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 Table of Contents  
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 17-21

Episiotomy at Aminu Kano Teaching Hospital, Kano, Nigeria: A 3-Year Review

1 Department of Obstetrics and Gynaecology, Bayero University Kano; Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication28-Jul-2016

Correspondence Address:
Dr. Rabiu Ayyuba
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, PMB - 3011, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-9596.187202

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Background: Episiotomy continues to be increasingly performed in our labor wards despite current scientific evidence restricting its use. The objective of this study was to determine the incidence, indications, and establish reference point for future studies on episiotomy in Aminu Kano Teaching Hospital.
Patients and Methods: This was a 3-year retrospective study of vaginal deliveries in Aminu Kano Teaching Hospital, Kano, from January, 1, 2010 to December 31, 2012. The parturients who had episiotomy were identified from the labor ward register and the following information was extracted: Parity, type of vaginal delivery, gestational age at delivery, birth weight, Apgar scores, and estimated blood loss. The information obtained were analyzed and presented.
Results: The episiotomy rate was 41.4%. Episiotomy was commonly performed in primigravidae (79.4%) than multigravidae (X2 = 3017, P < 0.001), fetal macrosomia in 86.9% of the cases (X2 = 669.7, P < 0.001) and assisted vaginal delivery seen in 75% of the cases (X2 = 172.4, P < 0.001). Episiotomy was also associated with more postpartum blood loss when compared with parturients without episiotomy and was statistically significant (t = 95.82, P < 0.001).
Conclusion: Episiotomy rate is high in Aminu Kano Teaching Hospital. Midwives and doctors conducting deliveries should be educated on the indications for episiotomy and early repair to reduce associated postpartum blood loss.

Keywords: Episiotomy, indications, Kano, rate

How to cite this article:
Garba I, Ozegya MS, Abubakar IS, Ayyuba R. Episiotomy at Aminu Kano Teaching Hospital, Kano, Nigeria: A 3-Year Review. Arch Int Surg 2016;6:17-21

How to cite this URL:
Garba I, Ozegya MS, Abubakar IS, Ayyuba R. Episiotomy at Aminu Kano Teaching Hospital, Kano, Nigeria: A 3-Year Review. Arch Int Surg [serial online] 2016 [cited 2022 Nov 26];6:17-21. Available from:

  Introduction Top

Episiotomy is a surgical incision made on the perineum to increase the diameter of the vulval outlet during the last part of the second stage of labor in order to facilitate vaginal delivery.[1],[2],[3] It is the most commonly performed obstetric procedure.[2],[3] Carl Braun coined the term episiotomy and was introduced as an obstetric procedure more than 200 years ago.[1],[4]

The World Health Organization (WHO) recommends an episiotomy rate of 10% for normal deliveries;[1] however, an episiotomy rate as high as 30% has been documented.[5] Episiotomy rates around the world are still high, especially in developing countries but they are declining in developed countries.[3],[6],[7],[8],[9],[10],[11] In the United States, the rate of episiotomy decreased from 60.9% in 1979 to 24.5% in 2004.[11] In England, the episiotomy rate decreased from 37% in 1985 to 20% in 1995.[12] The recent episiotomy rate in Ghana was 17.4%.[13] In Nigeria, the episiotomy rate was 34.3% in Ogbomoso,[3] 39.6% in Enugu,[2] 34.5% in Benin,[7] 35.6% in Zaria,[10] and 39.1% in Port Harcourt.[9]

The scarcity of high quality data has affected the ability to provide evidence-based recommendations for indications of episiotomy; indications for the procedure are largely based on clinical opinions and anecdote.[14] Episiotomy is commonly done in cases of fetal distress to shorten the second stage of labor. Other conditions where episiotomy can be done are in the pliable perineum, assisted breech delivery, instrumental vaginal delivery, preterm delivery, fetal macrosomia, shoulder dystocia, previous pelvic floor surgery, and occipitoposterior position of the fetal head.[1],[2],[4],[7],[10] Female genital cutting is an important indication for episiotomy.[15]

The various types of episiotomy are median, mediolateral, J-shaped incision, and lateral, each with its merits and demerits.[1],[4]

The incisions are made at crowning during uterine contraction but before sufficient tissue bruising and devitalization occur and tearing of the perineum is imminent.[4] The incision is made using episiotomy scissors in a single cut and is usually 3-6 cm long, depending on the size of the perineum.[1],[16] Prior to performing episiotomy, adequate analgesia is obtained by local infiltration with 10 mL of 1% plain xylocaine.[1],[4] The median (central or midline) episiotomy is widely used in the United States. The incision commences at the center of the fourchette and extends posteriorly along the midline toward the anus. The median episiotomy is usually associated with less blood loss, easy repair, quicker wound healing, less pain in the postpartum period, and reduced incidence of dyspareunia.[1],[4],[16],[17] It however, has a major disadvantage of more than sixfold risk of extending to involve the anal sphincter.[1] It is also not suitable for manipulative deliveries or in abnormal presentation or position; as such its use is selective.[17]

The mediolateral episiotomy is widely performed worldwide and is the standard in the United Kingdom. The incision commences at the center of the fourchette and is directed at an angle of 45° toward the ischial tuberosity. It is relatively safe from rectal involvement and the incision can be extended, making it suitable for manipulative deliveries.[17] Mediolateral episiotomy is more difficult to repair; apposition of tissues is not too good, has more blood loss, more pain and dyspareunia, and poor healing.[4],[17]

The J-shaped incision is not widely done. The incision begins at the center of the fourchette and is directed posteriorly along the midline for about 1.5 cm and then directed downward and outward along the 5 'o clock or 7 'o clock position to avoid the anal sphincter. Apposition is not perfect and the repaired wound tends to be puckered.[17]

Lateral episiotomy begins about 1 cm away from the center of the fourchette and extends laterally. It has some drawbacks including a chance of injury to the Bartholin's duct. This type of episiotomy is not recommended.[17]

The practice of episiotomy varies from one region to another. The departmental policy in the labor ward of Aminu Kano Teaching Hospital is that of restrictive episiotomy and mediolateral episiotomy is favored.

Episiotomy should be sutured immediately after delivery to prevent increasing risk of infection, blood loss, wound breakdown, asymmetry, and perineal pain.[10] The continuous suturing technique, which is considered as the current method of repair,[14],[18] is associated with less pain and overall reduction in need for analgesia compared to interrupted technique.[19] Continuous subcuticular stitching is associated with less perineal pain when compared with interrupted transcutaneous suturing technique.[19] It is recommended that the bulbospongiosus muscle should be repaired in an interrupted fashion before closure of the skin, which is performed with a subcuticular stitch. In addition, sutures should be placed perpendicular to the angle of the incision to avoid distortion of the anatomy of the perineum.[14]

Routine episiotomy was almost the standard procedure in labor ward practice in the second half of the 20th century.[20] It involves performing episiotomy on almost every parturient prophylactically without necessarily any indication. This is because routine episiotomy was thought to reduce the incidence of 3rd and 4th degree perineal tears, improve perineal healing, prevent fetal trauma and birth asphyxia, and reduce risk of urinary and anal incontinences and genital prolapse.[4], 5, [20],[21],[22],[23] Randomized controlled trial showed that routine episiotomy decreased the risk of anterior perineal trauma and moderate perineal laceration but increased the risk of severe perineal laceration.[20],[21],[22],[23]

Morhe et al.,[13] Shahraki et al.,[21] Carroli et al.[22] and Argentine Episiotomy Collaborative Group [5] have all shown that routine episiotomy does not prevent all the complications that were thought to be prevented by routine episiotomy. Complications of episiotomy such as infection, hematoma, increased maternal blood loss, poor wound healing, rectovaginal fistula, incontinence, pain, abscess and cellulitis as well as delay in resumption of sexual activity have led to some limitations against routine episiotomy.[4], 5, [20],[21],[22] Restrictive episiotomy involves performing an episiotomy only when there is an indication. It was advocated because of several problems associated with routine episiotomy. Restrictive episiotomy is associated with less posterior perineal trauma, less suturing, less perineal pain, fewer healing complications, and reduced long-term complications.[3],[5],[8],[20],[21],[22],[23] Restrictive episiotomy is however, associated with increased risk of anterior perineal trauma.[21],[22]

There has been a decline in the episiotomy rate, especially in developed countries as a result of many randomized controlled trials and meta-analysis favoring restrictive rather than routine episiotomy as earlier practiced.[5], 13, [20],[21],[22],[23]

Given the considerable evidence that routine episiotomy increases maternal morbidity and without evidence to support maternal or neonatal benefit, routine episiotomy has been abandoned.[5],[8],[13],[22]

Episiotomy and perineal trauma can be avoided by antenatal perineal massage,[24] changing position during labor (kneeling, all fours, upright position), presence of a caring companion in labor, avoidance of epidural analgesia, and use of vacuum extractor instead of forceps.[1]

Though considerable studies on episiotomy have been done in Nigeria,[2], 3, [7],[8],[9],[10] none was carried out at Aminu Kano Teaching Hospital. Another observation is that primigiravidae in Kano are likely to be younger and of a smaller stature, which will probably increase the rate of episiotomy in this region. We therefore, aimed to determine the rate of episiotomy in this center with a view of comparing it with other studies.

Aim and objectives

  1. To determine the rate of episiotomy at Aminu Kano Teaching Hospital.
  2. To determine the indications for episiotomy at Aminu Kano Teaching Hospital.
  3. To establish a reference point for future studies on episiotomy at Aminu Kano Teaching Hospital.

  Patients and Methods Top

This was a descriptive study of mothers who had vaginal deliveries at Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria. Data were retrospectively collected for deliveries over a 3-year period from January 1, 2010 to December 31, 2012. The parturients who had episiotomy were identified from the labor ward register and the following information was extracted: Parity, type of vaginal delivery, gestational age at delivery, birth weight, Apgar scores, and estimated blood loss. The information obtained were analyzed using Epi Info version 3.5.1 (Centers for Disease Control and Prevention, 1600 Clifton Road Atlanta, GA, USA), 2008. Chi-square and Student's t test were used to compare differences between categorical and continuous variables, respectively. P value was set at ≤5% (0.05) for consideration of statistical significance.

  Results Top

In this review, there were 12,168 vaginal deliveries and 5,040 of them had episiotomy, giving an episiotomy rate of 41.4%. One thousand seven hundred and ten (14.1%) had perineal tears and 5,418 (44.5%) had an intact perineum.

[Figure 1] shows parity distribution of the parturients.
Figure 1: Parity distribution of the parturients

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[Figure 2] shows gestational age at delivery.
Figure 2: Gestational age at delivery

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Good respiration at birth (Apgar scores of ≥7) was established in 11,193 (92%) babies, 342 (2.8%) babies had birth asphyxia, and 633 (5.2%) were stillborn. Women who had episiotomy had greater postpartum blood loss than those who did not have episiotomy (mean blood loss of 255.1 ± 29.4 mL versus 201.2 ± 31.3 mL) and this was statistically significant (t = 95.82, P< 0.001).

[Table 1] showed the indications for episiotomy. Primigravidity was associated with episiotomies as 79.4% of primigravidae had episiotomies and this was statistically significant (X 2 = 3017, P< 0.001). Episiotomy was significantly associated with assisted vaginal delivery, seen in 75% of the cases (X 2 = 172.4, P< 0.001). Episiotomy was also significantly associated with fetal macrosomia in 86.9% of the cases (X 2 = 669.7, P< 0.001).
Table 1: Indications for episiotomy

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  Discussion Top

In this study, the overall episiotomy rate was 41.4%. This high figure is consistent with findings in other parts of Nigeria and developing countries. The episiotomy rate was 39.6% in Enugu,[2] 39.1% in Port Harcourt,[9] 46.6% in Benin,[7] 34.3% in Ogbomosho,[3] 54.9% in Lagos.[22] and 35.6% in Zaria.[10] This figure is higher than the 17.4% reported in Ghana.[13] This is likely due to the higher number of primigravidae in this study with their corresponding lesser age at the first pregnancy.

The rate of episiotomy decreases with increasing parity as none of the grand multiparous women had episiotomy. This is similar to the findings in Ogbomosho and Ghana.[3],[13] Episiotomy was performed in 79.4% of the primigravidae, which was comparable to the findings in Enugu (79.1%),[2] Port Harcourt (77.1%),[9] Benin (90%),[25] Lagos (90.4%),[26] and Zaria (88.5%).[10] This was significantly higher than 31.4% in Ghana,[13] 6.5% in Zambia,[6] and the WHO-recommended rate of 10%.[1] This high rate in primigravidae could be attributed to their early age at first pregnancy and their corresponding larger proportion in this study. However, the study showed no difference with regardsto the high rate of episiotomy among primigravidae when compared to other primigravidae from other studies in the country. Primigravidae are also more likely to have a rigid perineum at risk of perineal tear, which was the most common indication for episiotomy in Benin (75.2%)[7] and Lagos (80.7%).[26]

Assisted vaginal delivery in this review was identified as a risk factor for episiotomy done in 75% of the cases. This was similar to the findings in Enugu (82.5%),[2] Ogbomosho (80%),[3] Aba,[8] and Benin.[7] Fetal macrosomia was also identified as a risk factor for episiotomy in this review. This was similar to the findings in Enugu,[2] Benin,[7] and Port Harcourt.[9] Fetal macrosomia and assisted deliveries increase the risk of episiotomy because of space required for the various manoeuvers to aid delivery.

Episiotomy was associated with more postpartum blood loss as was seen in other studies.[2],[10],[21],[27] However, early suturing could help to reduce postpartum blood loss. Of the babies with birth asphyxia, 79% of them were delivered without episiotomy. Episiotomy could therefore, be protective against birth asphyxia.[28] This is similar to the study in Benin [7] but other studies revealed no significant difference in Apgar scores.[5],[21]

  Conclusion Top

The episiotomy rate is high at Aminu Kano Teaching Hospital and is associated with increased postpartum blood loss. The rate among primigravidae in Kano, Kano State, Nigeria is not different from the rate among primigravidae in other parts of the country. Midwives and doctors conducting deliveries should be educated about the indications for episiotomy and early repair to reduce associated postpartum blood loss.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]

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