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Received: 29 November 2018    Revised: 20 March 2019    Accepted: 3 May 2019    First published online: 23 May 2019

DOI: 10.1002/ijgo.12843

B R I E F C O M M U N I C AT I O N
Obstetrics

FIGO Statement: Restrictive use rather than routine use

of episiotomy

Anwar H. Nassar1,* | Gerard H.A. Visser2 | Diogo Ayres-de-Campos3 | Ajay Rane4,5 | 

Sandhya Gupta4 | for the FIGO Safe Motherhood and Newborn Health Committee6,a

1
Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
2
University Medical Centre, Utrecht, The Netherlands
3
Department of Obstetrics and Gynecology, Univesirty of Lisbon, Lisbon, Portugal
4
Department of Obstetrics and Gynecology, James Cook University, Townsville, Qld, Australia
5
FIGO Committee for Fistula and Genital Trauma, London, UK
6
International Federation of Gynecology and Obstetrics (FIGO), London, UK

*Correspondence
Anwar H. Nassar, Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.
Email: an21@aub.edu.lb

a
FIGO Safe Motherhood and Newborn Health Committee Members are listed at the end of the paper.

K E Y W O R D S : Best Practice; Childbirth; Episiotomy; Maternity Care; Safe Motherhood

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, episiot-
omy has been widely used to enlarge the birth canal. Although
there is a global trend for reduced episiotomy rates, 1 these con-
tinue to be very high in some centers and areas of the world, with
rates up to 60 and 80% in India and China, respectively. 2,3 There
is no universally accepted rate of episiotomy for non-­o perative
vaginal delivery in a normal labor ward, but the WHO recom-
mends a rate of 10%, based on a 1984 English trial. 4 The latest
Cochrane review on the other hand reports a rate of 28% in the
restrictive episiotomy group. 5 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.6 Midline episiotomy is a strong independent risk factor for third-­
and fourth-­degree perineal lacerations.7 On the other hand, routine
mediolateral episiotomy decreases the risk of anterior perineal lacera-
tions, but increases the risk of posterior perineum lacerations, and the
need for suturing.5,8 Even in the context of shoulder dystocia, episiot-
9
omy has not been shown to have clear benefits.
There is some evidence that women with a prior episiotomy have
a two-­fold increased risk of 2nd degree lacerations in subsequent vag-
inal deliveries.10 In addition, there is evidence that episiotomy may
be associated with a decrease in pelvic floor musculature strength,11
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 deliv-
eries is not completely clear. A recent meta-­analysis of observational
data concluded that mediolateral episiotomy may reduce OASIS and
should not be withheld, especially in nulliparous women.12 In fact,
after adjusting for confounding factors, mediolateral episiotomy has
shown a significant 2.5 times reduction in developing lacerations in
primiparous women compared with no episiotomy.8 However, other
studies have shown that episiotomy and 3rd or 4th degree perineal
lacerations increase the risk of anal incontinence after vaginal birth by
1.7 and 2.7 times, respectively.13 A recent study suggested that medi-
olateral episiotomy is not protective of the occurrence of OASIS, but
the sample size was small, and therefore the study was not powered to
provide substantial clinical conclusions.14
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

Int J Gynecol Obstet 2019; 146: 17–19 © 2019 International Federation of |  17

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Gynecology and Obstetrics
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18       Nassar ET AL.
where there is a clear indication. Selective use of episiotomy can result
6
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.6,12
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 inci-
sion length, and greater average estimated blood loss, and should
therefore in principle be avoided.15 Episiotomies should be per-
formed in the expulsive phase of the 2nd stage of labor when the
presenting part is bulging the perineum during a bearing down
effort. In addition, an episiotomy angle ranging from 45° to 60°
from the midline is associated with the lowest risk of OASIS.16
The need to incise at 60° to protect the perineum was confirmed
in recent literature.17 Given the premise that it is not always easy
for an obstetrician to correctly determine the safe angle along
which to cut given the perineal stretching, a scissor instrument
(Episcissors-­60) was tried to allow cutting a mediolateral episiot-
omy at a fixed angle of 60° from the perineal midline at crowning.
This will correspond to an angle of 43° after delivery.18 However,
this is an expensive tool that is not available on most maternity
wards. An inexpensive low-­tech vellum paper based Episiometer
is being evaluated for global use. Phase 1 trials have shown it to
be acceptable and feasible to be used to direct an accurate angle
and length of an episiotomy. As for the length of the episiotomy, a
4–6 cm is usually recommended.19
Several strategies have been evaluated to reduce episiotomy rates
and to decrease the incidence of perineal trauma. Digital perineal mas-
sage applied before delivery and during the second stage of labor, as
well as warm compresses on the perineum during the second stage
appear to be helpful in decreasing perineal trauma.20–22 The use of
a birth ball during labor seems to help reduce pain, anxiety, and the
length of the first stage without any significant effect on the episiot-
omy rate.23 An upright position during the second stage of labor also
decreases the episiotomy rate but appears to increase 2nd degree
lacerations and postpartum hemorrhage.24 For vaginal breech deliv-
ery, the upright position also seems to be associated with a significant
reduction in the episiotomy rate when compared with vaginal delivery
in the dorsal position.25
Given all available evidence, FIGO supports the restrictive use of
episiotomy, where the procedure is limited to situations in which per-
ineal laceration has already begun or there is an imminent threat of
perineal tear or when there is urgency in delivering the fetus. Further
research is needed to identify strategies that result in the reduction
of episiotomies, as well as 3rd and 4th degree lacerations. Low 3rd
and 4th degree perineal tears at optimum episiotomy rates should be
considered as an indicator reflecting better quality of obstetrical care
in unassisted vaginal deliveries.
CO MMI TTE E ME MBE RS
Professor Gerard H.A. Visser (Past-chair), Dr. Diogo Ayres-­de-­Campos,
Dr. Eytan Barnea, Dr. Luc de Bernis, Dr. Gian Carlo Di Renzo, Dr. Maria
Fernanda Escobar, Dr. Isabel Lloyd, Professor Anwar H. Nassar (Chair),
Dr. Wanda Kay Nicholson, Dr. PK Shah, Professor William Stones, Dr.
Luming Sun, Dr. Gerhard Theron, Dr. Salimah Walani.
CO NFL I C TS O F I NT ER ES T
The authors declare no conflicts of interest.
REFERENCES
1. Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD.
Variation in and factors associated with use of episiotomy. JAMA.
2015;313:197–199.
2. Singh S, Thakur T, Chandhiok N, Dhillon BS. Pattern of episiotomy use
& its immediate complications among vaginal deliveries in 18 tertiary
care hospitals in India. Indian J Med Res. 2016;143:474–480.
3. Graham ID, Carroli G, Davies C, Medves JM. Episiotomy rates around
the world: An update. Birth. 2005;32:219–223.
4. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West
Berkshire perineal management trial. Br Med J. 1984;289:587–590.
5. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database
Syst Rev. 2009;(1):CD000081.
6. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine
use of episiotomy for vaginal birth. Cochrane Database Syst Rev.
2017;(2):CD000081.
7. Melamed N, Gavish O, Eisner M, Wiznitzer A, Wasserberg N, Yogev Y.
Third-­ and fourth-­ degree perineal tears–incidence and risk factors. J
Matern Fetal Neonatal Med. 2013;26:660–664.
8. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: More harm
than good? Obstet Gynecol. 1990;75:765–770.
9. Sagi-Dain L, Sagi S. The role of episiotomy in prevention and manage-
ment of shoulder dystocia: A systematic review. Obstet Gynecol Surv.
2015;70:354–362.
10. Alperin M, Krohn MA, Parviainen K. Episiotomy and increase in the
risk of obstetric laceration in a subsequent vaginal delivery. Obstet
Gynecol. 2008;111:1274–1278.
11. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E, Guaschino S.
The effects of mediolateral episiotomy on pelvic floor function after
vaginal delivery. Obstet Gynecol. 2004;103:669–673.
12. Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal
sphincter injuries after episiotomy: Systematic review and meta-­
analysis. Int Urogynecol J. 2016;27:1459–1467.
13. LaCross A, Groff M, Smaldone A. Obstetric anal sphincter injury and
anal incontinence following vaginal birth: A systematic review and
meta-­analysis. J Midwifery Womens Health. 2015;60:37–47.
14. Drusany Staric K, Lukanovic A, Petrocnik P, Zacesta V, Cescon C,
Lucovnik M. Impact of mediolateral episiotomy on incidence of
obstetrical anal sphincter injury diagnosed by endoanal ultrasound.
Midwifery. 2017;51:40–43.
15. Rusavy Z, Karbanova J, Kalis V. Timing of episiotomy and outcome
of a non-­instrumental vaginal delivery. Acta Obstet Gynecol Scand.
2016;95:190–196.
16. Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Oian P.
Episiotomy characteristics and risks for obstetric anal sphincter inju-
ries: A case-­control study. BJOG. 2012;119:724–730.
17. Kapoor DS, Thakar R, Sultan AH. Obstetric anal sphincter injuries:
Review of anatomical factors and modifiable second stage interven-
tions. Int Urogynecol J. 2015;26:1725–1734.
18. Freeman RM, Hollands HJ, Barron LF, Kapoor DS. Cutting a mediolat-
eral episiotomy at the correct angle: Evaluation of a new device, the
Episcissors-­60. Med Devices (Auckl). 2014;7:23–28.
19. Béchard F, Geronimi J, Vieille P, Letouzey V, de Tayrac R. Are we
performing episiotomies correctly? A study to evaluate French
Nassar ET AL.
technique in a high-­risk maternity unit. J Gynecol Obstet Hum Reprod.
2018;47:331–338.
20. Beckmann MM, Stock OM. Antenatal perineal massage for reducing
perineal trauma. Cochrane Database Syst Rev. 2013;(4):CD005123.
21. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques
during the second stage of labour for reducing perineal trauma.
Cochrane Database Syst Rev. 2017;(6):CD006672.
22. Demirel G, Golbasi Z. Effect of perineal massage on the rate of episi-
otomy and perineal tearing. Int J Gynecol Obstet. 2015;131:183–186.
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      19
23. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage
of labour for women without epidural anaesthesia. Cochrane Database
Syst Rev. 2017;(5):CD002006.
24. Hau W-L, Tsang S-L, Kwan W, et al. The use of birth ball as a method of
pain management in labour. Hong Kong J Gynaecol Obstet. Midwifery.
2012;12:63–68.
25. Louwen F, Daviss BA, Johnson KC, Reitter A. Does breech delivery
in an upright position instead of on the back improve outcomes and
avoid cesareans? Int J Gynecol Obstet. 2017;136:151–161.