Indications for the use of episiotomy in Qatar

Episiotomy is a surgical procedure performed at the time of delivery to enlarge the perineum. Current international trends are toward decreasing the use of episiotomy and limiting its use to specific indications. The World Health Organization (WHO) recommlends an episiotomy rate of 10% [1]. However, the rates reported in different centers vary widely, from 8% to 95% [2]. We examined the use of episiotomy at the Hamad Medical Corporation (HMC) Women's Hospital, the main healthcare provider in Doha, Qatar. A total of 263 singleton spontaneous vaginal deliveries were examined from January to March 2008. The episiotomy rate was 60%. Our results indicated that over 95% of nulliparous women had an episiotomy during their delivery. Although episiotomy rates decreased as parity increased, they were still high (Table 1). The indication for the procedure as reported by the provider was primiparity in 93% of cases (Table 2). The indication was instrumental delivery using a vacuum extractor in only one instance. Senior faculty members (consultants) and specialists were more likely to perform episiotomies than residents. However, the sample was too small to achieve statistical significance. Midwives used episiotomy the least of all groups (57%). Use of episiotomy was not significantly influenced by the patients' ethnic background. This was examined based on some practitioners' belief that Arab women require an episiotomy more often than their Asian counterparts. This is disputable since both groups were found to have similar rates of episiotomy. In fact, the highest rate was observed among Filipino women (87.5%), but this could have been influenced by other factors such as lower overall parity and older age. These results highlight that the decision to perform an episiotomy is primarily governed by the woman's parity, and as a function of current practice at the Women's Hospital is applied to all women irrespective of their national or ethnic background. An interesting trend was noted for patients of Sudanese or Somali ethnicity where the indication for episiotomy was frequently cited as the narrow introitus due to female circumcision. In these cases, anterior episiotomy was performed. Among the outcomes of episiotomy we found an associated higher mean blood loss. The mean estimated blood loss was 279 mL in the episiotomy group compared with 218 mL in the group of patients who did not undergo the procedure (P < 0.0001). Episiotomy was always repaired, while the non-episiotomy tears needed repair in 61% of cases. A higher number of previous vaginal deliveries (2 or more) was associated with decreased need for repair, but the results were not significant. In conclusion, the use of episiotomy at HMC Women's Hospital is higher than the current WHO recommendations, and low parity is the major factor determining the decision to perform the procedure. The episiotomy rate in Qatar could be reduced by limiting its use in primigravid women and installing protocols and guidelines restricting its use to selected cases only, which has been shown to have a number of benefits compared with routine episiotomy policies [3]. The high number of deliveries at the Women's Hospital in Qatar makes it a prime environment for conducting research into obstetric care. This study was made possible by a grant from the Qatar National Research Fund. The contents of the publication are solely the responsibility of the authors and do not necessarily represent the official views of the Qatar National Research Fund.