# Restrictive approach to episiotomy and the risk of third- and fourth-grade perineal tears: An analytical cross-sectional study at a rural tertiary hospital in South Africa

## TL;DR

This study found that a restrictive approach to episiotomy is effective in reducing severe perineal tears, as the hospital's episiotomy rate exceeded WHO recommendations.

## Contribution

The study provides evidence supporting restrictive episiotomy practices in a rural South African hospital setting.

## Key findings

- The episiotomy rate at Mthatha Regional Hospital was 19%, exceeding the WHO-recommended 5-10%.
- Young maternal age and primigravid status were significant risk factors for episiotomy.
- Only 0.3% of women without episiotomy experienced third-degree tears, with no fourth-degree tears observed.

## Abstract

Based on current evidence, the World Health Organization (WHO) recommends a restrictive approach to episiotomy, rather than routine performance, with a rate of between 5% and 10%. This study aimed to ascertain the rate and conformity to the restrictive patterns of episiotomy among women delivering at Mthatha Regional Hospital (MRH).

A cross-sectional analytical study was conducted with 400 participants at MRH between January and June 2022. Demographic and obstetric data were collected and analysed using SPSS software. Continuous data were analysed using the student’s t-test for normally distributed data and the Wilcoxon–Mann–Whitney U-test for skewed data, categorical data with the chi-square and Fisher’s tests, and logistic regression for the independent predictors of episiotomy. A p-value < 0.05 was considered significant.

The rate of episiotomy was 19% (74/400). The indications for episiotomy were macrosomia (8.1%), foetal distress during the second stage of labour (5.4%), delayed second stage of labour (5.4%), prolonged second stage (5.4%), previous C/S x2 in labour (2.7%), forceps delivery (2.7%) and tight perineum (1.3%); 74% (55/74) was undocumented. The factors associated with episiotomy were maternal age < 20 years (odds ratio [OR] 5.5, confidence interval [CI] 3.2–9.5) and primigravid status (OR 10.2, CI 5.2 – 19), p < 0.05. The rate of third-degree perineal tears among women without episiotomy was 0.3%. There were no fourth-degree tears.

The practice of episiotomy at MRH exceeds the recommendation by the WHO. Young maternal age and primigravid women were risk factors for episiotomy.

The low incidence of third- and fourth-degree tears among women without episiotomy reaffirms the advantages of a restrictive approach to the practice of episiotomy.