Epidural Anesthesia, Episiotomy, and Obstetric Laceration M. P. R. WALKER, MD, D. FARINE, MD, S. H. ROLBIN, MD, AND J. W. K. RITCHIE, MD ‘The relationships among epidural anesthesia, forceps use, arity, episiotomy, and laceration were studied in 9493 ‘uncomplicated vertex deliveries of spontaneous onset and normal course. The use of epidural anesthesia was not associated with an increased incidence or severity of birth- canal trauma. Episiotomy was associated with a decreased rate of perineal laceration, but an overall increase in the rate Of perineal trauma. The trauma that did occur with episiot- ‘omies was four times more likely to be major than that when no episiotomy was performed. (Obstet Gynecol 77:668, 1991) The influence of epidural anesthesia on the number and severity of lacerations with or without episiotomy has received scant attention in the obstetric and anes- thesia literature." Epidural anesthesia may reduce the incidence of laceration by allowing more complete relaxation of the perineal muscles and thus a more gradual delivery of the fetal head. In contrast, the value of both routine and nonroutine episiotomy is being questioned increasingly in the obstetric litera- ture.*" Reviews of the available literature have failed to demonstrate any clear evidence of benefit in reduc- ing perinatal morbidity, protecting against genital pro- lapse, or decreasing perineal laceration. "= Our study aimed to explore the relationships among epidural anesthesia, episiotomy, and perineal lacera- tion, as well as the interaction between these factors and parity and the use of forceps in uncomplicated labors. Materials and Methods Information was abstracted retrospectively from the medical records of 15,293 deliveries performed at our From the Department of Obstetrics and Gynecology, Mount Siuai Hospital, Toronto, Ontario, Cenada, The authors would like to acknowledge the assistance of S, Wood, MD, inthe statistical analysis ofthe data 668 0020-7844/91189.50 center between October 1, 1986 and January 1, 1990. The study sample included all deliveries that were vertex, of spontaneous onset, between 38-42 com- pleted weeks’ gestation, and with normal progress of labor, and excluded labors complicated by fetal dis- tress. These inclusion criteria yielded records of 9493 deliveries. Information regarding these deliveries in- cluded parity, type of delivery (spontaneous, mid- or Tow forceps), analgesia (epidural or no epidural), and the presence or absence of an episiotomy (midline or mediolateral). Our hospital serves an urban, middle- class, predominantly white population. Our outcome variable was the occurrence of a per- ineal laceration. First-degree laceration was defined as a perineal laceration extending through the vaginal ‘mucosa and perineal skin only, second-degree as one extending into the perineal muscles, and third-degree as one involving the external anal sphincter. Fourth- degree lacerations were classified with third-degree in our data base. Information regarding the type of lacer- ation was entered into the data base at the time of delivery by the attending nurse. Perineal lacerations were classified as minor (first or second degree) or major (thitd degree). A group of 499 patients (5.3%) were classified as “other”; these patients mainly had periurethral tears and were not included in the analy- because of the probable heterogeneity of the lacer- ations within this group. Sixty-one patients (0.64%) had cervical lacerations. Results OF the 8994 patients with spontaneous, term vertex deliveries, 5249 were multiparous (58%) and 3745 were primiparous (42%), Of the primiparas, 2896 (77%) had an epidural anesthetic, compared with 2799 (53%) of the multiparas (x? = 541, P < .00001), The data were analyzed with the JMP statistical package (SAS Institute, 1989). Using a four-factor mul- Obstetrics & GynecologyTable 1. Degree of Perineal Laceration by Parity Table 2. Degree of Perineal Laceration by Episiotomy Primiparous Muliparoas (N= 3745) (N = 5249) Laceration ‘None n Minor rn a Major 5 1 Total 100 100 Trauma None (no laceration and no episiotomy) 3.7 4 Minor (minor laceration andior 17 cry episiotomy) Major laceration 46 16 Total 100 100 Data are presented as percentages, tivariate nominal response model, we examined the relationship between the severity of perineal laceration and the factors epidural anesthetic, forceps use, epi otomy, and parity. Main effects were found for parity, ‘use of either a midline or mediolateral episiotomy, and use of low or mid-forceps. Use of epidural anesthesia was not associated with perineal laceration (P = .2351). There were no statistically significant interactions among these factors. Table 1 demonstrates the relationship between par- ity and perineal laceration. Primiparas had a 29% laceration rate compared with 42% for multiparas; however, only 1% of the multiparas sustained major lacerations, compared with 5% of the primiparas (x? = 9.5, P = .0021). When women who had no episiotomy were examined separately, primiparas had an 83% laceration rate and multiparas 74%. If one considers an episiotomy as perineal trauma equivalent to a second- degree laceration, thus placing these women in a ‘minor perineal trauma group (Table 1), multiparas had an 86% perineal trauma rate compared with 96% in primiparas (,* = 325, P < .000001). Primiparas had a 4.6% rate of major perineal trauma compared with 1.6% in multiparas, giving an odds ratio of 3.01 (95% confidence interval 2.30-3.95). ‘Table 2 shows the distribution of perineal lacerations by the use of episiotomy. There was no difference between the two episiotomy methods in the propor- tions of patients with minor and major lacerations. Although episiotomy reduced the apparent percentage of patients sustaining a perineal laceration from 75 to 11%, the percentage sustaining major degrees of lacer- ation increased from 1 to 4% (x2 = 692, P < 00001), giving an odds ratio of 4.17 (95% confidence interval 2,9-5.8). If one considers all nonextended episiotomies VOL. 77, NO. 5, MAY 1991 None Midline Mediolateral (N= 3538) (N= 3816) (N= 1640) Laceration None 25 89 8 Minor m 8 7 Major 1 3 4 Total 100 100 100 Trauma ‘None (no laceration and no 25 ° episiotomy) Minor (minor laceration m %6 andlor episiotomy) [Major laceration 1 4 Total 100 100 Daa are presented as percentages as minor perineal trauma (Table 2), then 96% of the women who had an episiotomy had minor perineal trauma and 4% had major perineal trauma, compared with rates of 25% with no trauma and 75% with minor or major perineal trauma in those who had no episiot- omy (x7 = 1552, P < .000001). Table 3 correlates the use of forceps and perineal trauma. There was no difference between mid- and low forceps. The percentage of minor lacerations de- creased from 38 to 26% with the use of forceps and the associated increase in the use of episiotomy, but the percentage of major lacerations increased from 2 to 4% (@ = 16.2, P = ,0003). If nonextended episiotomies are considered as minor trauma (Table 3), then the use of forceps increased the rate of minor perineal trauma from 77 to 92% (x? = 535, P < .000001). Major perineal Table 3. Degree of Perineal Laceration by Use of Forceps ‘None Low forceps Mid forceps 925) (N = 1580) _(N = 1489) Laceration ‘None o 70 @ Minor 38 2% 2 Major 2 3 4 Total 100100 100 Trauma None (no laceration and no 21 33 32 episiotomy) Minor (minor laceration 7 2 93 ‘and/or episiotomy) Major laceration 2 47 38 Total 100100 100 Data are presented as percentages, Walker et al Epidurals and Lacerations 669trauma increased from 2 to 4.3% when forceps were used, giving an odds ratio of 2.3 (95% confidence interval 1.8-3.0). Discussion Our data confirm other studies regarding the lack of efficacy of episiotomy in reducing the incidence or severity of perineal trauma. This question has been addressed extensively in the literature, with no appar- ent evidence showing any beneficial effect." We found that patients delivering with episiotomies had significantly more perineal trauma than those who did not have episiotomies; in addition, the lacerations that they did sustain were much more likely to be thitd- degree. These findings were independent of parity or the use of forceps. Our conclusion, in agreement with recent studies,*"” is that episiotomy, although associ- ated with a reduction in the laceration rate, was associated with an increase in the overall rate of perineal trauma, and that this trauma was more likely to be major than if no episiotomy had been used (relative risk 4.17, 95% confidence interval 2.9-5.8). In agreement with Wilcox et al,"® we found no difference between midline and mediolateral episiotomies in this respect, We found that perineal trauma was significantly increased in primiparas as compared with multiparas; in addition, ras were three times more likely to have major perineal trauma than were multiparas (95% confidence interval 2.30-3.95). The use of forceps in- creased the rate of minor perineal trauma from 77 to 92% and was associated with twice the risk of major perineal trauma (odds ratio 2.3, 95% confidence inter- val 1.8-3.0). Cervical laceration occurred in only 61 patients (0.64% of our study group). Seventy-seven percent of these patients were delivered by forceps (odds ratio 6.58, 95% confidence interval 3.5-12.5). We recognize the problems inherent in a retrospec- tive report. Underreporting of minor degrees of lacer- ation cannot be excluded, but this is likely to be less of a problem with major lacerations. Our data did not include birth weight or any measure of the difficulty of the delivery, although labor was not augmented in any of our patients, Wilcox et al," in their retrospective review of perineal laceration, found that third-degree lacerations were more likely if the birth weight was over 3999 g, with an odds ratio of 1.42; however, the 95%. confidence interval was 1.00-2.04. Similarly, a second stage of labor longer than 90 minutes gave an odds ratio for third-degree laceration of 1.39 (95% confidence interval 0.99-1.94). Therefore, we believe that our data support the conclusion that episiotomy 670 Walker et al Epidurals and Lacerations not only lacks benefit, but is harmful to the perineum. It is interesting to note that the best-fit nominal re- sponse model, using our factors to explain the distri- bution of perineal laceration, explained only a part of the distribution observed, indicating that many as yet undefined factors were also involved. It seems likely that perineal laceration is multifactorial, including such variables as attendant experience and philosophy, as well more obvious factors. Contrary to the relative merits of episiotomy, the influence of epidural anesthesia on the occurrence of birth-canal trauma has rarely been addressed in the obstetric or anesthesia literature." When we analyzed our data using a multifactorial nominal response model, the use or non-use of an epidural was not associated with perineal laceration. There was also no significant interaction between epidural anesthesia and the use of forceps, episiotomy, or parity as regards this incidence. We therefore conclude that the use of an epidural does not appear to be related to the incidence of perineal laceration in this retrospectively analyzed group. This contrasts with the findings of a retrospec- tive case-control study by Legino et al,? who found epidural uptake to be greater in patients who had third- and fourth-degree lacerations. However, this study did not control for confounding factors such as parity, use of forceps, or oxytocin. In a study of Patients between 1960-1968, Bickers" found that lacer- ns occurred in only 2% of patients with epidurals, compared with 13% in historic controls from the pre- epidural era. This remarkably low rate of laceration is ‘not consistent with findings in our population. Nodine and Roberts® studied the factors related to perineal outcome in 275 nurse-midwifery clients and found episiotomy to be significantly more common when a parturient had had an epidural anesthetic. None of the women studied had third-degree lacerations; first- and second-degree lacerations were not associated with the use of an epidural. This study was inconclusive be- ‘cause the data were analyzed using non-multivariate methods, which do not allow for interaction between factors. In conclusion, we found no evidence of a detrimen- tal effect of epidural anesthesia on the integrity of the perineum, but demonstrated that the use of episiot- ‘omy increases fourfold the likelihood of major perineal trauma. References 1, Bickers WML. Epidural analgesia in obstetrics. J Reprod Med. 1970351-9. 2. Legino L], Woods MP, Raybuen WF, McGoogan LS. Third- and Obstetrics & Gynecologyfourth-egree perineal tars, 30 years experience ata university hospital. J Reprod Med 1988:33:i23-6, 3. Nodine PM, Roberts J, Factors associated with perineal outcome during chldbieth. J Nurse Midwifery 1987;32:129-90 4. Thorp JM, Bowes WA, Brame RJ, Cefalo R. Selected use of ‘midline episiotomy: Effet on perineal trauma. Obstet Gynecol 1987:70:260-2. 5. Reynolds JL, Yudkin PL. Changes in the management of labour: 2. Perineal management. Can Med Assoc | 1987/136:1045-9, 6, Sleep J, Grant A. West Berkshire perineal management tral: Three year follow up. Br Med J 1987:295:749-51 7. Buekens P, Lagasse R, Dramaix M, Wollast E. Episiotomy and third degree tears. Br} Obstet Gynaecol 1985;92870-3. 8. Green JR, Soohoo SL. Factors associated with rectal injury in spontaneous deliveries. Obstet Gynecol 1989;73732-8, 9, Gass MS, Dunn C, Stys SJ. Effect of episiotomy on the frequency cof vaginal outlet lacerations. J Reprod Med 1986:3:240-4, 10. Thacker $8, Banta HD. Benefits and riske of episiotomy: An Interpretive review of the English language literature, 1860-1980. ‘Obstet Gynecol Surv 1983;36:322-38, 11 Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: More harm than good? Obstet Gynecol 199075:765-70. 12. Thorp JM, Bowes WA. Episiotomy, can its routine use be de- fended? Am Obstet Gynecol 1989:160:1027-30. VOL. 77, NO. 5, MAY 1991 13, Wileox LS, Strobine DM, Baruffi G, Dellinger WS. Epislotomy and its role in the incidence of perineal laceration in a maternity center and tertiary hospital obstetric service. Am J Obstet Gynecol 1999;160:1097-52 ‘Address reprint requests to: M. P. R. Walker, MD Department of Reproductive Medicine H813a University of California San Diego Medien! Center 225 Dickinson Street San Diego, CA 92108 Received June 6, 1990. Receive in revised form December 6, 1990, Accepted December 19, 1990, Copyright © 1991 by The American College of Obstetricians and Gynecologists Walker et al Epidurals and Lacerations 671