title: Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two-centre randomised controlled trial of restrictive versus routine use of episiotomy.
abstract: OBJECTIVE
  To explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy.
  
  
  METHODS
  Longitudinal prospective cohort study embedded within a two-centre randomised controlled trial (RCT).
  
  
  METHODS
  Two UK tertiary-level maternity units.
  
  
  METHODS
  Antenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD.
  
  
  METHODS
  A self-completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum.
  
  
  METHODS
  Urinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity.
  
  
  RESULTS
  Longitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01-1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00-2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum.
  
  
  CONCLUSIONS
  Morbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.
authors: Division of Clinical & Population Sciences & Education, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK. m.macleod@dundee.ac.uk
authors: M
authors: M
authors: Macleod
authors: K
authors: K
authors: Goyder
authors: L
authors: L
authors: Howarth
authors: R
authors: R
authors: Bahl
authors: B
authors: B
authors: Strachan
authors: D J
authors: DJ
authors: Murphy
mesh_terms: D000328:Adult; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods / Q000523:psychology; D004414:Dyspareunia / Q000453:epidemiology / Q000209:etiology*; D004841:Episiotomy / Q000009:adverse effects* / Q000523:psychology; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D009017:Morbidity; D010146:Pain / Q000453:epidemiology / Q000209:etiology*; D010502:Perineum / Q000601:surgery*; D011247:Pregnancy; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D006113:United Kingdom; D014549:Urinary Incontinence / Q000453:epidemiology / Q000209:etiology*