Mediolateral episiotomies: more astute decisions and fewer acute incisions
When a mediolateral episiotomy is performed at an angle of 60° from the midline, it is associated with the lowest incidence of an obstetric anal sphincter injury. However, it has been reported that doctors and midwives believe a mediolateral episiotomy should be performed at 45o from the midline. The aim of this study was to assess doctors’ and midwives’ awareness of the optimal technique when performing a mediolateral episiotomy.
An interview-administered questionnaire, with an associated pictorial diagram, was completed by 78 doctors and midwives in a London maternity unit.
Midwives reported that mediolateral episiotomy should be performed at a significantly more acute angle than doctors (45° compared with 60°, P<0.05). Doctors and midwives that had been supervised for at least 10 mediolateral episiotomy procedures were significantly more likely to be aware of (45° compared with 60°, P=0.04) and depict (50° compared with 60°, P=0.03) an optimal mediolateral episiotomy, which is performed at 60° from the midline.
Midwives and doctors that had been supervised for at least 10 mediolateral episiotomy procedures prior to independent practice knew that a mediolateral episiotomy should be performed at 60° from the midline; therefore, consideration should be given to making supervised practice mandatory, to minimise risks to pregnant people.
Obstetric anal sphincter injuries occur in 2.9% of vaginal deliveries in the UK (Thiagamoorthy et al, 2014), and 38% of pregnant people experience anal incontinence following primary repair of an obstetric anal sphincter injury (Sideris et al, 2020). A mediolateral episiotomy is known to reduce the risk of obstetric anal sphincter injuries during assisted vaginal deliveries (van Bavel et al, 2018). In nulliparous pregnant people, mediolateral episiotomies are associated with an eightfold reduction in the rate of obstetric anal sphincter injuries during forceps birth and a sixfold reduction during vacuum extraction (van Bavel et al, 2018).
Some 64% of midwives and obstetricians have reported dissatisfaction with their training prior to performing their first perineal repair (Andrews et al, 2005). In the UK, it is now mandatory for trainees in obstetrics and gynaecology to attend a practical training course in perineal trauma. In addition, the Royal College of Obstetricians and Gynaecologists have introduced an objective structured assessment of technical skills. Trainees in obstetrics and gynaecology have to demonstrate competence in this technical skill prior to completing their specialist training (Royal College of Obstetricians and Gynaecologists, 2021). Similarly, preceptee midwives must witness and undergo supervision when performing perineal repairs.
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