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BJOG. 2008 Jan;115(1):104-8. Epub 2007 Nov 12.

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery.

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  • 1Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, The Netherlands.



To determine the risk factors for anal sphincter injuries during operative vaginal delivery.


A population-based observational study.


All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.


Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.


Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.


Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.


Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.

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