear (25 per cent) and delay in the second stage (21 per cent) (Table 2). The majority of women with a delayed second stage had a spontaneous vaginal delivery (59 per cent); 41 per cent required instrumental assistance. Just over one-third (1172/3160) did not have an episiotomy, but had perineal or other tears (Table 1). Forty-three per cent (199+1172) had a first-, second- or third-degree perineal or other tear. In common with previously reported data, the most common tear was second degree (57 per cent).1415 Twenty-three women had third-degree tears; of whom 12 had had episiotomies (Table 3). The likelihood of having an episiotomy was significantly higher when the second stage of labour exceeded one hour. The proportion of women having episiotomies showed marked

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Table 1 Trauma during delivery Number Episiotomy Episiotomy and perineal and other tears Perineal and other tears Not applicable - caesarean section* Missing data or no tearst Total 1255 199 1172 190 344 3160 % 39 7 6.3 37.1 60 10.9 100.0

'Excludes three women who had episiotomies at some point before a caesarean section during their second stage of labour. tSeparation of missing data and no tear is impossible in this data set.

Table 2 Reasons for performing an episiotomy Reason Foetal distress Impending tear Delay in second stage Unit policy Other* Total Number 475 443 373 26 464 1781 % 26.7 24.9 20.9 1.5 26.1 100.0

*Fifty-six per cent of 'other' was instrumental delivery or rigid perineum.

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JOURNAL OF PUBLIC HEALTH MEDICINE Table 3 Severity of perineal tear according to type of trauma
Severity of tear First degree Second degree First and second degree Third degree (Incomplete data and N/A)* Total (Total) Perineal tears 3297 588 3 11 (241) 931 (1172) Episiotomy with and without perineal tears 32 161 1 12 (1248) 206t (1454) (N/A and incomplete data) Total 391 784 4 23 (1958) 1202 (3160)

30 35 0 0 (469) 65 (534)

*The categories of incomplete data and not applicable include genuinely missing data but also some data for women who would not be expected to have perineal tears. For example, the column for episiotomy and episiotomy with perineal tears includes the women who had just an episiotomy (without a perineal tear) and the last column includes women who had a caesarean section tSeven women had more than one tear (199 + 7 = 206)

geographical variation, ranging from 26 to 67 per cent. In general, high (or low) rates for episiotomy were balanced by low (or high) rates for perineal or other tears (r=-0.85). Mode of delivery was very strongly related to episiotomy, and the likelihood of an episiotomy increased 19 times for women having instrumental delivery when compared with spontaneous vaginal delivery (Table 4). We repeated the analysis for women separated according to instrumental delivery and spontaneous vaginal delivery. The risk factors were the same for women having a spontaneous vaginal delivery as for the whole group. By contrast, for women who had instrumental delivery the rates of episiotomy were significantly higher with greater maternal age, with longer second stage of labour, for mothers who were not married or cohabiting, and varied by geographical region. The rates of episiotomy for women from the Indian subcontinent were almost double those of white women and almost five times higher in women from the Orient. This relation persisted when the analysis was performed for only spontaneous vaginal deliveries and was present, but less significant because of smaller numbers, for deliveries requiring instrumental assistance. The small numbers in these ethnic groups make interpretation of the data difficult. However, the women originated from many hospitals (41 for women from the Indian sub-continent and 20 for women from the Orient) and therefore extreme rates in a small number of hospitals is not the explanation for the high rates in these groups.

Discussion
This is the first paper to report regional rates of episiotomy and perineal tears in UK primigravidae. There were four major findings. First, women from the Indian sub-continent and the Orient had significantly higher rates of episiotomy than white women. This finding is in contrast to the experience of women from these ethnic groups living in countries outside the United Kingdom. Second, there was a large variation in the rates of episiotomy according to geographical region of the United

Kingdom. Third, a large majority (83 per cent) of women had some form of perineal trauma. Fourth, the risk of episiotomy increased according to the length of the second stage of labour, irrespective of whether or not instrumental assistance had been necessary. It is unclear why women from the Indian sub-continent and from the Orient should have such high episiotomy rates. If our findings can be confirmed, it would be important to determine whether or not there is any physical or clinical justification for this variation. In the Netherlands two groups have reported associations between ethnicity and episiotomy.16'17 The work by Gerrits et a/.16 excluded women of Asiatic and African origin, because of small numbers, and refers only to women of European and Mediterranean origin. In these women the proportions of episiotomy were respectively 40 per cent and 34 per cent. The terms 'of European and Mediterranean origin' were not explained. In the other Dutch study17 ethnicity had an independent effect on the risk of episiotomy. Twenty-seven per cent of Mediterranean, Creole and Hindu women had an episiotomy compared with 50 per cent of white Dutch women (odds ratio 0.47; 95 per cent confidence interval (CI) 0.44-0.51). Forty-three per cent of women from Asia had an episiotomy and an odds ratio of 0.76, 95 per cent CI 0.66-0.87, compared with white Dutch women. In a study from Jamaica,18 only 0.3 per cent of women had an episiotomy. The data were not categorized by parity, but out of 995 deliveries, 32 per cent were primigravidae, 75 per cent were discharged with an intact perineum, and 25 per cent suffered laceration of whom only 17 per cent required suturing. The large geographical variation in rates throughout the United Kingdom reflects controversy about whether to perform an episiotomy or to let the perineum tear. The lowest rates were almost half those of the highest. So great a variation suggests that there is scope to reduce the episiotomy rates, perhaps through implementation of national guidelines. The high negative correlation between the rates for episiotomy and perineal tears suggests that hospitals follow a policy either to

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Table 4 Significant associations in the multiple regression analysis with the proportion of women having an episiotomy as the dependent variable Variable Geographical region 1* 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Woman's ethnic group White* Indian sub-continent Afro-Caribbean Oriental Other Duration of stage II (hours) n/total (%) 44.05 39/70 (56) 107/265(40) 63/164(38) 10/36(28) 50/104(48) 147/331 (44) 113/242(47) 9/35 (26) 90/183(49) 33/82 (40) 44/85 (52) 98/214 (46) 162/340(48) 82/181 (45) 91/163 (56) 57/142 (40) 95/142 (67) 164/331 (43) 15.81 1326/2883 (46) 59/106(56) 18/66(27) 16/24(67) 17/48(35) 28 45 625/1617(39) 426/764 (56) 220/301 (73) 58/80 (73) 36/62 (58) 220.09 2326/3160(74) 591/3160(19) <0.0001 1.00 19.20 13.0-28.38 <0.0001 1 00 1.47 2.27 1.46 1.62 1.19-1 81 1.58-3.26 0.70-3.05 0.75-3.47 0.0033 1.00 1.83 0 27 4.87 0 52 1.10-3.14 0.33-1 56 1.54-15 44 0.23-1.14 df 17 <0.0001 1.00 0.43 0 41 0.20 0.62 0 62 0.54 011 0.51 0 46 0.73 0.52 0.65 0 57 0.89 0 52 1.28 0 45 0.22-0 84 0.20-0.84 0.06-0.68 0.28-1.34 0.32-1.20 0.27-1.07 0.03-0.41 0.25-1.03 0 19-1 13 0.32-1.66 0.25-1 06 0.33-1.26 0.28-1.16 0.43-1.82 0.25-1 12 0.60-2.73 0.23-0.87 Odds ratio

95% Cl

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0-0.9* 1-1 9 2-2.9 3-3 9 4+

Dehvery Spontaneous vaginal delivery Instrumental delivery

*This is the reference group, and has an odds ratio of 1.00.

allow women to tear or to perform an episiotomy. If this is the case, then a woman should be informed about the operating policy at the time she completes her birth plan and made aware of the advantages and disadvantages of each procedure. The entry criteria to the study were very strict to ensure exclusion of all foreseeable intrapartum complications and the common indications for performing episiotomy (breech delivery and preterm birth) did not apply. Despite this, 46 per cent of women had an episiotomy. The rationale for performing an episiotomy for maternal indications includes the prevention of severe perineal laceration and minimization of damage to the muscles of the pelvicfloor.However, there is controversy about the protective effect on the muscles of the pelvic floor.19'20 Research suggests that rather than limiting major damage, episiotomy may be associated with an increasedriskof third- and fourth-degree lacerations.20"22 Although in our study

very few women had third-degree lacerations, our findings are consistent with this view. The rate of third-degree lacerations was five times higher in women who had episiotomies when compared with women who had only perineal or other tears. There is no controversy about performing episiotomies for foetal indications; the purpose is to minimize distress and to reduce compression of the head.23 In our study maternal indications constituted 60 per cent of the reasons for performing an episiotomy. If episiotomies are really only necessary for foetal indications and the recommendation of the Argentine Episiotomy Trial Collaborative Group1 that the routine episiotomy rates in primigravidae of above 40 per cent cannot be justified then the high rate found in our study implies much unnecessary surgery. Our finding that 37 per cent of primigravidae with a spontaneous vaginal delivery had had an episiotomy is higher

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than the 26 per cent given for England in the Department of Health's analysis of the Maternity Hospital Episode Statistics (HES) for the year 1994-1995.5 The disparity was also observed for primigravidae requiring instrumental delivery 93 per cent compared with 76 per cent. The Department of Health's rates are unlikely to be comparable with our rates because of problems with data collection. For the period 19941995 the response was 'poor nationally and non-existent in some parts of the country'.5 Only 67 per cent of deliveries generated usable information for HES. The geographical coverage varied greatly and data collection was under 30 per cent in several regions. The differences in estimates between the two studies were not due to the inclusion of data from Scotland, Wales and Northern Ireland in the present study. Our English rate was the same as our UK rate (46 per cent). The rates in Wales and Scotland were lower whereas those in Northern Ireland were higher. Our study has shown a very different rate of use of episiotomy in the United Kingdom compared with the HES. We believe our rate may be closer to the true value because of a much higher acquisition of complete data. That the likelihood of episiotomy was significantly associated with duration of the second stage of labour is not surprising. Many hospitals recommended that this stage of labour should be limited to about one hour of active pushing, unless an epidural had been given. This policy may explain the increased risk of episiotomy with increasing duration of this stage; although only 11 per cent of women with a delayed second stage of labour had instrumental assistance. There is a some belief that the second stage should not be limited if the condition of mother and baby is satisfactory.23 If correct, then the policy to perform an episiotomy to expedite labour may be in need of review. The lower odds ratio observed for durations in excess of 4 hours in women having a spontaneous vaginal delivery is likely to be an artefact of small numbers in this category. We verified that the information was correctly coded and entered into the computer, but error in the abstraction form cannot be excluded. There is one methodological weakness in the study, which might affect the interpretation of the data. We asked for information about a consecutive number of women. Detailed data were requested about the women who were entered into the study and information was also requested about women who were excluded. In practice, not all hospitals returned information about the excluded women and not all hospitals returned information about 40 included women. We have no accurate way of determining the completeness of the returned data as, given the size of this study, it was not practicable to have an independent research in each participating hospital. The ratio of the included to excluded women indicates that our sample represented about 50 per cent of primigravidae delivering in the UK. This accords well with the frequently quoted figure of 40-50 per cent for truly low-risk primigravidae. Thus our excluded data set seems reasonable. The main concern for

this paper, however, are the data about the missing women who were eligible for inclusion. We obtained information on 81 per cent of the expected sample. However, we do not believe that appreciable bias was introduced as the shortfall in returns was spread over all participating hospitals and not concentrated in just a few. It could be argued that women experiencing very quick labours were missed and that our sample was biased towards more difficult labours. This would have led to overestimates of the proportions of episiotomy and perineal tears. However, we do not believe that hospitals missed any one group of women because the forms were specifically designed to be completed prospectively, by any midwife, as the labour progressed. Our sample included 6 per cent who delivered under four hours. The most likely explanation for the shortfall is simply that some forms were lost and that some women were inadvertently missed in a busy maternity unit. This study raises three concerns of particular relevance for public health medicine. First, why are women from the Indian sub-continent and the Orient who live in the United Kingdom experiencing such high rates of episiotomy in comparison with white women? Second, why do women delivering in the United Kingdom suffer from such high rates of perineal trauma in comparison with Jamaican women delivering in Jamaica? Third, do hospitals operate a policy of preferring perineal tears to episiotomies and vice versa, and if they do are women aware of the policy advocated when they complete their birth plan? The publication of Changing childbirth24 placed great emphasis on the need to orientate the maternity services more towards the needs and wishes of women. It also recommended that the service should be subject to regular clinical audit. We recommend that obstetricians and midwives through their Royal Colleges should develop a standard or guideline for performing episiotomies. They are a necessary prerequisite for undertaking audit and should result in the identification of an optimal episiotomy rate.

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Acknowledgements
We thank the CS AG sub-committee for their help and guidance (Professor V. R. Tindall, St Mary's Hospital, Manchester; Mrs S. Blunt, Solihull Hospital; Dr M. Bull, Headington; Miss R. Graham, St Mary's Hospital, Manchester; Miss M. Harwood, North Tyneside DGH, North Shields; Mrs R. Jenkins, Royal College of Midwives; Miss H. Mellows, Bassetlaw DGH, Notts; Ms A. Macfarlane and Ms C. Middle, National Perinatal Epidemiology Unit, Oxford; Ms V. Nix, Royal College of Nursing; Dr N. Patel, Ninewells Hospital, Dundee; Professor L. Regan, St Mary's Hospital Medical School, London); all midwives and obstetricians involved in the study for their tremendous support and goodwill; and the CSAG secretariat, Paul Marshall, Mark Noterman, Geoffrey Rees, for their help and enthusiam. The work was funded by DoH Research Grant JR121/3119.

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