The influence of the attending midwife on the occurrence of episiotomy: A retrospective cohort study

Abstract

Background: Episiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy. Aim: To examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy. Methods: A retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy. Results: A total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife. Conclusion: This study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.