Introduction
Episiotomy is typically a minor surgical procedure through which the introitus is enlarged to enable delivery of a neonate during the second stage of labor (Wahab et al., 2023). Episiotomy is among the most common procedures conducted among women during delivery, which healthcare practitioners have primarily used. According to Wahab et al. (2023), the WHO discourages episiotomy and recommends a 10% rate. Episiotomy is 10% in Europe and high in Asia, Africa, and South America (Wahab et al., 2023). Despite limits, episiotomy is common worldwide. In Brazil, Cesar et al. (2022) found that 51.3% of women had episiotomies during birth within five years. Mousavi et al. (2020) observed 54.4% episiotomy in Iran. About 80% of US women undergo episiotomy (Mousavi et al., 2020). Therefore, the prevalence of episiotomy is moderately high around the world; hence, it is necessary to understand its application and usage. It is essential to understand that the application of episiotomy has always been subject to controversy and debate. Some researchers believe that episiotomy is essential to improving APGAR score, preventing intracranial teas, simplifying recovery of episiotomy incision compared to tears, stopping severe and irregular perineal tears, and preventing incidences of pelvic floor muscle loosening (Mousavi et al., 2022). In addition, the study notes that researchers also note that the surgical incision during the surgical incision results in pain and sexual disturbances, which are annoying to the majority of women. The common complications observed among women who used the episiotomy include hematoma, bleeding, infections, extension of the incision, asymmetry, and skin tags.
Objective and purpose
This essay seeks to comprehensively investigate and understand the various aspects related to the complications of episiotomy. Therefore, it is a critical study to help analyze and examine the various types and occurrences of episiotomy per the most recent journal reviews. Thus, this essay purports to retrieve and review five peer-reviewed journals to shed light on the complications of episiotomy and its impacts on women’s postpartum health. Accordingly, this offers the direction of evidenced practice for healthcare professionals, specifically midwives, as it raises awareness of the prevalence, severity, and prevention measures for episiotomy complications. Therefore, this is a critical essay to guide and inform midwives and healthcare professionals to gain practical insights and knowledge towards understanding the need for episiotomy, its prevention measures, and the management of episiotomy.
Evidence retrieval
Literature analysis and discussion
The literature analysis is vital to comprehend the diverse trends, prevalence, and the associated factors connected to episiotomy and its complications. In their cross-sectional study, Cesar et al. (2022) note that episiotomy is a commonly observed procedure conducted among women in Southern Brazil during labor and delivery. According to Cesar and colleagues, approximately 51.3% of women undergo in Rio Grande of Southern Brazil in 5 years. However, the study notes that episiotomy has reduced from 2007 to 2019 by 70.9% and 19.4% respectively. The majority of women who underwent episiotomy were young (2.23), had more significant family income (1.25), higher education (1.21), primiparous (3.41), oxytocin-induced labor (1.18), private prenatal sector (1.25), newborn weight more than 4000grams, and those who underwent forceps (1.32). Albeit the episiotomy prevalence reduced during the period of study, the occurrence of episiotomy is likely to occur amidst women with a lower risk for developing birth complications. Despite restrictions, Cesar et al. (2022) noted that episiotomy has been conducted more than it should be within Rio Grande. As a result, it has contributed to potential complications such as dyspareunia, lacerations, and urinary and fecal incontinence. Therefore, this practice should be discouraged as a routine practice, and hence, it should be implemented as a selective and parsimonious practice to avoid potential harm to the clients (Cesar et al., 2022). Furthermore, this study paves the need to explore the factors associated with the presence of family members, mandatory authorization, and continuous care during episiotomy.
A different cross-sectional study by Mousavi et al. (2020) investigates the frequency and the early complications associated with episiotomy in Zahedan, Iran, between 2014 and 2016. According to the study, the rate of episiotomy between 2014 and 2016 was 54.5%, with a significant association with the age and parity of mothers. The study pinpoints that episiotomy contributes to high rates of perineal rapture, hemorrhage, 24-hour pain frequency, and hematoma. In addition, episiotomy lowers the APGAR scores of the first and the fifth minutes among neonates. However, it is noted that episiotomy does not impact the trauma related to the anterior vagina.
Furthermore, a prospective cohort study essayed by Pebolo et al. (2020) relates that the rate of episiotomy in a Ugandan hospital was 73%, implying that it is highly practiced. This is a critical study in nursing. tudy utilized the numerical pain scale (NPS) and the Redness, Ecchymosis, Edema, discharge, and Apposition (REEDA) scale to compare the women who underwent episiotomy and those who did not within Mulago National Hospital within the first 14 days of delivery. Accordingly, the study found a higher score of REEDA among women who used episiotomy compared to those who did not use episiotomy on both day one and day fourteen each p<0.0001. However, for the NPS, the scores were not significantly different on day 1 (p-0.541), but for day 14, those with episiotomy had a higher mean p<0.0001 (Pebolo et al., 2020). Hence, there is a potential difference between mothers who underwent episiotomy and those who did not. It is also noted that women who incurred more extended labor periods encountered higher scores of pain as compared to those who had shorter labor. Similarly, those who were highly educated experienced higher scores of pain as compared to those who were less educated. It is crucial to undertake post-natal review bi-weekly for episiotomy clients or those with teas to help manage morbidities. The study suggests the need to restrict episiotomy to help address its potential morbidity.
Wahab et al. (2023) examined the immediate perineal complications related to vaginal delivery with episiotomy (group B) and an expected vaginal delivery within a term pregnancy (group A). The complications reported for group A include cervical tears (3%), vaginal tears (5%), perennial tears (7.5%), para-urethral tears (1.6%), and mixed tears (1.7%) (Wahab et al., 2023). On the other hand, in group B the frequencies of complications include mixed tears (1.7%), cervical tears (2.6%), and vaginal tears (2.6%). Accordingly, it is crucial to understand that the study found no difference in the scores of pain among the two groups. Therefore, the study recommends the restriction of episiotomy since there were no notable differences between the complications experienced in groups A and B during delivery.
Moreover, a prospective cohort by Sule and Shittu (2003) investigated the epidemiological variables related to episiotomy and its complications at a teaching hospital in Nigeria. This study found a possibly low rate of episiotomy, which was 35.6% compared to other earlier studies. The study relate that 88.5% of primigravidas had episiotomy, which implies it is the highest in this group of mothers (Sule & Shittu, 2003). The mean time for repairing the episiotomy was 60.5 minutes. The pain was the most common complication, which occurred for an average of 5.5 days. The other potential complications comprised infections (23.7%), asymmetry (32.9%), skin tags (7.9%), partial dehiscence (14.5%), extension of incision (1.3%), and hemorrhage (5.3%). The study established that no risk factor was connected to the complications. The study suggests the need to re-acquaint accouncheurs for the episiotomy indications to help reduce the episiotomy rate, especially among the primigravida. It is also important to address pain relief and the time for delivery repair during episiotomy.
Recommendation
- Selective episiotomy: It is crucial to encourage the use of selective episiotomy and discourage routine care episiotomy. The use of selective episiotomy should be directed by evidence-based practice.
- Improved episiotomy care: It is also vital to foster improved pre and post-episiotomy care by encouraging appropriate assessment, management monitoring, and evaluation for effective episiotomy indication and care of complications.
- Education and training: Healthcare professionals and midwives should often be trained on up-to-date and evidence-based guidelines to help effectively indicate, apply, prevent, manage, and evaluate episiotomy.
Conclusion
Various studies have pinpointed the diverse complications that are associated with episiotomy. The most common complication that has been established is perennial pain. The research studies aligned that pain is a commonly seen aspect that is experienced by women undergoing episiotomy, and this affects maternal and neonatal well-being. The pain was shown to even extend in some cases beyond the recovery phase; hence, there is a need to stress the pain experienced by the others who underwent episiotomy. The other common complications highlighted by the studies comprise perennial tears, hemorrhage, dyspareunia, hematoma, and reduced APGAR scores for neonates. Understanding these complications is vital to help comprehend the best approaches to assessing, managing, monitoring, and reducing the specific complications to enable immediate repair. Thus, this calls for the need to mitigate and restrict the use of episiotomy, as the World Health Organization suggested.
i. References
Cesar, J. A., Marmitt, L. P., & Mendoza-Sassi, R. A. (2022). Episiotomy in Southern Brazil: prevalence, trend, and associated factors. Revista de Saúde Pública, 56, 26. https://www.scielosp.org/article/rsp/2022.v56/26/.
Mousavi, S. H. S., Miri, M., & Farzaneh, F. (2020). Episiotomy and Its Complications. Zahedan Journal of Research in Medical Sciences, 23(2). https://brieflands.com/articles/zjrms-104127.html.
Pebolo, P. F., Judith, A., & Dan, K. K. (2020). Episiotomy related morbidities measured using redness, edema, ecchymosis, discharge and apposition scale and numerical pain scale among primiparous women in Mulago National Referral Hospital, Kampala, Uganda. Pan African Medical Journal, 36(1). https://www.ajol.info/index.php/pamj/article/download/216367/204076.
Sule, S. T., & Shittu, S. O. (2003). Puerperal complications of episiotomies at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. East African Medical Journal, 80(7), 351-356. https://www.ajol.info/index.php/eamj/article/download/8717/1977.
Wahab, S., Kamran, Q., Karim, R., Khan, R., & Pervaiz, M. (2023). ASSESSMENT OF IMMEDIATE PERINEAL COMPLICATIONS OF NORMAL VAGINAL DELIVERY VERSUS VAGINAL DELIVERY WITH EPISIOTOMY IN TERM PREGNANCY IN A TERTIARY CARE HOSPITAL. J Med Sci, 31(1), 31-35. https://jmedsci.com/index.php/Jmedsci/article/download/1504/906.
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