Obstetric anal sphincter injury after episiotomy in vacuum extraction: an epidemiological study using an emulated randomised trial approach

Objective To emulate a randomised controlled trial investigating whether lateral or mediolateral episiotomy compared with no episiotomy reduces the prevalence of obstetric anal sphincter injury (OASIS) in nulliparous women delivered with vacuum extraction. Design A population-based observational study. Setting Sweden. Population 63 654 nulliparous women delivered with vacuum extraction derived from the Swedish Medical Birth Register 2000-2011, with a live singleton baby with no known malformations in cephalic presentation in gestational week >= 34(+0), and subject to lateral or mediolateral episiotomy or no episiotomy. Methods The effect of episiotomy was calculated using a causal doubly robust estimation method based on propensity scores. Results are presented as the average treatment effect and numbers needed to treat (NNT). Main outcome measures OASIS (third- and fourth-degree perineal injury) in nulliparous women delivered with vacuum extraction. Results Episiotomy was associated with a reduction in OASIS from 15.5% to 11.8%, average treatment effect of -3.66% (95% CI -4.31 to -3.01) and NNT 27. Third-degree perineal injuries were reduced from 14.0% to 10.9% (-3.08, 95% CI -3.71 to -2.42) with NNT 32. Fourth-degree perineal injuries were reduced from 1.6% to 1.0 % (-0.58%, 95% CI -0.79 to -0.37) with NNT 172. Conclusions Lateral or mediolateral episiotomy reduced the prevalence of OASIS in nulliparous women delivered with vacuum extraction, compared to women with no episiotomy. Tweetable abstract To prevent one case of OASIS in first-time mothers delivered with vacuum, 27 episiotomies had to be performed.

Automated summary

A randomized controlled trial showed that lateral or mediolateral episiotomy can reduce the prevalence of OASIS in nulliparous women delivered with vacuum extraction, compared to women with no episiotomy. The study also found that third- and fourth-degree perineal injuries were reduced with episiotomy, with specific numbers needed to treat for each type of injury.