African Journal of Primary Health Care & Family Medicine

ISSN: (Online) 2071-2936, (Print) 2071-2928

Page 1 of 6 Original Research

The perception and knowledge about episiotomy:

A cross-sectional survey involving healthcare workers
in a low- and middle-income country

Authors: Background: Episiotomy was introduced into clinical practice without clear evidence of its
Cyprian M. Maphanga1,2
[Link] knowledge and understanding of episiotomy guidelines and practice by
Thinagrin D. Naidoo1,2
healthcare workers is substandard in our setting; hence, the injudicious use of this procedure
Affiliations: have led to high rates.
1
Department Obstetrics
and Gynaecology, Greys Aim: To assess the knowledge, perception and practice of episiotomy by healthcare workers.
Hospital, Pietermaritzburg,
South Africa Setting: Research was conducted in a Pietermaritzburg complex, South Africa.

2
Nelson R Mandela School Methods: A questionnaire-based survey was conducted amongst healthcare workers regarding
of Medicine, University of episiotomy practice. In addition to providing demographic data, the participants were
KwaZulu-Natal, requested to respond to 35 proposed statements regarding episiotomy practice. Data were
Pietermaritzburg,
South Africa
analysed using SPSS (Statistical Package for the Social Sciences) software.
Results: One hundred and forty-two midwives and 66 medical practitioners completed
Corresponding author:
Cyprian Maphanga, the questionnaires. There were variations in responses to several statements on episiotomy
mfanafuthimaphanga@ practice by medical practitioners and nurses based on their level of experience. This study found
[Link] that the majority of HCWs did not have access to a protocol or policy on episiotomy practice
Dates: in their units; furthermore, nor knowledge of the South African guidelines for maternity
Received: 22 Mar. 2020 care on episiotomy practice. Significantly, more medical practitioners felt a need for more in-
Accepted: 04 Feb. 2021 service training and an increase in the number of episiotomies performed under supervision.
Published: 28 Apr. 2021
The commonly reported reason for performing an episiotomy by both medical practitioners
How to cite this article: and midwives was to reduce 3rd – 4th degree perineal tears.
Maphanga CM, Naidoo TD.
The perception and Conclusion: Healthcare workers in our setting displayed poor knowledge about the practice
knowledge about episiotomy: of episiotomy and were not aware of existing national guidelines on episiotomy practice.
A cross-sectional survey
involving healthcare workers Keywords: questionnaire; healthcare workers; episiotomy; obstetricians; professional nurses.
in a low- and middle-income
country. Afr J Prm Health Care
Fam Med. 2021;13(1), a2424.
[Link] Introduction
phcfm.v13i1.2424
Although episiotomy has become one of the most commonly performed procedures in obstetrics,
Copyright: it was introduced into clinical practice without strong scientific evidence of its benefits and hence,
© 2021. The Authors. it is the subject of much debate.1 Episiotomy rates vary widely worldwide, depending on whether
Licensee: AOSIS. This work
is licensed under the the procedure is used restrictively or routinely.2 These variations in rates seen worldwide clearly
Creative Commons indicate that episiotomy is heavily driven by professional norms, different experiences in training
Attribution License. and individual provider preference and not by physiological necessity.3,4 These differences could
also result from varying personal opinions regarding the benefits of episiotomy and an
inconsistency in their acquaintance with the reports from the literature. A Cochrane review has
found that a selective episiotomy policy has more benefits compared to routine episiotomy use.1
Rates of episiotomies remain high especially in developing countries despite national guidelines
uniformly agreeing that restricted use of episiotomy is preferable.5 Often, research on episiotomy,
including those from low-resource settings, has centred mainly on the views, attitude and
experiences of women undergoing episiotomy.6,7 Current literature suggests that a policy of
restricted episiotomy use is preferable,8 but indications for this selective performance are not
firmly defined and the benefits are not clearly determined. There is a paucity of data on perception
Read online: and knowledge about episiotomy involving healthcare workers (HCWs) in low- and middle-
Scan this QR income country context. Hence, we decided to conduct this study, with the aim of evaluating
code with your
smart phone or
the perception and knowledge of episiotomy amongst HCWs in the public health hospitals
mobile device and clinics with delivery units conducting deliveries in the Pietermaritzburg Metropolitan area of
to read online.
KwaZulu-Natal, South Africa.

[Link] Open Access

 Page 2 of 6 Original Research

Methodology the reasons for episiotomy use (including the main reason).
The questionnaire was divided into two sections. The first
This was a cross-sectional observational descriptive survey section of the questionnaire focused on background
of HCWs providing intrapartum care at public health demographic data, whilst the second section focused on
facilities in the Pietermaritzburg Metropolitan hospitals perception and knowledge about episiotomy. A multiple
(Greys hospital, Edendale hospital and Northdale hospital) choice questionnaire was used where participants could
and 3 clinics with delivery units with the help of a structured choose one or more appropriate answers. Selection of these
questionnaire on episiotomy practice. The study population statements was based on international literature and
was stratified into two groups: medical practitioners (interns, national guidelines9,10 and their validity was evaluated by a
medical officers, registrars and specialist obstetricians) and feedback from HCWs.
midwives (advanced and registered).

All the medical practitioners and midwives registered in the

Statistical analysis
department of obstetrics and gynaecology at Greys hospital, Data were entered into Statistical Package for the Social
Edendale hospital, Northdale hospital and 3 clinics with Sciences (SPSS) version 25 for analysis and a p value < 0.05
delivery units volunteered to participate in the study. A was considered to be statistically significant. Subgroup
survey cover sheet explaining the study was attached to the analysis was performed for medical practitioners versus
questionnaire and the participants who gave informed midwives and professional experience (≤ 8 years vs. > 8 years).
consent went to the next step of questionnaire completion. A descriptive statistical analysis of the data was performed
Subject identifiers were not used in the questionnaire and using the above software.
hence, confidentiality was maintained. A research nurse
volunteered to enrol all the willing participants and returned Ethical considerations
to the principal investigator.
Ethical clearance was obtained from the Biomedical Research
and Ethics Committee (BREC) of the University of KwaZulu-
The questionnaires included demographic data including
Natal and the KwaZulu-Natal Provincial Department of
their experience and rankings and statements of episiotomy
Health (BE088/18).
practice. Midwives and medical practitioners who provided
care for women at the time of delivery and had the opportunity
to perform episiotomies were eligible to participate. Results
All 208 obstetricians and midwives who provide delivery
Data collection care at Greys hospital, Edendale hospital, Northdale hospital
and clinics with delivery units were eligible to complete a
A pretested and structured self-administered questionnaire
questionnaire about their perception and knowledge towards
was used for data collection. The collected data were checked
episiotomy use. The response rate was 100% (208/208). Two
for completeness and consistency by the principal investigator
hundred and eight HCWs participated in the study, 66
and supervisor. As per the guidelines, experts in research
HCWs (31.7%) were medical practitioners, which included
methodology, obstetrics and gynaecology and oncology interns, medical officers, registrars and specialist obstetricians,
further confirmed the validity of the questionnaire before the and 142 HCWs (68.3%) were midwives, which included
pilot study. The instrument was pretested on 10 study advanced and registered midwives with different durations
participants who were working in other health facilities that of experience in obstetrics. Most participants were female
were not part of the actual study. Findings from the pre-test with up to 8 years of experience in providing maternity care.
were used to modify the instrument in terms of clarifying the Their years of obstetric experience ranged from 0 to 3 years
questions. Minimal changes were required to the survey to > 13 years with the majority (31.3%) having 0–3 years of
following pilot testing (e.g. additional options were added to experience (Table 1).
the reasons for episiotomy use), so it was decided that re-
piloting was not necessary. The questionnaire was divided A total of 69.7% of the participants, including 30.3% of the
into 2 main parts, first dealing with the socio-demographic medical doctors, defined episiotomy as surgical enlargement
profile characteristics, professional status of the respondents of the posterior aspect of the vaginal orifice by an incision to
and knowledge about episiotomy practice. The questionnaire the perineum during the expulsive phase of the 2nd stage of
was conducted in English. labour. More than 60% (67.3%) of the HCWs had performed
at least 5 episiotomies under supervision. The majority
A structured questionnaire including 35 statements (75.9%) of HCWs stated that their obstetric unit did not have
regarding episiotomy practice was used in this study. a protocol or policy on episiotomy practice. When asked to
Information collected on participant characteristics included pinpoint the most important obstacle to reducing episiotomy
profession (medical practitioners or midwife), gender and rates, both medical practitioners and midwives reported lack
years of experience in maternity care. The practice questions of training (Table 1 and Table 2).
included the frequency of episiotomy use amongst
nulliparous and multiparous women, type of episiotomy The knowledge of HCWs regarding the episiotomy procedure
used (midline/median, mediolateral or mediolateral) and varied, with only 38.9% being able to identify all the structures

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 Page 3 of 6 Original Research

TABLE 1: Breakdown of healthcare workers’ health facilities where they were TABLE 2: Health care workers’ perception, knowledge and practice of episiotomy.
employed, years of experience and training. Knowledge and perception about episiotomy n %
Use of episiotomy n % How do you define episiotomy?
Breakdown of HCWs’ health facilities where they were Surgical enlargement of vaginal orifice during labour 38 18.3
employed and years of experience
Surgical enlargement of the posterior aspect of the 145 69.7
Medical practitioners vaginal orifice by an incision to the perineum during
Interns 1st year 12 5.8 last part of 2nd stage of labour
Interns 2nd year 9 4.3 Enlargement of the posterior aspect of the vaginal orifice 5 2.4
because of tearing during delivery
Medical officers > 5 years 13 6.3
All of the above defines an episiotomy 20 9.6
Medical officers < 5 years 8 3.8
What anatomical structures are cut during episiotomy?
Registrars 1st 2 years 10 4.8
Skin and subcutaneous tissue 50 24.0
Registrars 2nd 2 years 5 2.4
Bulbocavernosus muscle and fascia 46 22.1
Specialist obstetricians 9 4.3
Transverse perineal muscle 21 10.1
Midwives
Levator ani muscle and fascia 10 4.8
Registered midwives 89 42.8
All of the above 81 38.9
Advanced midwives 53 25.5
How many types of episiotomy do you know of?
Health facility where registered
1 46 22.1
District hospital 50 29.8
3 56 26.9
Regional hospital 65 36.1
7 9 4.3
Tertiary hospital 61 34.1
2 97 46.6
Clinics 32
What type of episiotomy is recommended in your facility?
Years of obstetric experience (years)
Right lateral episiotomy 101 48.6
0–3 65 31.3
Left lateral episiotomy 42 20.2
4–8 62 29.8
Right mediolateral episiotomy 49 23.6
9–12 46 22.1
> 13 35 16.8 Left mediolateral episiotomy 14 6.7

Training of HCWs with regard to episiotomy practice Midline episiotomy 2 0.9

Have you received any formal training on episiotomy? What is the recommended angle from midline for a
properly constituted mediolateral episiotomy?
Yes 160 76.9
40–60 56 26.9
No 13 6.3
60 16 7.7
Unknown 35 16.8
< 30 111 53.4
Where did you get the training?
Angle does not matter 27 12.9
Medical school 76 36.5
Practice of episiotomy
Nursing school 83 39.9
Do you think that in your practice you need to limit the number of episiotomy?
During internship 0 0.0
Yes 48 23.1
Continued training in labour ward 1 0.5
No 160 76.9
Special courses 1 0.5
How often do you perform episiotomy on primigravidae?
Unknown 48 23.1
Always 55 26.4
How many episiotomies did you do under supervision?
Sometimes 153 73.6
0–5 140 57.3
Rarely 0 0.0
5–10 65 31.3
Never 0 0.0
> 10 3 1.4
Do you think episiotomies help expedite deliveries in
Do you think there is adequate training with regard to episiotomy practice? a busy and overcrowded labour ward?
Yes 181 87 Yes 106 50.9
No 27 12.9 No 102 49.0
Do you think there is a need for more in-service training? What do you consider the optimal time to perform episiotomy?
Yes 94 45.2 When the parturient patient has the urge to push 148 71.2
No 53 25.5 When 3–4 cm of presenting part visible during contraction 34 16.3
Unknown 61 29.3 When the perineum is bulging 14 6.7
Does your unit have protocol/policy on episiotomy practice? When delivery is expected with the next 3–4 contractions 6 2.9
Yes 49 23.6 When all the above is present 6 2.9
No 158 75.9 How often do you take verbal consent for the procedure?
Don’t know 1 0.5 Always 14 6.7
HCWs, healthcare workers. Sometimes 171 82.2
Rarely 21 10.1
that are incised during the procedure. Knowledge about Never 2 0.9
different types of episiotomy was poor, with 48.6% of How often do you give local anaesthetic before cutting?
HCWs responding that the right lateral episiotomy was Always 133 63.9
recommended at their centre. More than 50% of the HCWs Sometimes 40 18.2
Rarely 11 5.3
stated that less than 30 degree from the midline is the
Never 24 11.5
recommended angle for a properly constituted mediolateral
episiotomy (Table 2).
of the HCWs responded that episiotomies help expedite
Episiotomies were not routine on primigravidae but deliveries in a busy and overcrowded labour ward. The
performed sometimes by 73.6% of the HCWs. More than 50% majority (71.2%) of HCWs responded that the parturient’s

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 Page 4 of 6 Original Research

TABLE 3: Responses to statements of repair and management of episiotomies. TABLE 3 (Continues...): Responses to statements of repair and management of
Response to episiotomy practice n % episiotomies.
Response to episiotomy practice n %
When do you normally repair the episiotomy?
Immediately after delivery of the baby 11 5.3 All of the above recommended 148 71.2

After delivery of the placenta 167 80.3 What are long-term complications of episiotomies?

Depends on the bleeding 30 14.4 Dyspareunia 117 56.3

Which suture material do you use to repair episiotomy? Anal incontinence 47 22.6
Urinary incontinence 20 9.6
Vicryl round 2.0 95 45.7
Pelvic organ prolapse 15 7.2
PDS 3.0 23 11.1
Recto-vaginal fistula 86 41.3
Chromic gut 90 43.3
Vulvodynia 38 18.3
Vicryl round 1.0 0 0.0
Which suture technique do you use? PDS, P-dioxanone suture.

Continuous suture 135 64.9

Continuous locking stitches 39 18.8 urge to push was the optimal time to perform episiotomy.
Interrupted stitches 34 16.3 The response to taking verbal consent for the procedure
What are maternal reasons for performing episiotomy? varied from never to always, but most HCWs (82.2%) would
Primiparity 24 11.5 sometimes take verbal consent with 63.9% of HCWs
Perceived tight perineum 87 41.8 administering local anaesthetic prior to the procedure.
To prevent impending perineal tears including 3rd and 4th 158 75.9
degree perineal tears Aiming to reduce 3rd – 4th degree perineal tears was
Poor maternal effort 33 15.7 the most commonly identified reason for performing an
Prolonged 2nd stage of labour 35 16.8 episiotomy by both medical practitioners and midwives.
Instrumental deliveries 83 39.9 The second most frequent main reason for performing
Previous episiotomy 0 0.0 episiotomies reported by medical practitioners was operative
What are foetal indications for episiotomy delivery, but this was infrequently reported as a main reason
Big baby 135 64.9
by midwives who do not perform operative deliveries,
Premature babies 31 14.9
whilst 64.9% considered a big baby as the foetal indication.
Non-reassuring foetal heart tracing to expedite delivery 13 6.3
The majority (69.7%) of HCWs would give analgesia post-
Breech presentation 48 23.1
Shoulder dystocia 115 55.3
repair of episiotomy, and on discharge, 59.1% would
Abnormal positions such as occipito-posterior and face 55 26.4 sometimes give prophylactic antibiotics and 50.5% would
presentations counsel patients on wound and perineal care post-
Multiple pregnancies 7 3.4
episiotomy, whilst 71.2% would follow all recommendations
What are the immediate complications of episiotomy
stated in the guidelines (Table 3).
Excessive bleeding 148 71.2
Vulva/vaginal hematoma 61 29.3
3rd and 4th degree perineal tears 54 25.9 Discussion
Infection with abscess formation 38 18.3
In this study, we sought to describe the perception knowledge
Extension of the episiotomy 56 26.9
and practice of medical practitioners and midwives regarding
Deep vaginal lacerations 24 11.5
episiotomy use in the greater Pietermaritzburg area. We
Wound dehiscence 14 6.7
Rectal injury 41 19.7
found that medical practitioners and midwives differ with
Do you give analgesia post repair of episiotomy and on regard to perception and knowledge towards episiotomy.
discharge The use of our classification of medical practitioners and
Always 145 69.7 midwives makes it possible to distinguish episiotomy
Sometimes 63 30.3
practices amongst these HCWs.
Rarely 0 0.0
Never 0 0.0
There are many different opinions in the literature about
Do you often give prophylactic antibiotics?
Always 62 29.8
using episiotomy restrictively or routinely. The repeated
Sometimes 123 59.1 Cochrane collaboration meta-analysis of randomised
Rarely 23 11.1 controlled trials together1,8 with the American College of
Never 0 0.0 Obstetricians and Gynaecologists,11 the National Institute
How often do you counsel your patients on wound and for Health and Care Excellence12 and the Swedish guidelines13
perineal care?
recommend restrictive rather than routine use of episiotomy.
Often 105 50.5
South African national episiotomy guidelines14 state that
Sometimes 83 39.9
Rarely 23 11.1
restricted use is preferable. Moreover, one study reported
Never 0 0.0
that restrictive use of episiotomy did not only decrease the
What do you recommend perineal wound care? risks for maternal health but was also less costly than its
Use of antiseptic solution after urinating or bowel evacuation 0 0.0 routine use.10 In our study, more than 70.0% of our HCWs
Sit baths 60 28.8 did not practice restrictive episiotomy. Routine episiotomy
Daily shower and washing with mild soap and water 0 0.0 is discouraged according to maternity care guidelines for
Stool softeners 0 0.0 public health facilities on episiotomy use.11 This guideline
Table 3 continues on the next column → suggests that episiotomy should only be considered for

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 Page 5 of 6 Original Research

the following reasons, namely, thick or rigid perineum they will perform the episiotomy wrong, with 48.6%
preventing delivery and prolonging the second stage, foetal performing right lateral episiotomies compared to only
distress in the second stage of labour and maternal conditions 23.6% who were performing right mediolateral episiotomy.
where rapid delivery is required, for example, cardiac It is evident that there is confusion about mediolateral and
disease, breech or forceps delivery, previous third degree lateral episiotomies in clinical practice.21,22 Additional
tear and preterm delivery where the perineum is tight. research comparing mediolateral with lateral episiotomies to
avert the confusion in clinical practice is needed. A survey
Whilst the current local and international consensus favours from Nordic countries showed that the majority of
a restrictive episiotomy policy,14 our study showed that obstetricians opted to perform a lateral episiotomy, but 64%
HCWs are still practising episiotomy routinely regardless of called it a mediolateral episiotomy.23
indications and lacked awareness regarding the consequences
of episiotomy. This study found that the majority of HCWs Concerns about 3rd – 4th degree tears were both the most
did not have access to a protocol or policy on episiotomy commonly reported reason and the primary reason for
practice in their units; furthermore, they had little or no episiotomy for both medical practitioners and midwives
knowledge of the South African guidelines for maternity care and lack of training in delivering women with an intact
on episiotomy practice. These findings were similar to an perineum was reported as a major obstacle to reducing
earlier questionnaire-based study, where accoucheurs lacked
episiotomy rates.
awareness of the existing evidence and national guidelines
regarding episiotomy use.15 However, significantly more
In our study, there were variations in responses to several
midwives compared to medical practitioners were aware of
statements on episiotomy practice by HCWs based on
the national guidelines.
their level of experience. Significantly, more medical
practitioners felt that there was a need for more in-service
In our study, a majority of HCWs felt that there was no need
training and the need to increase the number of
to limit the number of episiotomies. Another recent study
episiotomies performed under supervision. Similarly,
reported that 35.4% of the midwives and 44.4% of the
wide variations in episiotomy practice exist around the
obstetricians agreed with the expression ‘that episiotomy
should be performed routinely at every birth’.16 Furthermore, world as an expression of the difference in routine
these authors reported that 37.5% of some midwives and a episiotomy use between countries and within countries
greater number of medical practitioners agreed that and amongst midwives and obstetricians with the same
episiotomy gives an opportunity to save more time.17 Diniz et level of experience in obstetric care.24,25
al.17 observed in their study that a significant number of
midwifes in their study felt that episiotomies help expedite In addition, our study showed that episiotomy indications
deliveries in a busy labour ward and medical practitioners were subjective, not consistent with international practice
felt that it was easy to repair an episiotomy rather than an guidelines,20 variable by country26,27 and dependent on the
irregular large tear.18 Furthermore, the authors explain that type of obstetrical staff involved.27 Also, many of the
in a context of shortage of beds in overcrowded hospitals, indications reported by HCWs were not congruent with
interventions such as this expedite labour and delivery. Lack international clinical guidelines.20
of time was a major reason cited by both the midwives and
medical practitioners for why they cut the perineum – to The implementation of evidence-based practices remains a
deliver women faster.19 The same reason was cited in a study significant challenge that requires comprehensive approaches
on quality of maternity care practices amongst skilled birth at different levels.28,29 As shown by Althabe et al. reducing a
attendants in Cambodia: episiotomy was performed in order common practice such as episiotomy is difficult.30
to accelerate the delivery, given the high number of women
in the labour ward.17 The main limitation of this study was the small number of
HCWs included in the study and the relatively small numbers
In our study, 51% of HCWs thought that episiotomy helped of each subgroup surveyed means that the study was not
expedite deliveries but did not show a preference for suturing adequately powered to allow us to be certain that such
episiotomy rather than irregular large tears. Celibi and Guler differences do not exist (a beta error). A larger study would
in their study in 2018 found that the vast majority of HCWs be required to confirm this. Self-assessment does not always
did not see a need to take consent when performing an reflect well on actual knowledge and ability.
episiotomy.15 We report similar findings.

Earlier studies on the effects of episiotomy do not specify the

Conclusion
type of episiotomy and mediolateral episiotomies are mainly Healthcare workers in our low- and middle-income setting
preferred in Europe although lateral episiotomies are used in displayed poor knowledge about the practice of episiotomy
Finland.18,19,20 Our findings show that the most common type and were not aware of the Republic of South Africa (RSA)
of episiotomy practised was right lateral episiotomy, and the existing national guidelines on episiotomy practice. The
SA maternity guidelines recommend mediolateral type. findings in our study are in line with studies carried out in
In our study, 53.4% of HCWs obtained the angle at which other centres, including those in high-income countries.

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 Page 6 of 6 Original Research

Recommendations 7. Zaidan A, Hindi M, Bishara A, et al. The awareness regarding the episiotomy
procedure among women in Saudi Arabia. Mater Sociomed. 2018;30(3):193–197.
[Link]
Routine episiotomies are no longer recommended. Still, the 8. Jiang H, Qian X, Carroli G, et al. Selective versus routine use of episiotomy for
procedure is sometimes needed. It is mandatory that HCWs vaginal birth. Cochrane Syst Rev. 2017;(2):CD000081. [Link]
14651858.CD000081.pub3
need to be familiar with existing RSA guidelines on 9. World Health Organization. WHO recommendation on episiotomy policy. Geneva:
episiotomy practice. World Health Organization 2018.
10. World Health Organization. WHO recommendations: Intrapartum care for a positive
childbirth experience. Geneva: World Health Organization, 2018; p. 150–155.
Acknowledgements 11. American College of Obstetricians and Gynaecologists. ACOG practice bulletin:
Episiotomy. Clinical management guidelines for obstetrician-gynaecologists.
The authors would like to acknowledge all healthcare Obstet Gynecol. 2006;107(4):957–962. [Link]
200604000-00049
workers who participated in this questionnaire-based study 12. National Institute for Health and Care Excellence (NICE). Delay and complications
and the statistician for data analysis. in second stage of labour [homepage on the Internet]. 2015 [cited 2019 July].
Available from: [Link]/pathways/intrapartum-care
13. Bergendahl S, Ankarcrona V, Leijonhufvud Å, et al. Lateral episiotomy versus no
episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery
Competing interests in nulliparous women: Study protocol on a randomised controlled trial. BMJ
Open. 2019;9:e025050. [Link]
The authors declare that they have no financial or personal 14. South African maternity care guidelines [homepage on the Internet]. National
relationships which may have inappropriately influenced Department of Health; 2019 [cited 2019 July]. Available from: [Link]
[Link]/elibrary/guidelines-maternity-care-south-africa
them in writing this article.
15. Borghi J, Fox-Rushby J, Bergel E, et al. The cost-effectiveness of routine versus
restrictive episiotomy in Argentina. Am J Obstet Gynecol. 2002;186(2):221–228.
[Link]
Authors’ contributions 16. Celebi N, Guler H. Opinions of midwives and obstetricians about the episiotomy.
IOSR J Nurs Health Sci (IOSR-JNHS). 2018;7(3):41–47. [Link]
C.M.M. and T.D.N. contributed to the design and 10.9790/1959-0703014147
implementation of the research, to the analysis of the results 17. Diniz SG, Chacham AS. ‘The cut above’ and ‘the cut below’: The abuse of
caesareans and episiotomy in São Paulo, Brazil. Reprod Health Matters.
and to the writing of the manuscript. 2004;12(23):100–110. [Link]
18. Ith P, Dawson A, Homer C. Quality of maternity care practices of skilled birth
attendants in Cambodia Int J Evid Based Healthc. 2012;10(1):60–67. [Link]
Funding information org/10.1111/j.1744-1609.2012.00254.x
19. Schantz C, Sim KL, Ly EM, et al. Reasons for routine episiotomy: A mixed-methods
This research received no specific grant from any funding study in a large maternity hospital in Phnom Penh, Cambodia. Reprod Health
Matters. 2015;23(45):68–77. [Link]
agency in the public, commercial or not-for-profit sectors. 20. Blondel B, Alexander S, Bjarnadóttir RI, et al. Variations in rates of severe perineal
tears and episiotomies in 20 European countries: A study based on routine
national data in Euro-Peristat project. Acta Obstet Gynecol Scand. 2016;95(7):​
Data availability 746–754. [Link]
21. Räisänen SH, Vehviläinen-Julkunen K, Gissler M, et al. Lateral episiotomy protects
Data sharing is not applicable to this article as no new data primiparous but not multiparous women from obstetric anal sphincter rupture.
Acta Obstet Gynecol Scand. 2009;88(12):1365–1372. [Link]
were created or analysed in this study. 00016340903295626
22. Murphy DJ, Macleod M, Bahl R, et al. A randomised controlled trial of routine
versus restrictive use of episiotomy at operative vaginal delivery: A multicentre
Disclaimer pilot study. Br J Obstet Gynecol. 2008;115(13):1695–1703. [Link]
10.1111/j.1471-0528.2008.01960.x
The views and opinions expressed in this article are those of 23. Tincello DG, Williams A, Fowler GE, et al. Differences in episiotomy technique
between midwives and doctors. Br J Obstet Gynecol. 2003;110(12):1041–1044.
the authors and do not necessarily reflect the official policy or [Link]
position of any affiliated agency of the authors. 24. Lund NS, Persson LK, Jangö H, et al. Episiotomy in vacuum-assisted delivery affects
the risk of obstetric anal sphincter injury: A systematic review and meta-analysis.
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