Methods and consequences of changes in use of episiotomy.

OBJECTIVES--To evaluate the use of feedback by graphical profiles of rates of episiotomy and the impact on clinical practice and perineal state after spontaneous vaginal deliveries assisted by midwives with different attitudes towards episiotomy. DESIGN--Observation period in labour ward followed by feedback to midwives about their own and other midwives'' use of episiotomies. The periods before and after the intervention were compared. SUBJECTS--All women (n = 3919) delivering during the two periods who had been assisted by one of 30 midwives; each midwife supervised at least 20 deliveries during each period. MAIN OUTCOME MEASURES--Overall rates of episiotomies and indications, incidence of intact perineums, perineal lacerations, and tears of anal sphincter. RESULTS--The overall rate of episiotomy during the observation period was 37.1% (615). During the second period the rate was 6.6% lower (95% confidence interval 3.6% to 9.6%), corresponding to a relative decrease of 17.8% (10.1% to 24.7%). Higher rates of episiotomy during the observation period were associated with larger reductions in the second period. The decrease could be explained by less use of episiotomy in deliveries with rigid perineum or impending perineal tear. Compared with the observation period, in the second period 3.2% more women (0.3% to 6.3%) had an intact perineum after delivery and 3.4% (0.4% to 6.2%) experienced perineal tears. The overall incidence of tears of the anal sphincter remained unchanged. Women had a slightly reduced incidence of tears of the anal sphincter, however, if they were delivered by midwives who reduced a medium or high initial rate of episiotomy and a tendency towards an increased incidence of tears if they were assisted by midwives who reduced low initial rates (around 20%) of episiotomy. CONCLUSIONS--Changes in the use of episiotomy induced by awareness of clinical practice among midwives seem to increase the incidence of parturients with intact perineum without a concomitant rise in tears of the anal sphincter. To avoid the increase of such tears these changes should probably be restricted to midwives with rates of episiotomies above 30%.     

Is routine episiotomy necessary?

One hundred and eighty one primigravid women delivering vaginally in July and August 1982 in the Rotunda Hospital, Dublin, were randomly 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. Assessments 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 questioned, but the final decision can be made only by the accoucheur at the time of imminent delivery.     

Midline episiotomy and anal incontinence: retrospective cohort study

ObjectiveTo evaluate the relation between midline episiotomy and postpartum anal incontinence.DesignRetrospective cohort study with three study arms and six months of follow up.SettingUniversity teaching hospital.ParticipantsPrimiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration.ResultsWomen who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. ConclusionsMidline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.     

Association between median episiotomy and severe perineal lacerations in primiparous women

OBJECTIVE: To evaluate the association between median episiotomy and severe (third- and fourth-degree) perineal lacerations in primiparous women. DESIGN: Retrospective cohort study. SETTING: University-affiliated hospital providing secondary obstetric care in Quebec City. PATIENTS: A total of 6522 primiparous women who gave birth vaginally to a single live baby in cephalic position between 1985 and 1993. OUTCOME MEASURE: Incidence of third- and fourth-degree perineal lacerations. RESULTS: Median episiotomy was performed in 4390 women (67.3%). A total of 1002 women (15.4%) had a third- or fourth-degree laceration. The frequency of severe perineal lacerations was 20.6% with episiotomy and 4.5% without episiotomy (relative risk [RR] 4.58, 95% confidence interval [CI] 3.74-5.62). This association persisted after adjustment by stratified analysis for type of delivery and birth weight (RR 3.03, 95% CI 2.52-3.63) and by logistic regression for type of delivery, birth weight, epidural analgesia, shoulder dystocia, baby''s head circumference, experience of the physician and year of delivery (odds ratio 3.58, 95% CI 2.84-4.50). CONCLUSION: Median episiotomy is strongly associated with third- and fourth-degree perineal lacerations in primiparous women. Reducing the use of this procedure could decrease the occurrence of severe perineal tears.     

Changes in the management of labour: 2. Perineal management.

An analysis of 24,439 deliveries between 1980 and 1984 in a large British obstetric unit showed a striking decline in the rate of episiotomy. The rates of first- and second-degree perineal tears increased during the study period, but overall there was a significant rise in the proportion of women who gave birth with an intact perineum (p less than 0.001). There was no increase in the rate of third-degree tears or of other perineal complications. Delivery with an intact perineum was more likely among younger women, those with a short second stage of labour and those with a small baby (p less than 0.001). These findings confirm the short-term safety of lowering episiotomy rates and should be helpful to all obstetric professionals in reducing unnecessary perineal morbidity among childbearing women.     

Anal sphincteric neurogenic injury in asymptomatic nulliparous women and fecal incontinence

While anal sphincter neurogenic injury documented by needle electromyography (EMG) has been implicated to cause fecal incontinence (FI), most studies have been uncontrolled. Normal values and the effects of age on anal sphincter motor unit potentials (MUP) are ill defined. The functional significance of anal sphincter neurogenic injury in FI is unclear. Anal pressures and EMG were assessed in 20 asymptomatic nulliparous women (age, 38 ± 5 yr; mean ± SE) and 20 women with FI (54 ± 3 yr). A computerized program quantified MUP duration and phases. These parameters and MUP recruitment were also semiquantitatively assessed by experienced electromyographers in real time. Increasing age was associated with longer and more polyphasic MUP in nulliparous women by quantitative analysis. A higher proportion of FI patients had prolonged (1 control, 7 patients, P = 0.04) and polyphasic MUP (2 controls, 9 patients, P = 0.03) at rest but not during squeeze. Semiquantitative analyses identified neurogenic or muscle injury in the anal sphincter (11 patients) and other lumbosacral muscles (4 patients). There was substantial agreement between quantitative and semiquantitative analyses (κ statistic 0.63 ± 95% CI: 0.32-0.96). Anal resting and squeeze pressures were lower (P ≤ 0.01) in FI than controls. Anal sphincter neurogenic or muscle injury assessed by needle EMG was associated (P = 0.01) with weaker squeeze pressures (83 ± 10 mmHg vs. 154 ± 30 mmHg) and explained 19% (P = 0.01) of the variation in squeeze pressure. Anal sphincter MUP are longer and more polyphasic in older than younger nulliparous women. Women with FI have more severe neurogenic or muscle anal sphincter injury, which is associated with lower squeeze pressures.     

Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.

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 randomized 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 implications.     

Five year prospective survey of risk of booking for a home birth in Essex.

A prospective survey was undertaken in 26 practices in Essex to assess the risks associated with a home birth. The 202 women who were booked for a home confinement were compared with a similar group of 185 women who were booked for hospital delivery under consultant care. The principal difference in outcome was the induction rate of 19% in the hospital group compared with 8% in the group booked for delivery at home. A higher rate of episiotomy and second degree tears and more Apgar scores of 7 or below were found in those who were booked for hospital. There were no perinatal deaths in either group. The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital.     

Reducing the frequency of episiotomies through a continuous quality improvement program.

OBJECTIVE: To determine the effectiveness of a continuous quality improvement (CQI) program in reducing episiotomy rates. DESIGN: Before-and-after study; CQI methods were used to examine the process of care during labour and birth. INTERVENTIONS: Identification of care factors that would increase the probability of episiotomy. Implementation of initiatives that would change the process of care to minimize the probability of episiotomy. Educational strategies included promotion of better understanding of what constitutes an appropriate episiotomy rate and ways to reduce maternal exhaustion and true fetal distress as well as manoeuvres to protect the perineum during birth. SETTING: Low-risk family practice obstetrics service in a tertiary care hospital in southwestern Ontario. PARTICIPANTS: All 102 family physicians at the study hospital who provided intrapartum care in the year before and the year during which the CQI program was implemented and the women for whom the care was provided (approximately 1,400 per year). OUTCOME MEASURES: Episiotomy rates (overall, among primiparous and multiparous women, and among individual family physicians) and rates of perineal tear, perineal infection and postpartum readmission. RESULTS: Although the planned reduction in the episiotomy rate was not achieved during the study period, the overall rate decreased significantly from 44.5% to 33.3% (p < 0.001). Among the primiparous women the rate decreased from 57.6% to 46.2% (p < 0.001) and among the multiparous women from 34.3% to 23.6% (p < 0.001). The reduced episiotomy rate among the primiparous women was associated with a significant decrease in the rate of third- and fourth-degree perineal tears and a significant increase in the number of women giving birth with an intact perineum or a minor (first-degree) tear. These benefits were not seen among the multiparous women, whose decreased episiotomy rate was associated with a significant increase in the number of women experiencing a second-degree perineal tear. During the intervention period, there was no increase in the rates of vaginal trauma or postpartum bleeding, infection or readmission because of complications related to perineal trauma. The episiotomy rates for most physicians decreased significantly during the intervention period. CONCLUSIONS: The CQI model may be useful in modifying clinical practices such as episiotomy because it focuses on understanding the process of care and the environment in which care is provided, both of which may have a major impact on physician behaviour. Further study is needed to ascertain the sustainability of the effects of this approach and which components of the model had the greatest effect.     

The Association of Episiotomy with Obstetric Anal Sphincter Injury–A Population Based Matched Cohort Study

Objectives

To estimate the independent association of episiotomy with obstetric anal sphincter injuries (OASIS) using first a cross-sectional and then a matched pair analysis.

Design

A matched cohort.

Setting

Data was gathered from the Finnish Medical Birth Register from 2004–2011.

Population

All singleton vaginal births (n = 303,758).

Methods

Women resulting matched pairs (n = 63,925) were matched based on baseline risk of OASIS defined based on parity (first or second/subsequent vaginal births), age, birth weight, mode of delivery, prior caesarean section, and length of active second stage of birth.

Results

In cross-sectional analysis episiotomy was associated with a 12% lower incidence of OASIS (adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.80 to 0.98) in first vaginal births and with a 132% increased incidence of OASIS in second or subsequent vaginal births (aOR 2.32, 95% CI 1.77 to 3.03). In matched pair analysis episiotomy was associated with a 23% (aOR 0.77, 95% CI 0.69 to 0.86) lower incidence of OASIS in first vaginal births and a 61% (aOR 1.61, 95% CI 1.14 to 2.29) increased incidence of OASIS in second or subsequent vaginal births compared to women who gave birth without an episiotomy. The matched pair analysis showed a 12.5% and a 31.6% reduction in aORs of OASIS associated with episiotomy, respectively.

Conclusions

A matched pair analysis showed a substantial reduction in the aORs of OASIS with episiotomy, due to confounding by indication. This indicates that results of observational studies evaluating an association between episiotomy and OASIS should be interpreted with caution.     

Mesenchymal stem cells can improve anal pressures after anal sphincter injury

Objective.Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury.Methods.Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter.Results.MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP.Conclusion.MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury.     

West Berkshire perineal management trial.

One thousand women were allocated at random to one of two perineal management policies, both intended to minimise trauma during spontaneous vaginal delivery. In one the aim was to restrict episiotomy to fetal indications; in the other the operation was to be used more liberally to prevent perineal tears. The resultant episiotomy rates were 10% and 51% respectively. An intact perineum was more common among those allocated to the restrictive policy. This group experienced more perineal and labial tears, however, and included four of the five cases of severe trauma. There were no significant differences between the two groups either in neonatal state or in maternal pain and urinary symptoms 10 days and three months post partum. Women allocated to the restrictive policy were more likely to have resumed sexual intercourse within a month after delivery. These findings provide little support either for liberal use of episiotomy or for claims that reduced use of the operation decreases postpartum morbidity.     

THIRD DEGREE LACERATION AT DELIVERY—Etiological Considerations,and a Technique for Repair

In a series of 14,080 cases in which either median or mediolateral episiotomy was used to facilitate delivery, third degree extension occurred in 75 cases (0.5 per cent). In related data extension of laceration was observed to occur in an inordinately high proportion of cases in association with use of forceps, greater than normal anterior pelvic depth, delivery of a large baby, primiparity, abnormal position and presentation, use of median incision (although extension also occurred in some cases in which mediolateral episiotomy was done), and hyperflexion and extreme abduction of the thighs.The method of immediate postpartum repair employed was associated with a minimal amount of postpartum discomfort, and late complications were almost nil.     

Third degree laceration at delivery; etiological considerations,and a technique for repair

In a series of 14,080 cases in which either median or mediolateral episiotomy was used to facilitate delivery, third degree extension occurred in 75 cases (0.5 per cent). In related data extension of laceration was observed to occur in an inordinately high proportion of cases in association with use of forceps, greater than normal anterior pelvic depth, delivery of a large baby, primiparity, abnormal position and presentation, use of median incision (although extension also occurred in some cases in which mediolateral episiotomy was done), and hyperflexion and extreme abduction of the thighs. The method of immediate postpartum repair employed was associated with a minimal amount of postpartum discomfort, and late complications were almost nil.     

Management of labour in an isolated rural maternity hospital.

OBJECTIVES--To evaluate the use of a maternity unit run by general practitioners and midwives, describing the outcome of labour in an unselected group of women and quantifying the contribution made by general practitioners. DESIGN--Retrospective population based review of obstetric patients who had access to an isolated rural maternity unit. SETTING--Rural area 120 km from a consultant maternity unit. SUBJECTS--997 consecutive women delivered between January 1987 and May 1991. MAIN OUTCOME MEASURES--Mode of delivery and complications by place of booking and place of delivery; need for medical intervention and transfer. RESULTS--530 women (53%) were booked for delivery in the rural unit; this group had a caesarean section rate of 3.8% and an unplanned transfer rate of 12.8% to the consultant unit in labour. Of the 462 who delivered in the low risk unit, 25 (5%) required a forceps delivery; postnatal complications requiring emergency medical support occurred in a further 33 (7%). CONCLUSIONS--Risk characterisation is possible, but medical support from general practitioners and obstetricians is required in almost a third of women at low risk for complications of delivery. Results of this study support the team approach to obstetric management but not the move towards isolated units without organised medical support.     

West Berkshire perineal management trial: three year follow up.

Women who had participated in a randomised controlled trial of policies of restricted (10%) versus liberal (51%) episiotomy during spontaneous vaginal delivery were recontacted by postal questionnaire three years after delivery. Altogether 674 out of 1000 responded, and there was no evidence of a differential response rate between the two trial groups. Similar numbers of women in the two groups reported further deliveries, almost all of which had been vaginal and spontaneous. Fewer women allocated to restrictive use of episiotomy required perineal suturing after subsequent delivery, but this difference was not significant. Pain during sexual intercourse and incontinence of urine were equally reported in the two groups. The similarity in incontinence rates persisted when severity, type of incontinence, and subsequent deliveries were taken into account. Liberal use of episiotomy does not seem to prevent urinary incontinence or increase long term dyspareunia.     

Results of Parks operation for faecal incontinence after anal sphincter injury.

Parks operation for faecal incontinence was performed on 97 patients with total loss of anorectal control due to injury. All had sustained complete division of the anal sphincters as a result of trauma, anal surgery, or obstetric tears and either were incontinent or had been given a colostomy. In all patients the divided sphincters were repaired using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There was no operative mortality. Continence was completely restored in 65 (78%) and improved in a further 11 (13%) of the 83 patients assessed from four to 116 months postoperatively. Minor complications which did not affect the eventual clinical outcome occurred in 23 patients. Factors associated with failure of the operation included breakdown of the repair in the early postoperative period, fistula, and pelvic floor neuropathy. The results show that even after severe injury to the sphincters surgical reconstruction can restore continence in most patients.     

Opinions of general practitioners in Nottinghamshire about provision of intrapartum care.

OBJECTIVE--To examine the beliefs of general practitioners concerning intrapartum care. DESIGN--Postal questionnaire survey. SUBJECTS--All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES--General practitioners'' current involvement in maternity care, and beliefs on intrapartum care. RESULTS--Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women''s choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS--The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.     

How women view postepisiotomy pain.

Episiotomy is one of the most commonly performed operative procedures and yet little information is available on the subjective reactions in the puerperium to this procedure. The present study was designed to furnish information on the attitudes of patients, levels of pain, and of course recovery by studying a consecutive series of 101 Caucasian primiparea who received episiotomies at delivery. Women were interviewed within 24 hours of delivery and then, at three months after delivery, completed a questionnaire. The high level of pain experienced was noteworthy. Labour pain and episiotomy pain were uncorrelated, indicating the importance of distinguishing between them. Several women were experiencing problems at the three-month follow-up, with some attributing these to the episiotomy repair. The data are presented in the framework of providing women in the postpartum period with systematic information on the nature of postepisiotomy pain and subsequent recovery to facilitate their adjustment.     

Care in a birth room versus a conventional setting: a controlled trial.

A controlled clinical trial was carried out to assess whether a birth room setting would influence the care of mothers and newborns. Of the 163 low-risk women enrolled, 49 (30%) manifested some prenatal risk and were excluded. The remaining 114 were allocated by strict alternation to a birth room or a conventional setting. Of the 56 women allocated to the birth room, 63% of the primiparas and 19% of the multiparas were later transferred. The numbers in the two settings who had oxytocin stimulation, epidural anesthesia, forceps delivery or cesarean section did not show statistically significant differences. The episiotomy rates were slightly lower in the birth room than in the conventional setting, and the rates of an intact perineum were higher in the birth room. Neither the Apgar scores nor the morbidity rates of the infants showed statistically significant differences related to the setting to which the mother had been allocated, although more infants from the conventional setting were admitted to a special care unit. Both "experimental" groups of women less often received routine perineal shaving, enemas or intravenous infusions than did an obstetrically similar nonexperimental comparison group. Despite the apparent inability in this setting for the birth room to influence the rate of major obstetric procedures (except for episiotomy) and outcomes, the authors believe that a birth room is desirable in tertiary care centres as well as in community hospitals.