An Gopinath, (2015) conducted a large observational study

An episiotomy is an incision into the tissues surrounding
the opening of the perineum. The procedure is typically performed during a
difficult birth. Often, it is used as a preventative measure to enlarge the
opening in a controlled manner, to make delivery easier and to avoid extensive
tearing of adjacent tissues. Episiotomies were initially developed to prevent perineal
trauma during deliveries, most importantly third and fourth-degree lacerations (Muhleman et al,
2017). These severe lacerations often have long term implications regarding
health and quality of life for women (Muhleman et al, 2017). Episiotomies may
also be used where there is: fetal distress and complicated birthing situations
such as forceps deliveries, breech births, as well as to enable easier passage
of larger babies (Jiang et al., 2017).

There is substantial
evidence that episiotomies can prevent severe tearing, as many studies have
shown that a mediolateral episiotomy has a protective effect against perineal
trauma and OASIS.  Some conclude that it should
be used routinely, whilst others advise restrictive use in normal vaginal
deliveries (Kapoor et al., 2015; Twidale et al., 2013; Revicky et al., 2010;
Verghese et al., 2016). However, it is this area of disagreement which
impacts practice as routine or restrictive use of episiotomy appear to have
significantly different outcomes. When comparing the results of routine
episiotomy with restricted episiotomy, Jiang et al (2017) showed, in a Cochrane
review that a restrictive episiotomy policy is superior to routine episiotomy
policy. Their analysis showed that in the first instance there is less
posterior perineal trauma, suturing, and subsequent complications. Nevertheless,
there was also an increased risk of anterior perineal trauma with restrictive
episiotomy (Carroli and Mignini, 2009).

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In addition, there is evidence that episiotomy with
instrumental deliveries reduces the risk of third and fourth degree tears. de Leeuw et al. (2007) concluded that
mediolateral episiotomy has a protective effect against OASIS in operative
vaginal deliveries. Also, Keriakos and Gopinath, (2015) conducted a large
observational study in the Netherlands of 28 732 operative vaginal deliveries.
They concluded that mediolateral episiotomy is protective against severe
perineal trauma and OASIS in both ventouse and forceps deliveries. Although,
this evidence cannot be applied to a UK context as the Netherlands has a very
different approach and culture surrounding birth. During an instrumental
vaginal delivery, the perineum is manually stretched to a greater extent than
it otherwise would be in a non-instrumental vaginal delivery. Thus, it is more
susceptible to severe trauma, such as third and fourth degree tears and OASIS. Therefore,
according to NICE (2017) an episiotomy should be used routinely with operative
births as a protective measure. The main indication for operative vaginal
delivery is fetal distress and so episiotomy also allows for a quicker delivery
of the neonate, preventing potential for fetal compromise, as well as
protection of the mother from severe perineal trauma.

However, a meta-analysis of fifteen studies by Sagi-Dain and
Sagi (2015) found that both median and mediolateral episiotomy in ventouse
deliveries did not appear beneficial for either neonate or mother. Parity is another
significant variable in episiotomy research. A mediolateral episiotomy in multiparous
woman may increase the rate of OASIS during ventouse delivery, whilst an episiotomy
in primiparous women is associated with a decreased risk of OASIS. A
mediolateral episiotomy was also associated with higher incidences of
postpartum haemorrhage and perineal pain. This evidence was deemed to be low
quality as many of the studies examined contain high levels of confounding
variables that may have impacted results. Sagi-Dain and Sagi, (2015) conclude
that further high-quality randomised trials are required to provide a
definitive conclusion about the effectiveness of episiotomy.