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Episiotomy risk factors

Risk factors for episiotomy during vaginal childbirth: A

Abstract. From 376 randomly selected nulliparous women who delivered at the Grace Hospital in 1986, we selected 133 low-risk women and performed a retrospective chart review to ascertain the episiotomy rate for physicians by sex, years since graduation, and specialty status To identify risk factors for third-degree lacerations, they performed univariate analysis on the use of episiotomy and 14 other variables; unlike Combs et al , these investigators included several fetal variables — birth weight, fetal distress, meconium, and shoulder dystocia. Of all these, only episiotomy, birth weight, and parity proved.

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Episiotomy and perineal tear risk factors in a group of

  1. Objectives:Episiotomy is an important procedure in the clinical practice of many obstetricians, therefore, in this paper, we will review the proper literature discussing indications, risk factors, complications, and management of episiotomy.Methodology: PubMed database was used for articles selection, and the following keys were used in the.
  2. Episiotomy during first birth and scarring of the perineum during the procedure are major risk-factors for long-term dyspareunia
  3. An episiotomy is a cut (incision) through the area between your vaginal opening and your anus. This area is called the perineum. This procedure is done to make your vaginal opening larger for childbirth. Normally, once the baby's head is seen, your healthcare provider will ease your baby's head and chin out of your vagina
  4. deviation. Univariable Odds Ratio Regression and Multivariable Odds Ratio Regression reduced model were employed risk factors for episiotomy wound infection. Results showed that 39 (27%) women had episiotomy wound infection and 149 (79.3%) women were without episiotomy wound infection
  5. The prevalence of episiotomy among primiparous is high yet higher episiotomy rates are associated with increasing morbidities and lack of benefits. The factors associated with episiotomy practice were gestational age above 37 weeks and prolonged second stage
  6. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth..
Shoulder dystocia

The chance of birth trauma in the cases of younger maternal age, increasing gestational age, induction of labour, fundal pressure, Iranian nationality and nulliparity are increased. The incidence of perineal trauma in this study was high and should be minimised with a limited use of an episiotomy Instrumental deliveries, low forceps in particular, are significant risk factors for most lacerations. Episiotomy is not associated with third- and fourth-degree perineal lacerations but exerts strong protection against periurethral, vaginal, and labial lacerations. A long second stage of labor increases risks for perineal and vaginal. Among non-operative vaginal deliveries, epidural analgesia, non-reassuring fetal heart rate, meconium in the amniotic fluid, shoulder dystocia, and newborn weight (≥ 4,000 g) were risk factors for.. Risk factors associated with episiotomy include operative vaginal delivery, primiparity, inexperience and distress of the health-care provider, and fetal macrosomia. The indications of episiotomy can be fetomaternal

risk factors for postoperative infection in episiotomy of puerpera, thus it is desired to take corresponding intervention measures to reduce rate of postoperative infection in episiotomy and prevent incision infection. Keywords: Episiotomy, Pathogens, Infection, Risk factors. Accepted on October 14, 2017 Introductio Risk factors for episiotomy: A case-control study. September 201 Episiotomy Episiotomy was found to be a significant risk factor for OASIS using univariate analysis (OR = 2.08-95%CI [1.64-2.62] - p < 0.001), with a rate of 18.5% in cases versus 9.9% in controls

Review of Episiotomy and the Effect of its Risk Factors on

The study variables consisted of: whether episiotomy was performed, demographic, obstetric and fetal characteristics (primiparity, analgesia, instrumental delivery, fetal distress, etc.), external factors (day and time of delivery, professional attending delivery) and factors directly related to delivery RESULTS: In multivariate logistic regression analysis the factors which were independently associated were nulliparity, persistent occipitoposterior position, birthweight >3500 g, an angle of episiotomy <30°, a distance episiotomy-fourchette <5 mm and a distance of perineal body <30 mm In addition, mediolateral episiotomy was associated with fewer sphincter injuries. Separate analysis of nulli- and multiparous women demonstrated that high birthweight and epidural anaesthesia (increased risk) and mediolateral episiotomy (decreased risk) were factors associated with anal sphincter tear only in nulliparous women Mediolateral episiotomy is associated with a lower risk of third and fourth degree laceration than a median episiotomy. This topic will review the indications, risks, benefits, and procedure for episiotomy. The repair of episiotomy and obstetric anal sphincter laceration are presented separately

nursing care plan for pain related to episiotomy

Potential risk factors for puerperal hematoma included parity, maternal age, maternal body mass index, gestational age at delivery, neonatal birth weight, instrumental delivery, and episiotomy. Risk factors were compared between the two groups using the Wilcoxon signed-rank test and Fisher's exact probability test The most common site of infection in puerperal sepsis is the placental site in the uterus. Other sites of infection are tears of the cervix, vagina, perineum, and the site of episiotomy. Risk factors for puerperal sepsis-Patient-related risk factors:-Poor patient hygiene; Pre-existing anemia and malnutritio Episiotomy doesn't appear to be a statistically significant protective factor for OASIS (OR = .89-95%CI [0.68-1.16]). The principal independent risk factors for OASIS were nulliparity. In the logistic regression analysis, the risk factors most strongly associated with anal sphincter laceration included episiotomy and forceps delivery with ORs of 3.23 and 2.68, respectively To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy. Methods A retrospective cohort study of all singletons vaginal deliveries at term between 2007-2014. Spontaneous and operative vaginal deliveries were compared separately, as wel

The overall prevalence of episiotomy was 44.0% (1636/3721); 52.9% (1458/2756) among primiparas and 18.4% (178/965) among multiparas (P < 0.001). Adjusted risk factors significantly associated with episiotomy included primiparity, prolonged second stage of labor, and labor‐management personnel Conclusion: The episiotomy rate is high at our hospital (52%) in the face of current evidence based literature that supports restricted use of episiotomy. Nulliparity and instrumental deliveries appear to be the risk factors for episiotomy. Key words: Episiotomy, Instrumental deliveries, Indications, Nulliparity Purpose In Singapore, a developed Asian nation, a relatively high proportion of women undergo episiotomy. We assess risk factors and midwife-reported reasons for episiotomy among women undergoing normal vaginal deliveries (NVDs) conducted by midwives and ascertain the association between episiotomy and degree of perineal tear. Methods Participants included 77 midwives from a high-volume. Although episiotomy is a well-established risk factor for third- and fourth-degree perineal laceration through extension of the surgical incision at the time of delivery, 14 there are very limited data on the effect of episiotomy on the risk of obstetric laceration in subsequent deliveries. 15 Midline episiotomy (even without extension into the sphincter) is also a risk factor for FI and fourth-degree laceration has a higher risk compared to third-degree lacerations. 6,7 Repair of a fourth-degree laceration begins with repair of the rectal mucosa with either a subcuticular running or interrupted suture of 4-0 or 3-0 polyglactin (Vicryl)

n Risk factors for perineal wound infections are pr olonged rupture of membranes, instrumental delivery and episiotomies n There is an urgent need for further r esearch in this relatively. Common Risk Factors for Postpartum Haemorrhage. Some women are at greater risk of postpartum haemorrhage than others. Conditions that are generally recognised to increase the risks of PPH include: Overdistended uterus. Excessive enlargement of the uterus due to polyhydramnios or a large baby, especially with a birthweight over 4,000 grams Risk factors for episiotomy were assessed through logistic regression. Results: Primiparity, advanced maternal age, Indian ethnicity, higher birth weight and older midwife age were associated with.

Episiotomy - risk factors and outcomes: The Journal of

Episiotomy increases the risk of blood loss and anal sphincter tears; this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor.2 Adjusting for these possible compounding factors and the year of birth, the risk of undergoing a second‐degree or higher spontaneous tear at their next delivery was fivefold (adjusted OR 5.15, 95% CI 3.11-8.54), and the risk of undergoing an episiotomy in the second delivery was threefold (adjusted OR 3.20, 95% CI 2.19-4.69) for the. Bodner-Adler B, Bodner K, Kaider A. et al. Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med . 2001;46:752-75611547651 Google Schola Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight. CONCLUSION: Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries

Episiotomy in Low-Risk Deliveries: Physician Factor

Here are the reasons why these five risk factors were identified in the current review. Firstly, consistent with previous studies, episiotomy was identified as a risk factor for postpartum urinary retention in this review [5,37,38]. The possible reason could be the pain from an episiotomy can lead to reflex urethral spasms, followed by PUR An episiotomy may also be done if your baby needs to be born quickly, or if you at risk of a serious perineal tear. How do I care for my episiotomy and reduce my chance of infection? It is important to keep the area clean. Only use water to wash. Wash or shower at least once a day, and change sanitary pads regularly Risk factors: The strongest risk factors for OASIS include forceps delivery, vacuum-assisted delivery, midline episiotomy and increased fetal birth weight. Midline episiotomy, the most common type performed in the United States, is noted as a strong,independent risk factor for third-degree or fourth-degree lacerations Tegerstedt et al. compared 197 women with episiotomy to women without episiotomy and found 1.7 times (95% CI, 1.2-2.4) increased risk for genital prolapse. However, the most important problem in this study is the inclusion of women with Caesarean section (C/S) in the group of women without episiotomies The single most common risk factor for shoulder dystocia is the use of a vacuum extractor or forceps during delivery. 2 However, most cases occur in fetuses of normal birth weight and are.

Risk factors. While there is a high risk for perineal trauma following any vaginal birth, it is particularly important to note the risk factors that contribute to severe perineal tears (third-degree and fourth-degree). The risks can be best separated into the following subgroups: maternal, fetal and intrapartum risk factors (Box 2). 4,7-1 The risk of perineal tear is reduced by the use of medio-lateral episiotomy, although this procedure is also traumatic. Epidural anesthesia and induction of labor also reduce the risk. Instrumentation (the use of forceps or ventouse) reduces the risk if the fetus is in the occiput anterior (normal) position 9) For nulliparous women, breech presentation was also a risk factor for episiotomy, and for multiparous women, scarred uterus and multiple pregnancies were risk factors. In France, despite a reduction in episiotomy use over the last few years, the factors associated with episiotomy have not changed and are similar to the literature Risk factors for episiotomy: a case-control study Giordana Campos Braga, Suelem Taís Pereira Clementino, Patrícia Ferreira Neves da Luz, Adriana Scavuzzi, Carlos Noronha Neto, Melania Maria Ramos Amorim; Affiliations Giordana Campos Braga Suelem Taís Pereira Clementino. Among the various risk factors of OASIS, use of forceps delivery is the most significant one, with an odds ratio (OR) of 5.6 even if routinely combined with mediolateral episiotomy, and it has been found to associate with a higher risk then ventouse

In sum, risk factors for postpartum hemorrhage in the current study included retained placenta, multiple pregnancy, macrosomia, episiotomy, suture, as well as nonuse of active management of the third stage of labor. The majority of these factors are related to the second and third stage of labor. Therefore, an effort should be made, during the. Risk factors for female postpartum sexual dysfunction. Perineal Trauma Perineal tears are classified in 4 degrees: the 1st degree involves the fourchette, perineal skin, and vaginal mucous membrane. 2nd-degree tears involve the perineal muscles and skin. 3rd-degree tears extend from the vaginal wall and perineum to the anal sphincter and 4th. Risk alone cannot account for the higher rate of intervention in private hospitals as discrepancies in outcomes remain after accounting for obstetric and social risk factors . The relationship between model of care and normal birth is relevant for women's decision-making about their care, however the associated risks and benefits of different. There was however no association between maternal age, and induction of labor with episiotomy in this study, although a study done in Israel showed that maternal age above 22 years was found to be protective for episiotomy and induction of labor was a risk factor for episiotomy procedu Confounding factors may not be re. 18 equally distributed. Author's conclusion: episiotomy is an important risk factor for short term PPFSD. However, there is little evidence to support a possible long term effect. Breastfeeding, use of progestogen-only pill and the lack of postpartum sexual health counselling and treatment are other significant risk factors for PPFSD

The association between the use of episiotomy and perineal tears has been somewhat obscure and contradictory 9, 16-18, 24-27. The aim of the present study was to identify risk factors for third-degree and complete third- or fourth-degree anal sphincter tears in women undergoing vaginal delivery. Material and method Several risk factors, such as nulliparity, episiotomy, instrumental deliveries, large birth weight, induction of labor and the use of epidural analgesia have been reported in association with severe perineal laceration [1, 4-6]

Benefits and risks of episiotom

  1. ed at the national level in the United States. Th
  2. If episiotomy is applied only when there is fetal distress or additional risk factors for OASIS, the protective effect of episiotomy may be underestimated. Operator preferences, perceived episiotomy indications and episiotomy technique in Sweden are under investigation in an ongoing project
  3. Episiotomy continues to be a major potentially modifiable risk factor and efforts should be made to continue to limit this procedure to only when medically necessary. Cervical lacerations are associated with cerclage placement and some instances of oxytocin use, which may not be fully modifiable; however, full assessment of risks and benefits.
  4. A retrospective cohort study suggested that episiotomy use may put multiparous women at increased risk for third and fourth-degree tears. Because of such studies, the American College of Obstetricians and Gynecologists recommends against the routine use of episiotomy

Assess the post cesarean patient and those with other risk factors more frequently to monitor and report early signs of infection. The defining characteristics of wound infection are fever, pain or tenderness, edema, redness (erythema) surrounding the wound, induration (hardened tissue under the skin), purulent drainage, and separation of wound. Risk factors commonly cited for obstetric sphincter tear are primiparity, episiotomy, macrosomia, operative delivery, and shoulder dystocia. 4,11,13,19-23 The prevalence of anal sphincter tears in general is approximately 6% 20 but has been reported to be as high as 10%. 21 However, fewer studies have reported the occurrence of sphincter. episiotomy classifications. episiotomy risks. episiotomy technique. The surgical enlargement of the vagina during birth. -1st and 2nd degree laceration: are usually uncomplicated and. -Infection is the primary risk... -Risk of extension of the episi. Done with blunt-tipped scissors just before birth. episiotomy

An Overview on Episiotomy: Indications, Risk Factors, and

The obstetric literature was reviewed to assess the risk of episiotomy dehiscence and rectovaginal fistula formation from routine episiotomy, with and without third-and fourth-degree laceration into the rectal sphincter or rectal mucosa, respectively. Strong evidence suggests that elective episiotomy predisposes to severe 3rd and 4th degree. Objectives To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. Design (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary. The risk factors for OASIS were 2 nd stage of labour ≥1 hour (aOR 6.07, 95%CI 1.86-19.82, ), having episiotomy performed during labour (aOR 2.57, 95%CI 1.07-6.17, ), perineum support during delivery (aOR 0.03, 95%CI 0.01-0.12, ), and monthly income of >50,000 shillings (aOR 0.09, 95%CI 0.03-0.28, ). Conclusions and Recommendations.

Episiotomy performance in the first birth is a risk factor for the occurrence of spontaneous lacerations in subsequent births. Nevertheless, these data may reflect a more liberal practice of episiotomy in primiparous rather than any real need for the procedure in this group of women OBJECTIVE To assess the association between medio-lateral episiotomy and early perineal trauma. STUDY DESIGN A prospective observational cohort study of 667 consecutive vaginal deliveries was conducted over a 10-week period. On the day following delivery, all women were examined for the extent of early perineal trauma (swelling, oedema, haematoma), in addition to the episiotomy or lacerations Key words: Episiotomy, Indications, Risk Factors, Complications INTRODUCTION An episiotomy is a surgical obstetric intervention that is considered when a high risk of a third- or fourth-degree laceration or a concerning fetal heart tracing necessitating an expedite vaginal delivery [1, 2]. It is usuall

Episiotomy - Types, Risks & Complication

  1. Episiotomy is a common obstetric procedure, estimated to be performed in 25% of vaginal deliveries in the United States in 2004. 1 Restrictive use of episiotomy has been recommended given the risks of the procedure and unclear benefits of routine use. In 2006, the American Congress of Obstetricians and Gynecologists recommended against routine episiotomy, 2 and, in 2008, the National Quality.
  2. The main disadvantage of a midline episiotomy is the increased risk for tears that extend into or through the anal muscles. This type of injury can result in long-term problems, including fecal.
  3. Episiotomy as a risk or protective factor for OASIS is controversial: some studies report a reduced risk with a mediolateral incision, [5,21,22] and others are either in-conclusive, [7,24,26] or report increased risk [31]. How-ever, randomised controlled trials (RCTs) have failed to demonstrate a significant reduction in OASIS in wome
  4. Episiotomy is a major risk factor - Routine use associated with 2x as many severe perineal lacerations compared to selective episiotomy use (Rodriguez 2008) - Restricted use of episiotomies is recommended by ACOG Episiotomy utilization in routine delivery should be <5.5% by national benchmarks (AHRQ).
  5. Median episiotomy is a known risk factor for OASIS, especially in operative deliveries, whereas medio-lateral or lateral episiotomy has a protective effect [39,40,41]. Fundal pressure should be avoided because of its harmfulness. Another key issue would be to carefully convey to pregnant women the risk factors and respectful midwifery care.
  6. A vaginal tear (perineal laceration) is an injury to the tissue around your vagina and rectum that can happen during childbirth. There are four grades of tear that can happen, with a fourth-degree tear being the most severe. An episiotomy is a procedure that may be used to widen the vaginal opening in a controlled way. Appointments 216.444.6601

Video: Episiotomy Johns Hopkins Medicin

While there are a few situations where an episiotomy becomes a necessity, current evidence shows that natural tearing is often better in terms of severity, healing, infection, and risk factors. While routine episiotomy is no longer recommended, it does seem that some tearing can be seen as a normal part of the birthing process Khani S, Zare K, Ramezannezhad SE. [The frequency of episiotomy and its related factors]. Iran J Nurs. 2012;24(74):45-52. Persian. 15. Khani S, Taringou F, Shaaban Khani B. [Episiotomy: A preventive medication of extensive genital tract trauma or a risk factor]. Pathobiology Reaearch (Modares J Med Sci). 2001;4(1):9-16. Persian. 16 Historically, episiotomy was routinely performed with the intent of preventing anterior vulvar and severe perineal trauma by making a controlled, easily repaired enlargement of the distal vagina. Multiple major risk factors for OASIS present (do not use median episiotomy), as listed in Table 63-2 Factors associated with obstetric anal sphincter injury among operative vaginal deliveries include nulliparity, macrosomia and prolonged second stage of labour.1, 2, 18 - 20 Episiotomy is a potentially modifiable risk factor, although previous studies on the association between episiotomy use in operative vaginal delivery and obstetric anal.

Risk factors for Episiotomy Wound Infection of Parturients

Episiotomy is a surgical incision of the perineum to hasten the delivery. There is a scarce of information related to episiotomy practice, and its associated factors, in developing countries, including Ethiopia. Thus, this study was aimed to determine the level of episiotomy practice and to identify its determinants at public health facilities of Metema district, northwest, Ethiopia The aim of the researchers is to identify factors associated with episiotomy and the perineal tear. Analyses were performed using a model of a logistic regression. The study involved 4493 women. The episiotomy risk was related to: a birth weight exceeding 3500 grams, an instrumental delivery by means of forceps or vacuum extraction Abstract. Background: Most of the studies on the prevalence and predisposing factors of perineal tears have been in developed countries. A few studies have been carried out in developing countries including Cameroon. The aim of this study is two fold: to 1) determine the prevalence and risk factors of perineal tear during vaginal delivery at the Limbe Regional Hospital, and 2) provide baseline.

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episiotomy- could have cut through the delicate arteries that could have caused bleeding what are some risk factors of this what are some clinical manifestations what will the uterus feel like where will the fundal height be located what phase will the lochia return to Keywords: Perineum, trauma, episiotomy, incidence, risk factors Acknowledgments The Authors would like to acknowledge the research deputy in Kashan University of Medical Sciences for their supports and also all of the midwives in delivery wards of Shabihkhani Maternity, Shahid-Beheshti, and Milad Hospitals in Kashan City Emotional Risk Factors. Women who face emotional and mental stress before, during or right after pregnancy may be at a greater risk of developing postpartum depression. Stressors may include job loss, financial burdens, the death of a friend or family member, the end of a relationship or any other type of stressful life situation Webb, D., & Culhane, J. (2002). Hospital variation in episiotomy use and the risk of perineal trauma during childbirth. Birth, 29(2), 132-136. Williams, A., Marx, S., & Knibb, R. (2007). The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors. Journal of Clinical Nursing, 16, 549-56

Conclusions:Mediolateral episiotomy is an independent risk factor for anal sphincter injuries. Although a liberal policy of mediolateral episiotomy does not appear to reduce the risk of such injuries, it may be related to inappropriate technique The role of episiotomy as a protective factor against pelvic floor disorders postpartum has been debated for many years, but its routine use has been hitherto discouraged in the literature. Comparisons between restrictive and routine use of episiotomy in existent literature, however, fail to include any consideration relating to quality of life Episiotomy continues to be a major potentially modifiable risk factor and efforts should be made to continue to limit this procedure to only when medically necessary. Cervical lacerations are associated with cerclage placement and some instances of oxytocin use, which may not be fully modifiable; however, full assessment of risks and benefits. the groups (p < 0.05). Conclusion: Primiparity, induction of labor, episiotomy, instrumental delivery with forceps or spatula, and a birth weight of 3000 g or more are significantly associated with an increased risk of third and fourth degree perineal tears. Keywords: risk factors; perineal tear; obstetric vaginal tear; obstetric injuries 1. Risk factors shown to increase the risk of OASIS significanty in the unadjusted logistic regression analyses were nulliparity, planned hospital birth, epidural, use of ventouse, use of forceps, directed pushing, longer duration of second stage of labour, episiotomy, shoulder dystocia and birthweight

Modifiable risk factors associated with this condition were analyzed, specifically episiotomy, forceps-assisted vaginal delivery, forceps with episiotomy, vacuum-assisted vaginal delivery, and vacuum with episiotomy. There were a total of 168,337 deliveries in 1990 and 165,051 deliveries in 1991 in Pennsylvania Risk factors for postpartum hemorrhage include a prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia, and history of postpartum hemorrhage.3, 4, 11, 12 However. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia The risk factors associated with severe perineal laceration. Both bi-variable and multivariable logistic regression analysis revealed that episiotomy on current delivery; vacuum assisted delivery and high birth weight were the risk factors for severe perineal laceration in the current study (Table 3)

Episiotomy - risk factors and outcomes Request PD

Table 3: Factors associated with high-utilization hospitals on multivariable analysis. 4. Discussion. While routine episiotomy has been historically utilized in obstetric practice, current evidence demonstrates no clear benefits in women who undergo the procedure without a clinical indication [1, 3] Risk factors for birth-related perineal trauma: a cross-sectional study in a birth centre. Journal of Clinical Nursing, 2012. Esteban Tuesta. Ruth Osava. Sonia Oliveira. Flora Maria Barbosa Silva. Esteban Tuesta. Ruth Osava. Sonia Oliveira. Flora Maria Barbosa Silva. Download PDF

PPT - OBSTETRICAL HEMORRHAGE PowerPoint Presentation, freePerineal injury and episiotomy

Other risk factors common to both men and women include chronic diarrhea or urgency, obesity and older age. Systemic diseases that increase the risk of FI are irritable bowel syndrome and diabetes. The episiotomy rate per department and its evolution is described from 2007 to 2014. A mixed model was used to assess associations with episiotomy for non-operative vaginal deliveries and the risk factors related to the women's characteristics and the birth environment Among the various risk factors of OASIS, use of forceps delivery is the most significant one, with an odds ratio ( OR ) of 5.6 [sup][12] even if routinely combined with mediolateral episiotomy, [sup][12] and it has been found to associate with a higher risk then ventouse