Episiotomy is a common practice for all women delivering for the first time. The reason for its popularity included substitution of a straight surgical incision, which was easier to repair, for the ragged laceration that might result in its absence. Episiotomy, incision of the perineum at the time of vaginal childbirth, is a common surgical procedure experienced by women.^[1] The rationale for Routine prophylactic episiotomy is to protect the pelvic floor, thereby minimizing the risk of urinary incontinence and pelvic floor dysfunction.

FIGO endorses the restrictive use of episiotomy, rather than its routine use. Action needs to be exercised to decrease the rate of unnecessary episiotomies, which have potential for short-and long-term complications. To facilitate delivery and avoid perineal lacerations, episiotomy has been widely used to enlarge the birth canal. Although there is a global trend for reduced episiotomy rates,[2] these continue to be very high in some centers and areas of the world, with rates up to 60 and 80% in India and China, respectively.^[3,4]

There is no universally accepted rate of episiotomy for non-operative vaginal delivery in a normal labor ward, but the WHO recommends a rate of 10%, based on a 1984 English trial.[5] The latest Cochrane review on the other hand reports a rate of 28% in the restrictive episiotomy group.[6] A rate somewhere in the middle seems right.The need to reduce episiotomy rates stems from evidence that episiotomies cause serious perineal lacerations, rather than prevent them.^[7] Midline episiotomy is a strong independent risk factor for third-and fourth-degree perineal lacerations.^[8]

 On the other hand, routine mediolateral episiotomy decreases the risk of anterior perineal lacerations, but increases the risk of posterior perineum lacerations, and the need for suturing.^[9] Even in the context of shoulder dystocia, episiotomy has not been shown to have clear benefits.^[10] There is some evidence that women with a prior episiotomy have a two-fold increased risk of 2nd degree lacerations in subsequent vaginal deliveries.^[11]

 In addition, there is evidence that episiotomy may be associated with a decrease in pelvic floor musculature strength,^[12] more perineal pain, and future dyspareunia, when compared with spontaneous laceration. The effect of mediolateral episiotomy on obstetric anal sphincter injuries (OASIS) in spontaneous vaginal deliveries is not completely clear. Routine episiotomy should be avoided, but this does not mean that the procedure is withheld in all circumstances. In some situations, it prevents serious lacerations and may expedite delivery in fetuses

thought to be hypoxic.

               Episiotomy should be reserved for situations where there is a clear indication. Selective use of episiotomy can result in a 30% reduction in vaginal and perineal injury.

Mediolateral episiotomy is associated with a lower risk of obstetrical injuries, when compared with midline episiotomy.^[11] There are some modifications of the procedure that can reduce risk of lacerations. Performing an episiotomy before crowning is associated with increased vaginal trauma, longer average incision length, and greater average estimated blood loss, and should therefore in principle be avoided.[13] In 2006, ‘ACOG committee on practice bulletins,’ based on good scientific evidence, recommended that restricted use of episiotomy is preferable to its routine or liberal use.^[14]

OBJECTIVES:

1. Comparison of restrictive use of episiotomy versus routine episiotomy in primigravida undergoing vaginal birth
2. To compare the outcome of restricted versus routine use of episiotomy

Study Design: Prospective study

Study Centre: Department of OBGY, Rohilkhand Medical College and Hospital Bareilly.

Study Population: All full term labor cases admitted in labor room of Rohilkhand Medical College and Hospital Bareilly during study period such cases were included in the study,

Sampling method: Convenient sampling

Period of Study: December 2023 to December 2024

Sample size: 280 cases divided randomly into two groups’ one study group and another was control group

Inclusion Criteria:

1. All full term labor cases under going normal delivery

Exclusion criteria:

1. Instrumental deliveries
2. Preterm deliveries
3. Abnormal presentations
4. Vaginal birth after caesarian (VBAC)
5. Multiple gestations.

Approval for the study:

Written approval from Institutional Ethics committee was obtained beforehand. Written approval of OBGY and other related department was obtained. After obtaining informed verbal consent from all patients undergoing normal delivery such cases were included in the study.

Study procedure:

Study subjects were enrolled after obtaining clearance from ethics committee. All the subjects were explained in detail about study procedure in language she understands.

Informed written consent was obtained from study participants. Predesigned and pretested study proforma was used as a tool for data collection. Data was collected about sociodemographic characteristics, Parity, gestational age in weeks, ANC visits.

Details of each delivery were recorded with specific attention given to the age of patient, parity, episiotomy, birth weight of the neonate and need for NICU admission. Ascoring system was devised to record the severity of perineal laceration. Intact perineum and first-degree perineal tears were given a score of 0. Episiotomy and second-degree perineal tears were given a score of 1, and third and fourth degree tears were given a score of 2.

Data Analysis:

All the data collected was entered in excel spreadsheet and analyzed using SPSS version 21 software. Chi square test was used to study associations. P<0.05 was considered as significant

Table no: 1 Distribution of episiotomy by Parity

The above table shows distribution of episiotomy among primipara control and study group cases. Total normal delivery cases were 48 in control group and 56 in study group. Proportion of episiotomy among control group cases was 91.66% (44) and 28.57% (16) in study group cases. In multipara Total normal delivery cases were 92 in control group and 84 in study group. Proportion of episiotomy among control group cases was 44.56% (41) and 11.90% (10) in study group cases.

Table no: 2 Distribution of perineal tears among Primipara

The above table shows distribution of perineal tears by Primipara among control and study group in multipara. Proportion of second degree perineal tears among control group cases was 2.08% (01) and 19.64% (11) in study group cases.

Table no: 3 Distribution of perineal tears by Multipara

The above table shows distribution of perineal tears by Primipara among control and study group in multipara. Proportion of second degree perineal tears among control group cases was 2.08% (01) and 19.64% (11) in study group cases.

Table no: 4 Distribution of control Group according to age and parity

The above table shows distribution of control Group according to age group in Primipara

 Highest frequency found in the age group of 21-24 years i.e. 41.67 % (20) followed by ≤20 age group i.e.37.5% (18) and followed by 25-29 years age group i.e.16.67% (08) . The proportion of control group in the age group of 30-34 years, and above 35 years were 2.08% ,2.08% respectively.

 The above table shows distribution of control Group according to age group in Multipara Highest frequency found in the age group of 30-34 years i.e. 43.47 % (40) followed by 25-29 years age group i.e.22.82 % (21) and followed by 21-24 years age group i.e.18.47 % (17) The proportion of control group in the age group of years ≤20 and above 35 years were 11.95% (11) , 3.26 % (03) respectively.

Table no: 5 Distribution of study Group according to age and parity

The above table shows distribution of study Group according to age group in Primipara Highest frequency found in the age group of 21-24 years i.e. 42.85 % (24) followed by ≤20 age group i.e.39.28 % (22) and followed by 25-29 years age group i.e.14.28 % (08) The proportion of study group in the age group of 30-34 years, and above 35 years were 1.79 % ,1.79 % respectively.

The above table shows distribution of study Group according to age group in Multipara Highest frequency found in the age group of 30-34 years i.e. 45.23 % (38) followed by 25-29 years age group i.e.23.81 % (20) and

followed by 21-24 years age group i.e.22.62 % (19) . The proportion of study group in the age group of years ≤20 and above 35 years were 5.96% (05) ,2.38 % (02) respectively.

Table no: 6 Distribution of episiotomy as per birth weight

The above table shows majority of cases found in 2.5 to 2.9kg weight group 89 in control group 61 observed with Episiotomy, 81 in study group 10 cases found with Episiotomy. 3-3.5kg control group total 22 cases 14 episiotomy and total 27 cases in study group 9 episiotomy. <2.5kg in control group 22 cases 5 found with episiotomy and 27 in study group 2 cases with episiotomy.

 Table no: 7 Distribution of perineal lacerations by birth weight

The above table shows majority of newborn birth weight was 2.5 to 2.99kg. Perineal lacerations, in the study group was 18.57% (n = 26), which was significantly less when compared to 60.71% (n = 85) in the control group

Episiotomy has been routinely used to facilitate delivery. Maternal benefits attributed to the use of episiotomy include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction, prolapse, urinary incontinence, faecal incontinence, and sexual dysfunction. Potential benefits to the foetus were thought to include a shortened second stage of labour resulting from more rapid vaginal delivery 3.

This routine use of episiotomy has resulted in many researchers questioning the very purpose of this procedure, as well as questioning the potential benefits attributed to episiotomy. Liberal or routine use of episiotomy has also resulted in overlooking the potential

adverse consequences of episiotomy.

Maternal morbidity due to perineal trauma and episiotomy has been a subject of many studies. Macarthur AJ et al studied perineal pain inflicted due to perineal trauma and the average number of weeks from delivery until cessation of perineal pain. They concluded that women with intact perineum were pain free after 1.9 weeks, whereas women with second-degree perineal tears recovered after 2.4 weeks. Women with episiotomy recovered from perineal pain after 2.6 weeks 6. SartoreAet al concluded from their study that mediolateral episiotomy does not protect against urinary or anal incontinence and genital prolapse [12].

In current study distribution of episiotomy among primipara control and study group cases. Proportion of episiotomy among control group cases was 91.66% (44) and 28.57% (16) in study group cases. In multipara Total normal delivery cases were 92 in control group and 84 in study group. Proportion of episiotomy among control group cases was 44.56% (41) and 11.90% (10) in study group cases.

Saxena Rajiv et al [15] He revealed that the control group consisted of 85 primipara and 125 multiparous women. The study group constituted of 93 primipara and 155 multiparous women. The overall episiotomy rate in the control group was 68% (n = 142) and in the study group 24 % (n = 59). Dadhich B et al [16] He found that the about 29.8% women delivered with episiotomy, 65.5% had intact perineum; 5.67% women had first-degree perineal tear and only 1.42% women had second-degree perineal tear using a policy of restricted use of episiotomy.

Klein MC, Kaczorowski J, Robbins JM [17] He found that the episiotomy use: 10.2% in the restrictive use group and 51.4% in the routine use group. Women in the restrictive use group were more likely to have an intact perineum; 33.9% in the restrictive use group had neither posterior perineal lacerations nor episiotomy compared with 24.3% in the routine use group.

In current study distribution of perineal tears by Primipara among control and study group in multipara. Proportion of second degree perineal tears among control group cases was 2.08% (01) and 19.64% (11) in study group cases. In current study shows distribution of perineal tears by multipara among control and study group in multipara. Proportion of second degree perineal tears among control group cases was 2.08% (01) and 19.64% (11) in study group cases.

Saxena Rajiv et al [15] He reported that study group 37 primiparas (40%) and 22 multiparas (14%) delivered with an episiotomy Among primiparas in the control group there were no tears recorded. In the study group 13% (n = 12) primiparas had second-degree tears and 2% (n = 2) had severe degree perineal tears. Among multiparas, in the control group 1.6% (n = 2) had second-degree tears, whereas, in the study group second-degree tears were noted in 10% (n = 16).

Klein MC, Kaczorowski J, Robbins JM [17] He found that the Women in the restrictive use group were more likely to have an intact perineum; 33.9% in the restrictive use group had neither posterior perineal lacerations nor episiotomy compared with 24.3% in the routine use group. Third- and fourth-degree lacerations were rare (0.5% overall) and did not differ by group.

In current study shows majority of cases found in 2.5 to 2.9kg weight group 89 in control group 61 observed with Episiotomy, 81 in study group 10 cases found with Episiotomy. 3-3.5kg control group total 22 cases 14 episiotomy and total 27 cases in study group 9 episiotomy. <2.5kg in control group 22 cases 5 found with episiotomy and 27 in study group 2 cases with episiotomy. Saxena Rajiv et al [15] There was no third or fourth degree tears noted in either group of multiparas In the study group when the neonate weighed less than 3.5 Kg, then the episiotomy rate was only 22%, whereas with neonate weighing more than 3.5 Kg the episiotomy rate was significantly higher 62% (P < 0.001).

In current study shows majority of newborn birth weight was 2.5 to 2.99kg. Perineal lacerations, in the study group was 18.57% (n = 26), which was significantly less when compared to 60.71% (n = 85) in the control group. Saxena Rajiv et al [15] The total number of parturients who had perineal lacerations, in the study group was 36% (n = 89), which was significantly less when compared to 69% (n = 144) in the control group (P <0.001)

The policy of restricted use of episiotomy resulted in considerable reduction in maternal morbidity due to perineal lacerations, without any increase in adverse neonatal outcome. This policy of restricted use of episiotomy may be adopted as a norm for singleton vaginal term deliveries to improve the maternal outcome.

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