***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 
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    ***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 In a prospect i ve clinical investigation of 2,144 deliveries , we eluci date the indications for  episiotomy  and how different methods of anesthesia affect the frequency of episiotomy and the perineal problems after  episiotomy  compared with those after spontaneous perineal laceration . We found a significantly higher infection rate ( p less than 0.001 ) and a longer healing period in the episiotomy group . These differences remain even if only primigravida or the indication , imminent perineal laceration , is studied . The results indicate that many women will unnecessarily suffer after an episiotomy . The patient 's subjective problems are significantly increased , both immediately and at the 3-month postoperative follow-up This report presents results of a comparison perineal muscle function between antepartum and postpartum measurements in a cohort of women with different perineal conditions after childbirth . Data were obtained by using prospect i ve electromyographic perineometry measurements to objective ly determine perineal muscle function before and after delivery in 102 women . In addition , 24 nulliparous , non-pregnant women were studied to determine the effect of pregnancy on perineal muscle function . Pregnancy is associated with a decrease in perineal muscle strength and endurance compared with the postpartum state . The degree to which women improved or did not improve perineal muscle function after birth was related to perineal trauma at delivery . After controlling for parity , maternal age , birthweight , smoking status , and antepartum scores , the order of best to worst performance was cesarean birth , intact perineum , first-degree perineal injury , second- or third-degree perineal injury , and episiotomy .  Pre- and post-delivery scores were compared for each woman and analyzed according to perineal outcome . Although all other perineal outcome groups increased muscle function by 6 months postpartum , women with an episiotomy had a mean net loss of perineal muscle performance after birth . These observations do not support the use of episiotomy for the purpose of preserving perineal muscle function Background This study was carried out to identify risk factors associated with urinary incontinence in women three months after giving birth . Methods Urinary incontinence before and during pregnancy was assessed at study enrolment early in the third trimester . Incontinence was re-assessed three months postpartum . Logistic regression analysis was used to assess the role of maternal and obstetric factors in causing postpartum urinary incontinence . This prospect i ve cohort study in 949 pregnant women in Quebec , Canada was nested within a r and omised controlled trial of prenatal perineal massage . Results Postpartum urinary incontinence was increased with prepregnancy incontinence ( adjusted odds ratio [ adj0R ] 6.44 , 95 % CI 4.15 , 9.98 ) , incontinence beginning during pregnancy ( adjOR 1.93 , 95 % CI 1.32 , 2.83 ) , and higher prepregnancy body mass index ( adjOR 1.07/unit of BMI , 95 % CI 1.03,1.11 ) .  Caesarean section  was highly protective ( adjOR 0.27 , 95 % CI 0.14 , 0.50 ) . While there was a trend towards increasing incontinence with forceps delivery ( adjOR 1.73 , 95 % CI 0.96 , 3.13 ) this was not statistically significant . The weight of the baby , episiotomy , the length of the second stage of labour , and epidural analgesia were not predictive of urinary incontinence . Nor was prenatal perineal massage , the r and omised controlled trial intervention . When the analysis was limited to women having their first vaginal birth , the same risk factors were important , with similar adjusted odds ratios . Conclusions Urinary incontinence during pregnancy is extremely common , affecting over half of pregnant women . Urinary incontinence beginning during pregnancy roughly doubles the likelihood of urinary incontinence at 3 months postpartum , regardless whether delivery is vaginal or by Caesarean section Episiotomy is a widely-done intervention in childbirth , regardless of poor scientific evidence of its benefits . This r and omised controlled trial compares selective with routine use of a mediolateral episiotomy for women having first and second deliveries in 8 public maternity units in Argentina . 2606 women participated ; 1555 were nulliparous ( 778 in the selective group and 777 in the routine group ) and 1051 primiparous ( 520 in the selective group and 531 in the routine group ) . The two interventions compared were selective ( limited to specified maternal or fetal indications ) , and routine episiotomy ( following the hospital 's previous policy ) . Episiotomy was done in 30.1 % of deliveries in the selective , and 82.6 % in the routine group . The main outcome measure was severe perineal trauma . Severe perineal trauma was uncommon in both groups but was slightly less frequent in the selective group ( 1.2 % vs 1.5 % ) . Anterior perineal trauma was more common in the selective group but posterior perineal surgical repair , perineal pain , healing complications , and dehiscence were all less frequent in the selective group . Routine  episiotomy should be ab and oned and episiotomy rates above 30 % can not be justified 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 < 0.05 ) , both overall and because they felt that " fetal distress " or cesarean section necessitated exclusion of the subject . They used the lithotomy position for birth more often ( OR 3.94 to 4.55 , p < 0.001 ) , had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups . The patients of physicians who viewed episiotomy very favourably experienced more perineal pain ( p < 0.01 ) , and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience ( p < 0.01 ) than the patients of physicians who viewed the procedure very unfavourably . CONCLUSIONS Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour , and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience . This evidence that physician beliefs can influence patient outcomes has both clinical and research implication One hundred and eighty one primigravid women delivering vaginally in July and August 1982 in the Rotunda Hospital , Dublin , were r and omly allocated to one of two groups . Patients in one group were to undergo episiotomy . Those in the other group were not to undergo episiotomy unless it was considered to be essential . The outcome was compared with that of the clinical practice over the previous six months at the hospital . Of the 92 patients allocated not to undergo episiotomy  , seven ( 8 % ) had one done for medical reasons compared with 507 ( 89 % ) in the previous six months . First degree tears occurred in 23 ( 25 % ) and second degree tears in 43 ( 47 % ) . Nineteen ( 21 % ) , however , retained an intact perineum compared with only 35 ( 6 % ) of the women who had delivered in the preceding six months . Assessment s of perineal pain , bruising , swelling , and healing and records of ingestion of analgesics were made for the first four days after delivery , and again at a check up six weeks after delivery , in patients who had had spontaneous vertex deliveries . Forty patients who underwent episiotomy and 37 who sustained a second degree tear formed two comparable groups . There was no difference in outcome between them . Data were also evaluated for 19 women who retained an intact perineum , 22 who sustained a first degree tear , and 11 who underwent episiotomy and epidural anaesthesia ; all 52 of these women had spontaneous vertex deliveries . Despite severe soft tissue injury in two patients those who fared best were those who retained an intact perineum . First degree tears were associated with symptoms similar to those associated with second degree tears . Those who fared worst were women who underwent episiotomy after epidural anaesthesia . The value of routine episiotomy in primigravid patients is question ed , but the final decision can be made only by the accoucheur at the time of imminent delivery The incidence and outcome of third‐degree tears following 16583 vaginal deliveries were prospect ively assessed over a 55year period . Ninety‐three deliveries ( 0.56 per cent ) were complicated by a third‐degree tear and the patients underwent primary repair .  Eighty‐one patients were review ed 3 months postpartum at a colorectal clinic . Third‐degree tears were significantly more common in primigravidae and mothers with higher birth‐weight babies . They were significantly associated with the use of forceps and were not prevented by episiotomy . Of the 81 patients review ed , 30 had an abnormal anorectal examination .  Six patients ( 7 per cent ) were incontinent of faeces . A further ten ( 12 per cent ) were incontinent of flatus only . The overall incidence of faecal incontinence was 0.04 per cent . An important group of women with significant sub clinical sphincter injury was identified . Obstetric trauma causes significant anorectal dysfunction and patients with third‐degree tears require assessment by a colorectal specialist The association between  episiotomy and severe ( third- and fourth-degree ) perineal lacerations was studied in 24,114 women . The overall rates of severe lacerations were 8.3 and 1.5 % for primiparous and multiparous women , respectively . Women who had  midline episiotomies  were nearly 50 times more likely and women who had mediolateral episiotomies were over eight times more likely to suffer a severe laceration than were women who did not undergo an episiotomy .  Severe lacerations were also more common after use of forceps , in occiput transverse and posterior presentations , among women 
    Output:
    
EVIDENCE SYNTHESIS Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy , including severity of perineal laceration , pain , and pain medication use , are not better than those with restrictive use .
Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy .
Evidence regarding long-term sequelae is fair to poor .
With this caveat , relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation .
Likewise , no evidence suggests that episiotomy reduces impaired sexual function -- pain with intercourse was more common among women with episiotomy .
Evidence does not support maternal benefits traditionally ascribed to routine episiotomy .
In fact , outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision