1. Comparison of episiotomy rates in Anuradhapura Teaching hospital (ATH) and Labour room C, Castle street Hospital (LRC CSHW)

3. Episiotomy is often called the unkindest cut of all. Episiotomy rates in the world ranged from 8.3% in UK to 100% in Thailand. Episiotomy is medically warranted probably in less than 10% of NVDs.

4. A systematic review on outcomes of routine episiotomy concludes: That evidence do not support maternal benefits traditionally ascribed to routine episiotomy. In fact the outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury, instead had a surgical incision. Kathrine Hartmann, et al; JAMA 2005.

5. Outcome measures 1.Rate of episiotomy. 2.Type of analgesia used during labour and prior to episiotomy. 3.Complications due to episiotomy within 24hours after delivery.

6. Methodology

7. Hospital based retrospective study. Data collected from birth registry & BHTs of all NVDs from: 20 th April – 20 th May 2011 at ATH (30d) and 20 th March – 20 th May 2012 at LRC CSHW (60 days)

8. Excluded from the study : preterm births (<37 weeks), non-vertex presentations, multiple pregnancies, VBAC and instrumental deliveries

9. Results & discussion

10. Comparison of POA at delivery, BWs and age of the women ATH CSHW p value (t test) POA Average 39wks+4d 39 wks p<0.01 SD 1.5 1.2 BW Average 2860.8g 3000.7g p<0.01 SD 189 194 Age Average 25.6yrs 27.8yrs p<0.01 SD 4.2 4.7

11. There was a significant difference in the; average POA at delivery, mean age, and the mean BW at the above two units (P<0.01)

12. The different IOL practices at the two units may have contributed to the significant statistical difference of the mean POA at delivery.

13. 2007 Govt statistics: average BW; SL = 2886g Colombo = 2935g Anuradhapura = 2857g statistical significant difference in the mean BW can be attributed to the regional variations (urban & rural population).

14. comparison of episiotomy rates at the two units ATH CSHW P value (Pearson’s chi square test) NVDs 799 283 Number of episiotomies 463273P<0.01 Episiotomy rate 59% 96.5%

15. Episiotomy rate at LRC CSHW was significantly higher than ATH 96.5% & 59% (P<0.01) Yet, both units have a higher rate than the WHO recommended rate of 10%

16. Comparison of Episiotomy rate among nulliparous women ATH CSHWP value (Pearson’s chi square test) Nulliparous (n) 406 135 Episiotomy (n) 345 132 Episiotomy rate 85% 97.8% P<0.01

17. Comparison of Episiotomy rate among multiparous women ATH CSHW P value (Pearson’s chi square test) multiparous (n) 393 148 Episiotomy (n) 118 139 Episiotomy rate 30% 94% P<0.01

18. The rate of episiotomy was significantly higher statistically at CSHW among both nulliparous & multiparous women compared to ATH p<0.01

19. There was no significant difference in the rate of episiotomy between Primi and multiparous women at LRC CSHW. 97.8% & 94% (p=0.16)

20. There was a significant difference in the rate of episiotomy between Primi and multiparous women at ATH. 85% & 30% (p<0.01)

21. comparison of the time in LR until delivery, analgesia during labour and analgesia prior to performing episiotomy at the two units ATH CSHWP value Time in LR till delivery mean 176 minutes189 minutes Time range 12-560 min06 – 756 min Analgesia during labour Pethidine 234 (29%)94 (33%)P=0.21 Epidural 0002 Analgesia for episiotomy 00

22. None of the women at ATH or CSHW had effective analgesia prior to performing episiotomy, except in two women who had epidural anaesthesia at CSHW.

23. Complications due to episiotomy within 24 hours after delivery

24. There was no significant difference of the documented complications (within 24 hours) due to episiotomy at the 2 units. 2.6% ATH & 2.9% CSHW, p=0.7

25. Only at CSHW that low Hb% (<8g/dl) was documented in 3 women who had excessive bleeding / haematoma formation following episiotomy. (AN Hb% was normal)

26. Although post episiotomy pain is common, none of the BHTs had documented this complication at both the above units.

27. Rate of complications in nulliparous and multiparous women compared ATHCSHWP value Number of complications In nulliparous women 12 (345)05 (135) Rate 3.47%3.78%P=0.9 Number of complications In multiparous women 00 (118)03(139) Rate 0%2.27%P=0.1

28.  The rate of complications due to episiotomy was not statistically significant among the nulliparous (P=0.9) and multiparous women (p=0.1) when both units were compared.

29. There were no complications documented among multi parous women at ATH. The rate of complications was significantly low in multiparous women compared to nulliparous women at ATH (p= 0.014).

30. Rate of 3°perineal tears ATHCSHWP value 3°perineal tears n 05 02 rate 0.63%0.71% P=0.6 Labial tears n 03 01 rate 0.64% 0.36% P=0.6

31. Third degree perineal tears were within the range of reported incidence in literature(0.6-0.9%). There was no significant difference at the 2 units. ATH 0.63% & CSHW 0.71% p=0.6

32. Conclusion

33. The rate of episiotomy at CSHW was significantly higher than ATH. Episiotomy rates at both units were higher than recommended rates.

34. There was no significant difference in the rate of complications due to episiotomy. This may be due the higher rates of episiotomy than the recommended 10-15% at both units.

35.  The rate of complications due to episiotomy within 24hours was significantly low in multiparous women compared to nulliparous women at ATH (p= 0.014).  The rate of episiotomy was 30% in multi compared 85% in nulliparous.

36. Practise of analgesia prior to performing episiotomy was insufficient at both units.

37. Suggestions

38. WHO guideline on care in normal birth recommends a 10% rate of episiotomy, to be without harm to the mother or the infant. Routine episiotomy for nulliparous women is no longer recommended. There is no evidence of benefit from the use of routine episiotomy over restrictive episiotomy even in nulliparous women

39. NICE guideline on intrapartum care recommends (2007)

40. Carry out an episiotomy only when there is a clinical need such as : ● instrumental birth ● suspected fetal compromise Use medio-lateral technique, use effective analgesia

41. Evidence over the last 2 decades show that many women fare better without episiotomy, because the natural tears they suffer are often less severe than the episiotomy.

42. Some studies have suggested that a rate above 30% cannot be justified. While others have suggested rates of 10-20% to be appropriate/safe.

43. Sri Lankan birth attendants should be trained and educated to improve evidence based child birth practices, with more emphasis given to effective pain relief for episiotomy and labour.

44. If men had to have babies, they would only ever have one each !

45. presented by Dr.TRN Fernando, Lecturer, Obstetrics & Gynaecology, FMAS, RUSL.

46. Thank you

47. Acknowledgements  Dr. YAG Perera (consultant Obstetrician & Gynaecologist) CSHW.  Dr A. Amarasiri (consultant Obstetrician & Gynaecologist), ATH 2011.  Dr A. Jayasiri (consultant Obstetrician & Gynaecologist), ATH 2011.  Dr MAJS Fernando,(RHO,CSHW 2012)  Dr PB Samarasinghe, (RHO,CSHW 2012)  Students of group 8, 2005/06, FMAS, RUSL. (collected data from ATH)