A Comparative study of Perineal Morbidity in Labour Natural Versus Labour Natural with Episiotomy

The majority of patients in both the study and control group were aged between 21-24 yrs and had their baby weights between 2.5 to 2.9 kg (Table 1&3) . In the study group 27.27% patients were primis and 49.09% patients had two support during parturition (Table 2&4). Inspite of an episiotomy 16.97% had other tears (Anterior and Posterior perineal lacerations) and in that 4.24% patients had external anal sphincter tear (Table 5). In the study group 16.97% patients had no lacerations perineum and in those who sustained perineal lacerations 50 patients did not require suturing (Table 5 & 7). The vaginal wall lacerations in the study group were mostly mucosal tears. (Annexure to table 5 & 6). The majority of patients with anal sphincter tear in the study group were aged between 25 - 29 years, with baby weights > 3.0 kg. The sphincter tears were equally distributed in primi’s and 2nd gravida. (Table 8,9 & 10). Most of the patients with anal sphincter tear in the control group had two support. (Table 11). Out of the total of 23 patients with anal sphincter tear, 14 patients had more than 50% of EAS torn and only 10 could be followed up. (Table 12&17). In my study only 44.85% of episiotomies were indicated (Table 13). The incidence of episiotomy in my institution for the years 2003,2004 and first six months of 2005 were 81.95%,81.20% and 72.19% respectively. (Table 14). Out of the total of the 330 patients only 225 patients could be followed up and 69.67% patients in the control group had persistent pain for one or more week (Vs 14.56% in the study group) (Table 15 & 16). The short term perineal morbidity in parturients who delivered without an episiotomy is definitely less than those who delivered with an episiotomy indicating that perineal pain is more frequent and severe for women with increased perineal trauma. CONCLUSION: This study throws light on the fact that short term perineal morbidity is significantly lower in parturients who delivered without an episiotomy & that episiotomy did not offer protection against sustaining severe perineal lacerations. So an attempt should be made to keep the incidence of episiotomy as low as wisdom allows. Further large scale studies will raise the curtain for a better understanding of severe perineal lacerations in the Indian Sub Continent. It is difficult to obtain a global perspective on spontaneous perineal trauma requiring suturing due to inconsistency in classification and under reporting of perineal trauma. Severe perineal lacerations are associated with large babies, short 2nd stage of labour, lack of perineal support, rigid perineum and instrumental vaginal deliveries. Diverse rates of episiotomy in different countries suggest that the practice of episiotomy is not always justified. Episiotomy does not protect the anal sphincter complex. Prudent clinical judgement should dictate the necessity for an episiotomy. Changing the way physicians practice medicine can be difficult. Perhaps more hospital perinatal review committees should evaluate the episiotomy practices and strive to convince their staffs to decrease their episiotomies. (i.e should be given only to patients were it is indicated). By doing so we can learn to be more patient and allow the natural forces of labour to gradually stretch the perineum. Ideally a dedicated “Perineal dysfunction clinic” should be set up, for follow up of women experiencing persistent problems after delivery, consisting of an obstetrician and physiotherapist with access to appropriate investigation techniques such as endoanal ultrasound and manometry. Urinary problems are amenable to biofeedback techniques and physiotherapy input is vital to ensure that these are appropriately taught & reinforced.