Trends on the Use of Episiotomy in Non-Instrumental Vaginal Deliveries, in Portugal

Abstract

Background Episiotomy and Obstetric Anal Sphincter Injuries (OASIS) are indicators of safety and quality of intrapartum care. The goal of this study is to assess trends on episiotomy in non-instrumental vaginal deliveries that occurred in the Portuguese public health system maternities, in the last decade. Related third- and fourth-degree perineal laceration (OASIS) rates were also analyzed. Methods A retrospective secondary data analysis was conducted by requesting information to the Central Administration of the Health System (ACSS). Non-instrumental vaginal deliveries that occurred in the public system from 2013 to 2022 were included. Data of annual episiotomy procedures and third- and fourth-degree perineal lacerations were obtained. Other databases were consulted to evaluate data reliability. Variables were described through absolute and relative frequencies. Linear regression analyses were used to assess trends of episiotomy and of perineal lacerations over time. Data reliability was evaluated using the Intraclass Correlation Coefficient (ICC). A significance level of 5% was considered. Findings There were 676 091 deliveries, 511 077 (75·6%) vaginal, and 388 493 (57·5%) vaginal non-instrumental. The episiotomy rate in the latter was 39%. Episiotomy in non-instrumental vaginal deliveries significantly decreased (54·1% in 2013 to 17·2% in 2022, p < 0·001), but with a significant increase (0·13% to 0·32%, p < 0·001), and no impact (0·02, p=0·001) of third- and fourth-degree perineal laceration rates, respectively. Data reliability is acceptable to good, and compared databases report the same trends of the outcomes. Interpretation Birth attendants in Portuguese public maternities adopted a restrictive episiotomy practice on vaginal non-instrumental deliveries throughout the last decade, resulting in a significant decrease of episiotomy, a significant increase of third-degree perineal lacerations, though fourth-degree maintenance. Results demand to determine the cost-benefit of lower rates of episiotomy, the main indications, and the best surgical technique. Establishment of consensual data coding and facilitated access to information are crucial to evaluate intrapartum practices. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.