title: Methods and consequences of changes in use of episiotomy.
abstract: OBJECTIVE
  To evaluate the use of feedback by graphical profiles of rates of episiotomy and the impact on clinical practice and perineal state after spontaneous vaginal deliveries assisted by midwives with different attitudes towards episiotomy.
  
  
  METHODS
  Observation period in labour ward followed by feedback to midwives about their own and other midwives' use of episiotomies. The periods before and after the intervention were compared.
  
  
  METHODS
  All women (n = 3919) delivering during the two periods who had been assisted by one of 30 midwives; each midwife supervised at least 20 deliveries during each period.
  
  
  METHODS
  Overall rates of episiotomies and indications, incidence of intact perineums, perineal lacerations, and tears of anal sphincter.
  
  
  RESULTS
  The overall rate of episiotomy during the observation period was 37.1% (615). During the second period the rate was 6.6% lower (95% confidence interval 3.6% to 9.6%), corresponding to a relative decrease of 17.8% (10.1% to 24.7%). Higher rates of episiotomy during the observation period were associated with larger reductions in the second period. The decrease could be explained by less use of episiotomy in deliveries with rigid perineum or impending perineal tear. Compared with the observation period, in the second period 3.2% more women (0.3% to 6.3%) had an intact perineum after delivery and 3.4% (0.4% to 6.2%) experienced perineal tears. The overall incidence of tears of the anal sphincter remained unchanged. Women had a slightly reduced incidence of tears of the anal sphincter, however, if they were delivered by midwives who reduced a medium or high initial rate of episiotomy and a tendency towards an increased incidence of tears if they were assisted by midwives who reduced low initial rates (around 20%) of episiotomy.
  
  
  CONCLUSIONS
  Changes in the use of episiotomy induced by awareness of clinical practice among midwives seem to increase the incidence of parturients with intact perineum without a concomitant rise in tears of the anal sphincter. To avoid the increase of such tears these changes should probably be restricted to midwives with rates of episiotomies above 30%.
authors.affiliation: Department of Gynaecology and Obstetrics, Aarhus University Hospital, Denmark.
authors.forename: T B
authors.initials: TB
authors.lastname: Henriksen
authors.forename: K M
authors.initials: KM
authors.lastname: Bek
authors.forename: M
authors.initials: M
authors.lastname: Hedegaard
authors.forename: N J
authors.initials: NJ
authors.lastname: Secher
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000293:injuries; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D016009:Chi-Square Distribution; D004841:Episiotomy / Q000523:psychology / Q000706:statistics & numerical data*; D005246:Feedback; D005260:Female; D006801:Humans; D016015:Logistic Models; D008423:Maternal Age; D008880:Midwifery; D015999:Multivariate Analysis; D009721:Nurse Midwives / Q000523:psychology; D007744:Obstetric Labor Complications / Q000601:surgery*; D010298:Parity; D010502:Perineum; D011247:Pregnancy