***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE : To compare the outcomes of the current practice of liberally or routinely employing episiotomy to prevent perineal tears and pelvic floor relaxation ( control group ) to a policy of restricting episiotomy use to specific fetal and maternal indications ( experimental group ) . DESIGN : A r and omized controlled trial ( RCT ) . SETTING : Three university hospitals in Montreal . SUBJECTS : Seven hundred three low-risk women enrolled at 30 to 34 weeks of gestation were r and omized late in labor to the design ated trial arm , by parity , and followed up to 3 months postpartum . MAIN OUTCOME MEASURES : Antepartum and postpartum information on perineal trauma and pain , pelvic floor symptoms ( urinary incontinence ) , and sexual activity was collected through the use of st and ard question naires ; pelvic floor function was measured by electromyographic ( EMG ) perineometry . RESULTS : Restricting episiotomy use in primiparous women was associated with similar sutured perineal trauma to the liberal or routine approach . Multiparous women in the restricted episiotomy group more often gave birth with an intact perineum ( 31 % compared with 19 % , odds ratio ( OR ) = 1.85 , 95 % confidence interval ( CI ) = 1.09 to 3.16 ) . All but one 3rd/4th-degree perineal tear was associated with median episiotomy ( 46 of 47 in primiparous women and 6 of 6 among multiparous women ) . No difference between trial groups was found in postpartum perineal pain , antepartum and 3-month postpartum EMG perineometry , and urinary and pelvic floor symptoms . CONCLUSIONS : We found no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation . Virtually all severe perineal trauma was associated with median episiotomy . Restriction of episiotomy use among multiparous women result ed in significantly more intact perineums and less perineal suturing Background Despite all the evidence corroborating the selective use of episiotomy and although routine use of the procedure is contraindicated , there are no evidence s corroborating if episiotomy is necessary in any circumstance . The present clinical r and omized trial was performed to compare maternal and perinatal outcomes in women su bmi tted to a non-episiotomy protocol versus one of selective episiotomy .  Methods An open-labelled , r and omized clinical trial was carried out in a tertiary teaching hospital in Recife , Northeastern Brazil . Women in labor with a full-term live foetus , dilatation of 6 to 8 cm and cephalic presentation ( vertex position ) were included . Exclusion criteria consisted of bleeding disorders and an indication for a caesarean section . After signing the consent form , 241 women were r and omized to a non-episiotomy protocol ( the experimental group ) or to a selective episiotomy group ( the control group ) .  No episiotomies were to be performed in the experimental group except under exceptional circumstances . In the control group , selective episiotomies were to be performed in accordance with the healthcare professionals ’ clinical judgement . Maternal and perinatal outcomes were evaluated . Ratio Risk ( RR ) and the 95 % confidence interval ( 95 % CI ) were calculated for our outcomes . Results The analysis include 115 women assigned to a non-episiotomy protocol and 122 to selective episiotomy . There was no difference between the two groups with respect to maternal or perinatal outcomes . The episiotomy rate was similar ( two cases in each group , about 1.7 % ) , as was the duration of the second stage of labor , the frequency of perineal tears , severe perineal trauma , need for perineal suturing and blood loss at delivery . Conclusions A non-episiotomy protocol appears to be safe for mother and child , and highlights the need to investigate whether there is , in fact , any indication for this procedure . Trial registration This trial was registered at Clinical Trials.gov under reference number ( NCT02178111 ) OBJECTIVE To evaluate the prevalence of obstetrical anal sphincter injuries ( OASIS ) , which include third and fourth degree perineal tears in primigravida in routine versus selective mediolateral episiotomy . Secondly , to determine the rate of episiotomy in local setting s. METHODS This r and omized control trial was carried out in the labor ward of a tertiary hospital of the Universiti Kebangsaan Malaysia Medical Center , Kuala Lumpur , Malaysia between May and October 2009 . The trial included 171 primigravida beyond 38 weeks gestation who achieved vaginal delivery , and r and omly assigned to selective and routine episiotomy groups .  The  type of perineal injuries following childbirth among 171 women were evaluated . RESULTS The overall episiotomy rate from both groups was 76.6 % . The prevalence of third degree perineal tears was 3.7 % in the routine compared with selective mediolateral episiotomy at 1.1 % . There was no occurrence of fourth degree tears in both groups . However , selective mediolateral episiotomy was associated with an increased risk of periurethral and labial injury compared with the routine group ( 4.5 % versus 0 % ) . CONCLUSION Routine mediolateral episiotomy in primigravida is associated with a higher prevalence of obstetrical anal sphincter injuries . As anal sphincter injuries are known to have morbidities , selective mediolateral episiotomy in primigravida is therefore recommended in the implementation of new delivery practice , and in an attempt to reduce our high episiotomy rate OBJECTIVE To evaluate short-term perineal pain among primiparous women after mediolateral episiotomy ( MLE ) and lateral episiotomy ( LE ) .  METHODS The prospect i ve r and omized study was conducted in the Czech Republic during 2010 - 2012 . Consecutive primiparous women who gave birth at or after 37 weeks of pregnancy and had indications for an episiotomy were enrolled and r and omly assigned to undergo MLE or LE . Patients were unaware of the episiotomy type performed . The primary outcomes were pain at 24 hours , 72 hours , and 10 days post partum , measured by a visual analog scale , verbal rating scale , interference with activities of daily living , and amount of analgesic use . RESULTS The analysis included 266 women who underwent MLE and 297 women who underwent LE .  Complete relief of pain was observed in 6 ( 2.3 % ) of 266 women after 24 hours , 21 ( 8.0 % ) of 264 after 72 hours , and 77 ( 29.1 % ) of 265 after 10 days in the MLE group , and in 11 ( 3.9 % ) of 285 , 23 ( 7.7 % ) of 297 , and 78 ( 26.4 % ) of 295 in the LE group , respectively ( P=0.36 ) . There were no significant differences in overall pain scores from any rating system or in the amount of analgesics used . CONCLUSION Incidence and extent of pain in the first 10 days after LE correspond to those after adequately performed MLE Background . The influence of the restrictive use of episiotomy at perineal tears judged to be imminent on the urethral pressure profile , analmanometric , and other pelvic floor findings is unknown Introduction Episiotomy angle is a crucial factor in causation of obstetric anal sphincter injuries ( OASIS ) , which are the major cause of female bowel incontinence . Sutured episiotomies angled too close to the midline ( < 30 degree ) or too far away from the midline ( > 60 degree ) fail to unload the perineum sufficiently and predispose to OASIS . A 25-degree post-delivery episiotomy suture angle has a 10 % risk of OASIS while 45-degree episiotomy is associated with 0.5 % risk . To account for perineal distension at crowning , a 60-degree episiotomy incision is required to achieve 43–50 degree suture angles . We compared episiotomy suture angles with commonly used Braun-Stadler episiotomy scissors with the new fixed angle EPISCISSORS-60 ® . Methods Ethical approval was obtained . A prospect i ve cluster r and omization design was chosen . Thirty-one patients were required in each group for a 12-degree difference with power at 90 % and 5 % significance . Sutured episiotomy angles and post-delivery linear distance from caudal end of the sutured episiotomy to the anus were measured with protractors and rulers . Two-tailed t-tests were used to compare the two groups . Results Thirty-one nulliparae had episiotomies with EPISCISSORS-60  ® , 32 with Braun-Stadler . Mean age ( 25 versus 24.8 years ) was similar . EPISCISSORS-60 ® episiotomies were angled 12 degrees more laterally away from the anus compared to Braun-Stadler ( 40.6 degrees , 95 % confidence interval [ CI ] ±2 , interquartile range [ IQR ] 35–45 versus 28.3 degrees , 95 % CI ±2 , IQR 25–30 , P<0.0001 ) . The post-delivery linear distance from caudal end of the sutured episiotomy to the anus was 15 mm more with the EPISCISSORS-60 ® compared to Braun-Stadler ( 35 mm , 95 % CI ±2.2 , IQR = 30–39 versus 19.5 ; 95 % CI ±1.3 , IQR = 14.75–22.25 P<0.0001 ) . EPISCISSORS-60 ® episiotomies measured longer ( 47 mm versus 40 mm , P<0.0001 ) . There were no OASIS cases in the EPISCISSORS-60 ® group versus one in the Braun-Stadler group . Conclusion The EPISCISSORS-60 ® sutured episiotomies are much further away from the midline in angular and distance measures , hence at lower OASIS risk OBJECTIVE To evaluate the incidence and extent of vaginal and perineal trauma among primiparous women after mediolateral and lateral episiotomy .  METHODS In a prospect i ve r and omized study at University Hospital Pilsen , Czech Republic , 790 consecutive primiparous women were enrolled between April 2010 and April 2012 .  Mediolateral episiotomy ( MLE ) followed an angle of at least 60 ° from the midline . Lateral episiotomy ( LE ) started 1 - 2 cm laterally from the midline and was directed toward the ischial tuberosity . A  rectal examination was performed before episiotomy repair . RESULTS MLE was performed for 390 women , and LE for 400 . The groups did not differ in maternal or neonatal characteristics . No difference was found in incidence or extent of vaginal and perineal trauma ; or in additional perineal ( 1.8 % vs 1.5 % , P=0.6 ) or vaginal ( 8.5 % vs 10.6 % , P=0.2 ) trauma continuing along the episiotomy incision . The incidence of anal sphincter injury did not differ between MLE and LE ( 1.5 % vs 1.3 % , P=0.7 ) . MLE was associated with shorter repair times ( P<0.05 ) , less suturing material ( P<0.05 ) , and shorter distances from the anus ( P<0.001 ) . CONCLUSION Risk of additional vaginal and perineal trauma , and anal sphincter injury after adequately performed mediolateral episiotomy is relatively low and corresponds to that of lateral episiotomy OBJECTIVE To evaluate whether physicians ' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth . DESIGN Post-hoc cohort analysis of physicians and patients involved in a r and omized controlled trial of episiotomy .  SETTING Two tertiary care hospitals and one community hospital in Montreal . PARTICIPANTS Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women ( 226 primiparous and 221 multiparous ) attended by 43 physicians . Subjects attended by residents or nurses  were excluded . MAIN OUTCOME MEASURES PATIENTS intact perineum v. perineal trauma , length of labour , procedures used ( instrumental delivery , oxytocin augmentation of labour , cesarean section and episiotomy ) , position for birth , rate of and reasons for not assigning women to a study arm , postpartum perineal pain and satisfaction with the birth experience , physicians : beliefs concerning episiotomy .  RESULTS Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum ( 23 % v. 11 % to 13 % , p < 0.05 ) and to experience less perineal trauma . The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably ( p < 0.05 to < 0.01 ) , and the former physicians were more likely to use oxytocin augmentation of labour . Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour ( odds ratio [ OR ] 1.88 , p < 
    Output:
    
Subgroup analyses by parity ( primiparae versus multiparae ) and by surgical method ( midline versus mediolateral episiotomy ) did not identify any modifying effects .
One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women , and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy , but the analysis was underpowered .
Authors ' conclusions In women where no instrumental delivery is intended , selective episiotomy policies result in fewer women with severe perineal/vaginal trauma .
Other findings , both in the short or long term , provide no clear evidence that selective episiotomy policies results in harm to mother or baby .
The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence .