title: Risk factors and midwife-reported reasons for episiotomy in women undergoing normal vaginal delivery.
abstract: OBJECTIVE
  In Singapore, a developed Asian nation, a relatively high proportion of women undergo episiotomy. We assess risk factors and midwife-reported reasons for episiotomy among women undergoing normal vaginal deliveries (NVDs) conducted by midwives and ascertain the association between episiotomy and degree of perineal tear.
  
  
  METHODS
  Participants included 77 midwives from a high-volume delivery unit in Singapore. The study had three sequential phases: (1) medical record review of women undergoing NVDs conducted by midwives over a 1-month period to document the proportion with episiotomy; (2) focus group discussions with midwives to form a checklist of reasons for episiotomy; (3) checklist-based documentation of midwife-reported reasons for episiotomy and data collection on maternal, neonatal, practice and midwife factors, and degree of perineal tear among women undergoing NVDs conducted by midwives over a 2-month period. Risk factors for episiotomy were assessed through logistic regression.
  
  
  RESULTS
  Primiparity, advanced maternal age, Indian ethnicity, higher birth weight and older midwife age were associated with episiotomy. The most common midwife-reported reason for episiotomy among primiparous women was primiparity (55.1%), and among multiparous women was fetal distress (20.0%) and poor maternal effort (20.0%). All women with episiotomy sustained at least a second-degree perineal tear versus 27.1% among women without episiotomy.
  
  
  CONCLUSIONS
  Most midwife-reported reasons for episiotomy were not congruent with international practice guidelines. Women without episiotomy have lesser tears than those with episiotomy. Practice protocols and educational programs are needed to change episiotomy practice.
authors.affiliation: Duke-NUS Graduate Medical School, 8 College Road Singapore, Singapore, 169857, Singapore, linchiehwu@gmail.com.
authors.forename: Lin Chieh
authors.initials: LC
authors.lastname: Wu
authors.forename: Rahul
authors.initials: R
authors.lastname: Malhotra
authors.forename: John Carson
authors.initials: JC
authors.lastname: Allen
authors.forename: Desiree
authors.initials: D
authors.lastname: Lie
authors.forename: Thiam Chye
authors.initials: TC
authors.lastname: Tan
authors.forename: Truls
authors.initials: T
authors.lastname: Østbye
mesh_terms: D000328:Adult; D001724:Birth Weight; D004841:Episiotomy / Q000706:statistics & numerical data*; D005260:Female; D017144:Focus Groups; D006801:Humans; D016015:Logistic Models; D008423:Maternal Age; D008880:Midwifery; D015999:Multivariate Analysis; D009721:Nurse Midwives / Q000523:psychology*; D007744:Obstetric Labor Complications; D010298:Parity; D010502:Perineum / Q000601:surgery; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D011247:Pregnancy; D011256:Pregnancy Outcome; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D012846:Singapore / Q000453:epidemiology