Lateral episiotomy during vacuum assisted childbirth

The linked paper by Bergendahl and colleagues (doi:10.1136/bmj-2023-079014) provides much needed evidence supporting the use of episiotomy to prevent obstetric anal sphincter injury among nulliparous women needing vacuum assisted birth.1 The authors should be commended for conducting a well designed randomised trial with short and long term outcomes, which concluded that lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to substantially reduce the rate of obstetric anal sphincter injuries.

What does reducing anal sphincter injuries by more than half mean to birthing women? Although all forms of perineal injury cause morbidity, injury to the anal sphincter is associated with worse perineal pain, dyspareunia, and sexual dysfunction.23 Anal sphincter injury is also a major risk factor for anal incontinence, with about 38% of affected women developing symptoms after primary repair.4

Anal sphincter injuries can have a devastating and life changing impact on women and their families; the emotional trauma and psychological symptoms can have a similar or even more substantial effect than the physical symptoms.5 Patients may be unable to return to their …