At operative birth, the type of episiotomy may matter more than whether you cut

The edition in brief

In 5,277 operative vaginal deliveries from the US APEX cohort, one in five women had an obstetric anal sphincter injury (OASI). Episiotomy overall was associated with higher odds of OASI (adjusted OR 1.45), but the direction depended on the cut: midline episiotomy at vacuum delivery was linked to more injury whatever the parity, while mediolateral episiotomy was linked to less injury in women without a previous vaginal birth, for both vacuum and forceps. The data are observational. A pragmatic randomised trial in 1,206 nulliparous women found that directing them to extend their hips at crowning did not reduce second-degree or worse tears on intention to treat (66.6% vs 66.2%); a quarter did not adhere, and as-treated differences did not survive adjustment. A patient-level synthesis of 55 pregnancies with Crimean-Congo haemorrhagic fever found maternal mortality of 28.8% and fetal loss of 57.4%, with fetal loss highest in the first trimester and maternal death highest in the third; third-trimester ribavirin was associated with lower maternal mortality (OR 0.33). A meta-analysis of nine trials found warm-water bathing in the first stage did not reduce regional analgesia use but was associated with fewer instrumental births (RR 0.78), on low-certainty evidence. The pearl covers the assessment every woman needs after an operative birth.