Should all women with a history of OASI have a mediolateral episiotomy at their subsequent delivery?
No, this should not be a universal recommendation. Women with a history of obstetric anal sphincter injury (OASI) should be counseled regarding the risks of recurrence, potential risk factors such as macrosomia and increased length of the second stage of labor, and potential mediating factors such as mediolateral episiotomy (MLE) and cesarean delivery. The risks of both episiotomy and cesarean delivery need to be considered, as well as how the existing literature on this topic applies to the specific clinician and patient population involved.
Study strengths and limitations
A strength of this study was the large number of deliveries and the wide variation of practice included in the registry database, which promotes the generalizability of the results and reduces bias. This also provides an adequate base on which to determine an accurate rate of rOASI in the Dutch population.
One study limitation is that information is not available regarding how the episiotomies were performed (specifically, angle of incision), delivery techniques (“hands on” vs “hands off”), and indication for the episiotomy. Additional limitations suggested are that clinicians who perform an episiotomy may have an inherent bias regarding the protective nature of the procedure and may miss a rOASI due to inadequate examination postprocedure, overestimating its protective effect.
Finally, the relatively high rate of MLE and low rate of cesarean delivery (6.9%) in this study are specific to the Netherlands and do not reflect the obstetric practices used in many other countries. Generalizability of these results in the context of much lower MLE and higher cesarean delivery rates (as in the United States) would therefore be in question.●
Prevention of rOASI is important, as fecal incontinence is debilitating and difficult to treat. While this study provides evidence that MLE may protect against this complication, its results may not be generalizable to all patient or clinician populations. Differences in baseline rate of MLE and cesarean delivery, technique, indication, and comfort with repair—all not evaluated in this study—must be taken into account when counseling OASI patients about their options for delivery and the use of MLE in a subsequent pregnancy.
JAIMEY M. PAULI, MD
