https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Prevalence and Risk Factors of Episiotomy and Perineal Tear in the Maternity Teaching Hospital of Erbil City, Iraq ABSTRACT INTRODUCTION During child birth, tearing to the perineum can occur naturally or by the surgical pro- cess of an incision known as episiotomy. Both natural tearing and episiotomy are found to be traumatic to the genitalia *1+. Reported rates of episiotomies vary from as low as 9.7% in Sweden to as high as 100% in Taiwan considering both nullipa- rous and multiparous women *2,3+. More than 85% of women having a vaginal birth experience some form of perineal trauma, and 60–70% of women receive sutures post-delivery to repair the perineum. Ap- proximately one-third of the women in the United States and the United Kingdom Background and Objectives: During childbirth, women are at risk for experiencing perineal trauma to the genitalia resulting in a tear of the perineum or the surgical process of an epi- siotomy. Knowing the prevalence and the risk factors associated with perineal trauma may help in the reduction of episiotomy and prevention of occurrence of tear. The aim of the study was to find out the prevalence and risk factors associated with perineal trauma among women ages 15-48. Methods: A cross sectional study was conducted in the Maternity Teaching Hospital of Er- bil, Kurdistan region, Iraq. All records of mothers (n = 1500) who had been admitted to the delivery room for vaginal delivery during the month of May (2015) were reviewed. Chi- square test of association and binary logistic regression were used to interpret the data. Results: The overall rates of episiotomy, tear, their combined presence, and an intact peri- neum were: 47.8%, 7.2%, 26.1% and 18.9%, respectively. Incidence of having an episioto- my, tear, or combination of both, were significantly associated with women of young ages and women who were primigravida parity. There was a statistically significant association between high birth weight and the occurrence of perineal trauma. There was no associa- tion between perineal trauma and residency (urban/rural), occupation, gender of baby and time of delivery. Binary logistic regression analysis showed that having an episiotomy in- creased the risk of a tear by more than 30%. Conclusions: The prevalence of episiotomy was found to be 73.9% which is much higher compared to the World Health Organization recommendation which is 10%. Perineal trau- ma were associated with factors such as age, parity, and birth weight. Episiotomy is a risk factor for a vaginal tear. We recommend further research to inform the development and implementation of restrictive episiotomy policies to reduce and prevent occurrences of perineal trauma. Key words: perineal trauma, episiotomy, tear, prevalence, risk factors Hamdia Mirkhan Ahmed; Department of Midwifery , College of Nursing, Hawler Medical University, Erbil, Iraq. Warda Hasan Abdollah; Department of Midwifery , College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: hamdia.mirkhan@nur.hmu.edu.krd) Namir Ghanim Al-Tawil; Department of Community Medicine , College of Medicine, Hawler Medical University, Erbil, Iraq. 44 Erbil Journal of Nursing & Midwifery Received: 28/9/2018 Accepted: 25/2/2019 Published: 30/5/2019 mailto:hamdia.mirkhan@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article experience spontaneous tears to the peri- neum during delivery *2+. Women are affected by perineal trauma in the intermediate postnatal period and can extend beyond this period. The impact of perineal trauma to women’s physical, psy- chological, and social wellbeing may lead to negative effects on family life, disrup- tion of breastfeeding, and sexual relations. A study done in the UK showed that a con- siderable proportion of women continue to experience short-term complications such as pain, discomfort, dyspareunia, fecal in- continence, and urinary problems during the postpartum period. Depending on the severity of perineal trauma, some women may experience continued pain as a long- term effect due an expected complication. In addition, whether of not trauma man- agement was effective plays a role in the continued experience of long-term pain. *3+. A 2009 systematic review of eight random- ized trials found that women who gave birth in sites with restricted episiotomy policies experienced less severe perineal trauma, less requirement for suturing, and fewer complications, compared to women who gave birth in sites with routine episiot- omy policies. In addition, women who gave birth in sites with restricted episiotomy policies presented no difference in pain, urinary incontinence or dyspareunia, how- ever they had a higher risk of anterior peri- neal damage *4+. According to two previous studies con- ducted in Kurdistan, most of the midwives reported that the rate of episiotomy was high in their hospitals. They attributed this to the common practices of midwives and obstetricians and policies of the hospitals in their health system *5+. Another study showed that most of the reasons given by the midwives for perform- ing episiotomies were not evidence-based *6+. No study was done for determining the rate of episiotomy and perineal tear in Kur- distan's maternity hospitals. The authors believe that knowing the prevalence and risk factors of perineal trauma during deliv- ery may lead to a decrease in the incidence of vaginal tear. The aims of this study are to determine the prevalence and risk fac- tors associated with perineal trauma in the Maternity Teaching Hospital in Erbil city. Owing to the lack of research in this field in Erbil city, the results of this study will pro- vide valuable information leading to better practices in the delivery room. In addition, the results of this study may be used to inform and develop new evidence-based guidelines to help decrease the rate of epi- siotomies and prevent the occurrence of vaginal tears during childbirth. A retrospective cross-sectional study was conducted in the postpartum unit of the Maternity Teaching Hospital located in Er- bil city in the Kurdistan region of Iraq. This hospital is a public site hosting 300 patient beds. Records of mothers who had been admitted to the delivery room for vaginal delivery (n=1500) during the month of May (2015) were reviewed. As per hospital policy, the decision for per- forming episiotomy are made by midwives during the second stage of delivery. It is important to note the difference in educa- tional (graduated from a school, institute or college of nursing/midwifery) and expe- rience levels among midwives within the hospital. A tool was developed for the pur- pose of data collection and included demo- graphic and obstetrical characteristics of mothers who had an episiotomy, vaginal tear or both. Prior to data collection, per- mission to conduct the study was obtained from the Scientific and Ethics Committee of College of Nursing/Hawler Medical Uni- versity and the Erbil General Directorate of METHODS 45 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article (29.4%) of the same age experienced vagi- nal tearing in spite of doing an episiotomy. This percentage is much higher compared to women ages 40- 49, who experienced both an episiotomy and vaginal tearing (p < 0.001). A considerable proportion of pri- miparous women (28.9%) who experi- enced an episiotomy also developed a vag- inal tear, compared to 17.8% of the grand- multiparous women (p < 0.001). Among the women who delivered a big baby, approximately one-third (32.4%) of women experienced tearing in spite of epi- siotomy compared to 22.7% of the women women who delivered a small baby devel- oped tearing in spite of episiotomy (p = 0.013). There were no significant associa- tions between post-delivery perineum sta- tus and residency (p = 0.402), occupation (p = 0.223), time of delivery (p = 0.493), and gender of baby (p = 0.663). Table 2 shows that among all the women, the incidence of a vaginal tear was 33.3% regardless of whether or not an episioto- my was done. Among these women who experienced an episiotomy, the incidence of a tear was significantly high (35.3%), compared to the women (27.6%) without episiotomy (p = 0.006). Binary logistic regression analysis showed that an episiotomy may increase the risk of a tear by more than 30% (OR = 1.37; 95% CI 1.045 to 1.798).No significant associa- tion was found between the development of a tear with age, parity, and baby weight (Table 3). This study reviewed and analyzed the rec- ords of 1500 women who experienced a vaginal delivery during a month period. According to WHO, The prevalence rate of episiotomy vary widely from country to country*1+. Compared to the WHO *7,8+ recommended rate of episiotomy (10%), Health. Data were analyzed using the statistical package for Social Sciences (SPSS, version 22). Chi-square test of asso- ciation was used to compare proportions. Fisher’s exact test was used when more than 20% of the cells of the table have ex- pected count less than 5. Binary logistic regression was used where the dependent variable was the tear, and the independent variables (included in the regression model) were the factors found to be significantly associated (according to Chi square test) with the development of tear. A p value of ≤ 0.05 was considered as statistically significant. The files of 1500 women admitted to the Maternity Teaching Hospital for a vaginal delivery in May 2015 were reviewed. The mean age + SD of the women was 25.89 + 6.19 years, ranging from 15 to 48 years. The median was 25 years. The mean + SD of parity was 2.5 + 1.62. The mean baby weight was 3580.9 + 520 grams, ranging from 1800 to 6000 grams. The median was 3500 grams. Of the 1500 women, more than two-thirds of the women (1109) expe- rienced an episiotomy during childbirth. Nearly half (47.8%) of the women who ex- perienced an episiotomy during childbirth did not develop a vaginal tear and only 391 (26.1%) women who had episiotomy also experienced vaginal. The results also show that 108 (7.2%) women developed vaginal with knowledge of no episiotomy done and there were 283 (18.9%) women who experienced no episi- otomy or vaginal tearing (Table 1). There was a significant association be- tween age and perineum status. Women less than 20 years of age who had an episiotomy done (57.2%) did not devel- op vaginal tearing. Approximately one-third of the women 46 RESULTS Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *By Fisher’s exact test 47 Table 1: Risk factors of episiotomy and tears among study sample Erbil Journal of Nursing & Midwifery Variables Episiotomy (No tear) Tear (No episioto- my) Both None p-value N No. % No. % No. % No. % Age group <20 201 115 (57.2) 7 (3.5) 59 (29.4) 20 (10.0) <0.001 20-29 867 421 (48.6) 66 (7.6) 243 (28) 137 (15.8) 30-39 374 159 (42.5) 30 (8) 82 (21.9) 103 (27.5) 40-49 58 23 (39.7) 5 (8.6) 7 (12.1) 23 (39.7) Residency Urban 672 330 (49.1) 43 (6.4) 181 (26.9) 118 (17.6) 0.402 Rural 828 388 (46.9) 65 (7.9) 210 (25.4) 165 (19.9) occupation Housewife 1398 665 (47.6) 103 (7.4) 358 (25.6) 272 (19.5) 0.223 Employed 79 41 (51.9) 5 (6.3) 24 (304) 9 (11.4) Student 23 12 (52.2) 0 (0) 9 (39.1) 2 (8.7) Parity Primipara 484 311 (64.3) 15 (3.1) 140 (28.9) 18 (3.7) <0.001 Multipara 847 367 (43.3) 83 (9.8) 221 (26.1) 176 (20.8) Grandmulti 169 40 (23.7) 10 (5.9) 30 (17.8) 89 (52.7) Time of delivery Morning 374 187 (50) 31 (8.3) 84 (22.5) 72 (19.3) 0.493 Evening 394 191 (48.5) 27 (6.9) 110 (27.9) 66 (16.8) Night 732 340 (46.4) 50 (6.8) 197 (26.9) 145 (19.8) Birth weight Low birth weight 22 9 (40.9) 1 (4.5 ) 5 (22.7) 7 (31.8) 0.013 Normal 1077 540 (50.1) 83 (7.7) 256 (23.8) 198 (18.4) Big baby 401 169 (42.1) 24 (6) 130 (32.4) 78 (19.5) Sex of baby Male 786 387 (49.2) 53 (6.7) 202 (25.7) 144 (18.3) Female 707 329 (46.5) 54 (7.6) 186 (26.3) 138 (19.5) 0.663* Twin 7 2 (28.6) 1 (14.3) 3 (42.9) 1 (14.3) Total 1500 718 (47.8) 108 (7.2) 391 (26.1) 283 (18.9) Table 2: Incidence of tear by episiotomy No tear Tear Total Episiotomy No. % No. % No. % P-value No 283 72.4 108 27.6 391 100 0.006 Yes 718 64.7 391 35.3 1109 100 Total 1001 66.7 499 33.3 1500 100 https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article the rate of episiotomy was significantly higher (73.9%) in this study. A study in Tur- key (Karacam et al., 2013) , of 396 prim parous women found that among the women 56.35% experienced an episioto- my, 40.2% experienced vaginal tearing, 11.6% experienced both and 3.5% had an intact perineum. These results are not in agreement with the results of this present study *9+. The reported rates of episioto- my, tear and intact perineum in a study done in Iran (Rasouli et al., 2016) were 41.5%, 34.7% and 23.8% respectively, in which the rate of tear is higher than the results of the present study *10+. The over- all rate of episiotomies in a study done in Saudi Arabia was 51.2%, which is lower compared to the overall rate of episioto- mies in this study *11+. The rates of episiotomies and tears in this study are lower when compared to the re- sults obtained from studies done in Italy, and the United States, *12,13+ but are higher when compared to results obtained from studies done in the United Kingdom and Nigeria *5,14-17+. Findings from this current study indicate a significant associa- tion between age (p=0.187), parity (p=0.049), and birth weight (p=0.033) with perineum status, which agree with the re- sults of other studies done in Turkey, the United Kingdom, the United States and Singapore *9,15,18,19+. One study (Howden et al., 20014) found that high ed- ucational status, marriage, multiparty, and a history of Cesarean delivery among women 30 years of age and older are inde- pendent are independent risk factors for an episiotomy *13+. Another study (Enyindah et al., 2007) found the rate of episiotomy decreased with high parity while the rate of perineal tears slightly increased with parity. 48 Table 3: SPSS output for logistic regression analysis between tear as a dependent variable with several covariates. Erbil Journal of Nursing & Midwifery Covariates B p OR 95% C.I. for OR Lower Upper Age (years) 0.187 < 20 0.553 0.140 1.739 0.834 3.626 20-29 0.614 0.074 1.849 0.941 3.631 30-39 0.398 0.255 1.488 0.750 2.953 40-49 (Reference) Parity 0.049 Primi 0.174 0.455 1.190 0.754 1.880 Multi 0.401 0.053 1.494 0.994 2.245 Grand-multi (reference) Baby weight 0.033 Low birth weight (reference) Normal birth weight 0.189 0.699 1.208 0.463 3.154 Big baby 0.509 0.306 1.663 0.628 4.405 Episiotomy 0.315 0.023 1.370 1.045 1.798 Constant -2.028 0.001 0.132 https://doi.org/10.15218/ejnm.2019.06 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Nulliparity, vaginal breech deliveries, and instrumental deliveries were identified as risk factors for an episiotomy *16+. In the present study, the incidence of a tear was significantly higher among those who had an episiotomy, compared with those without one. Also, the results show that having an episiotomy will increase the risk of a tear by more than 30%. It is note- worthy that all cases had a mediolateral episiotomy. The increasing risk of a tear in case of episiotomy may be due to the small size of the episiotomy, timing of the episi- otomy or the incorrect technique of deliv- ery of the baby by the midwives. A routine practice among midwives of the Maternity Teaching Hospital is ‘hand on’. Midwives in this hospital start lubrication and dilatation of the vaginal opening once the 1st stage of labor has been completed. Ritgen Maneuver applies for all vaginal de- liveries at the time of head crowning, as well. Midwives are allowed to do the episi- otomy but not to suture it, which is the re- sponsibility of the obstetricians according to the hospital policy. We observed that midwives perform as small an episiotomy as possible to decrease the surgical trauma to the perineum. These results are supported by results of the re- view of six randomized trials which showed no differences in vaginal or perineal trau- ma between patients with and without an episiotomy *20+. Restrictive use of episiotomy policies helps women experience less severe perineal trauma, although overall, women experi- enced more anterior perineal damage with restrictive episiotomy *17,21+. The limitations of the present study were the variations in recording types and sever- ity of tears, indication of an episiotomy, mother position during the second stage of labor, midwifery technique in perineal sup- port and baby head circumference. In addi- tion, the relationship between oxytocin therapy with the mother's perineal status was not studied. Maternal age, parity, and birth weight are associated risk factors for perineal trauma resulting in vaginal tearing or an episioto- my. It was found that there is a correlation between having an episiotomy and in- creased risk factor for vaginal tears. The prevalence of episiotomies in this study is significantly higher than the WHO recom- mendation. The results from this study suggests that further research is necessary to inform, develop, and implement policies regarding restrictive use of episiotomy. There is no conflict of interest. *1+ Kettle C, Tohill S. Perineal care. BMJ Clinical Evidence 2008; 09:1401 *2+ Graham ID, Carroli G, Davies C, Medves JM. Episiotomy rates around the world: an up- date. Birth 2005; 32(3):219-23. doi: 10.1111/ j.0730-7659.2005.00373.x *3+ Alnakash AH, Jafar S, Abdul-Raheem Y. Whether selective or routine episiotomy is more useful to protect anal sphincter in pri- miparous women. Iraqi Journal of Medical Science 2012; 11(1):26-32 [4] Carroli G, Mignini L. Episiotomy for vaginal birth (review). 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