title: Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.
abstract: OBJECTIVE
  Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears.
  
  
  METHODS
  A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied.
  
  
  RESULTS
  Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently.
  
  
  CONCLUSIONS
  Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.
authors.affiliation: Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
authors.forename: M C
authors.initials: MC
authors.lastname: Klein
authors.forename: R J
authors.initials: RJ
authors.lastname: Gauthier
authors.forename: J M
authors.initials: JM
authors.lastname: Robbins
authors.forename: J
authors.initials: J
authors.lastname: Kaczorowski
authors.forename: S H
authors.initials: SH
authors.lastname: Jorgensen
authors.forename: E D
authors.initials: ED
authors.lastname: Franco
authors.forename: B
authors.initials: B
authors.lastname: Johnson
authors.forename: K
authors.initials: K
authors.lastname: Waghorn
authors.forename: M M
authors.initials: MM
authors.lastname: Gelfand
authors.forename: M S
authors.initials: MS
authors.lastname: Guralnick
mesh_terms: D000293:Adolescent; D000328:Adult; D000704:Analysis of Variance; D002170:Canada; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004841:Episiotomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D009126:Muscle Relaxation; D010149:Postoperative Pain / Q000209:etiology; D010298:Parity; D017773:Pelvic Floor / Q000503:physiopathology*; D010502:Perineum / Q000293:injuries* / Q000503:physiopathology; D011183:Postoperative Complications / Q000209:etiology* / Q000503:physiopathology; D011247:Pregnancy; D012044:Regression Analysis; D012735:Sexual Dysfunction, Physiological / Q000209:etiology*; D014555:Urination Disorders / Q000209:etiology