**Abstract**

Episiotomy is a common intervention used during the second stage of delivery. Current use of this procedure is restricted to certain births due to several complications. Almost all births in Chile are delivered by a gynecologist or a midwife in the public or private health system where episiotomy is performed. The objective of this study is to identify strengths and weakness in aspects of perineal management and episiotomy practice among obstetric health care providers with the purpose of promoting practice assessment and updating skills and competencies. Design: Questionnaire-based-cross-sectional study. Method: Anonymous questionnaire applied to gynecologists and midwives of public and private hospitals, between October and December 2019 using the Instrument designed by Cornet et al. addressing questions such as affiliation, number of births/year, knowledge of anatomy, knowledge of episiotomy, knowledge of perineal tear, competence in perineal repair, and presence of expert in perineal trauma at their unit. Results: 189 surveys responded, 51% from midwives and 37.6% from doctors. 71% of total were trained at their medical or midwifery schools and 69% during postgraduate internships. Episiotomy practice criteria: 19% always in primigravida patients and 14,3% always in premature deliveries. Majority of professionals, 79.4% with less than 100 deliveries a year had incorrect answers about depth or sphincter tear prevention technique. Conclusions: The majority of professionals indicated insufficient training capacities in relation to episiotomy techniques. Undergraduate programs should strength training on this intervention, national guidelines must include routine episiotomy performance in order to unify criteria.

**Keywords:** episiotomy, episiotomies, midwifery, obstetrics, sphincter injuries, clinical practice, Chile

## **1. Introduction**

In Chile vital statistics and indicators are methodically published by the bureau of vital statistics jointly with the national institute of statistics.

Chile has a mixed health system (public and private) in terms of financing, health insurance, and service delivery. Certified health professionals may work in either system. Midwives assist the vast majority of normal deliveries at the public service and in the private sector they work cooperatively with the gyn-ob.

Since 1982 until 2016 the rate of deliveries assisted by skilled health personnel, obstetricians or midwifes was 99,8% [1]. In 2016 the natality rate was 14,8% with 243.149 live newborns and the population was 18.191.000 inhabitants.

Episiotomy is the most commonly intervention practiced in obstetrics. It is recommended in order to facilitate the second stage of delivery and protect pelvic tissues from lacerations as well as the fetal head. The surgical incision was early described by Fielding (1742), Michaelis (1799) and Braun (1857) and has been widely used since then [2].

The routine practice of episiotomy has resulted in many researchers questioning the very purpose of this procedure as well as its potential benefits. Nowadays it is restricted [3] to certain deliveries because of the complications and long term outcomes such as infection, edema, pain, laceration or tearing into perineal muscles, bleeding, urinary and fecal incontinence and also esthetic defects [4–6].

If mediolateral episiotomy is practiced with an angle further than 45-60 degree it will not attain greater median levator muscle relaxation. When episiotomy is to short usually will not reduce perineal tissue stress and may provide a weak angle for uncontrolled laceration [2, 7], therefore inappropriate techniques hold greater risks of rectal sphincter injuries [8].

Medio-lateral episiotomy may prevent the recurrence of obstetric anal sphincter injuries (OASIS) specially in women with history of anal sphincter tears in previous deliveries [9], fetal macrosomia [10], nulliparity [11], first vaginal delivery with previous cesarean section, and a prolonged second stage of labour [10, 12], though discordant benefits have been reported with this procedure [13].

Even though there has been general agreement about restrictive episiotomy recommendations [14–16], available data demonstrates that professional viewpoints [17, 18], indications and individual patient conditions [19], are up until now associated with a large rate of episiotomies [20–23]. Correct categorization of patients based on profesional abilities and skills [7, 24] as well as risk factors [8] are very important in order to prevent OASIS [25].

Events affecting episiotomy recovery are technique used, incision extension, and third or fourth degree tear after procedure [2].

A British study about midwifery practice describes that concealed anal sphincter tears showed a twofold increment when re-evaluated by a qualified health profesional [26]. Still, only 17% of midwives tend to perform a rectal examination [27].

This study was designed to find out the principal strengths and weakness around birth assistance and determine doctors and Midwives competencies in aspects of perineal management and episiotomy practice in Chile, with the purpose of promoting professional practice assessment and updating skills and competencies.
