Ukrainian Journal Health of Woman. 2022. 6(163): 14-21; doi 10.15574/HW.2022.163.14
Liashko M. B., Govsieiev D. O.
Bogomolets National Medical University, Kyiv, Ukraine

For citation: Liashko MB, Govsieiev DO. (2022). Rationalization of approaches to managing episiotomy wounds. Ukrainian Journal Health of Woman. 6(163): 14-21; doi 10.15574/HW.2022.163.14.
Article received: Oct 14, 2022. Accepted for publication: Dec 10, 2022.

Episiotomy is a surgical manipulation that has become one of the most frequently performed surgical procedures in the world. According to World Health Organization recommendations, the overall frequency of episiotomy use should not exceed 10% of vaginal deliveries. However, in some developed countries, there are significant discrepancies in clinical experience with the use of episiotomies, with rates ranging from 5.2% (USA), 9.7% (Sweden) to 100% (Taiwan), including both primiparous and multiparous women.
Purpose – to evaluate global data on the appropriateness of routine episiotomy use, the importance of studying wound healing and methods of managing episiotomy wounds.
Considering that episiotomy continues to be used by physicians worldwide, there is a need for more detailed assessment of the appropriateness of performing episiotomy, wound healing, search for new approaches to managing episiotomy wounds, and prevention of complications.
Conclusions. The results of numerous studies indicate the importance of more detailed study of the issue of episiotomy wound repair and methods of treatment during the postpartum period. However, given the significant achievements reflected in publications on the study of episiotomy management, there is a need to search for an optimal approach to management, predicting success and risk factors affecting episiotomy wound healing.
No conflict of interests was declared by the authors.
Keywords: episiotomy, vaginal delivery, wound healing, hemostasis, inflammation, inflammatory cytokines, IL-1, IL-6 and TNF-α, pathogens.

REFERENCES

1. American College of Obstetricians and Gynecologists, Committee on Practice Bulletins, Cichowski S, Rogers R. (2016). Practice Bulletin No. 165: prevention and management of obstetric lacerations at vaginal delivery. Obstetrics and gynecology. 128 (1): e1-e15. URL: https://journals.lww.com/greenjournal/Abstract/2016/07000/Practice_Bulletin_No__165__Prevention_and.46.aspx. https://doi.org/10.1097/AOG.0000000000001523

2. Bader MS. (2008). Diabetic foot infection. American family physician. 78 (1): 71-79.

3. Barrientos S, Stojadinovic O, Golinko MS, Brem H, Tomic‐Canic M. (2008). Growth factors and cytokines in wound healing. Wound repair and regeneration. 16 (5): 585-601. https://doi.org/10.1111/j.1524-475X.2008.00410.x; PMid:19128254

4. Baum CL, Arpey CJ. (2005). Normal cutaneous wound healing: clinical correlation with cellular and molecular events. Dermatologic surgery. 31 (6): 674-686. https://doi.org/10.1097/00042728-200506000-00011; PMid:15996419

5. Bharathi A, Reddy DD, Kote GS. (2013). A prospective randomized comparative study of vicryl rapide versus chromic catgut for episiotomy repair. Journal of clinical and diagnostic research: JCDR. 7 (2): 326. https://doi.org/10.7860/JCDR/2013/5185.2758; PMid:23543639 PMCid:PMC3592303

6. Bols EM, Hendriks EJ, Berghmans BC, Baeten CG, Nijhuis JG, De Bie RA. (2010). A systematic review of etiological factors for postpartum fecal incontinence. Acta obstetricia et gynecologica Scandinavica. 89 (3): 302-314. https://doi.org/10.3109/00016340903576004; PMid:20199348

7. Broughton G, Janis JE, Attinger CE. (2006). Wound healing: an overview. Plastic and reconstructive surgery. 117 (7S): 1e-S-32e-S. https://doi.org/10.1097/01.prs.0000222562.60260.f9; PMid:16801750

8. Campbell L, Saville CR, Murray PJ, Cruickshank SM, Hardman MJ. (2013). Local arginase 1 activity is required for cutaneous wound healing. Journal of Investigative Dermatology. 133 (10): 2461-2470. https://doi.org/10.1038/jid.2013.164; PMid:23552798 PMCid:PMC3778883

9. Carroli G, Belizan J. (1999). Episiotomy for vaginal birth. Cochrane database of systematic reviews: 3. https://doi.org/10.1002/14651858.CD000081

10. Carroli G, Mignini L. (2009). Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews: 1. PMID: CD000081. https://doi.org/10.1002/14651858.CD000081.pub2

11. Costerton JW, Stewart PS, Greenberg EP. (1999). Bacterial biofilms: a common cause of persistent infections. Science. 284 (5418): 1318-1322. https://doi.org/10.1126/science.284.5418.1318; PMid:10334980

12. Cunningham F, Williams J, Leveno K, Bloom S, Hauth J. (2009). Bibliographic information. New York: McGraw-Hill Medical.

13. De la Fuente-Núñez C, Reffuveille F, Fernández L, Hancock RE. (2013). Bacterial biofilm development as a multicellular adaptation: antibiotic resistance and new therapeutic strategies. Current opinion in microbiology. 16 (5): 580-589. https://doi.org/10.1016/j.mib.2013.06.013; PMid:23880136

14. Delavary BM, van der Veer WM, van Egmond M, Niessen FB, Beelen RH. (2011). Macrophages in skin injury and repair. Immunobiology. 216 (7): 753-762. https://doi.org/10.1016/j.imbio.2011.01.001; PMid:21281986

15. Dudley L, Kettle C, Ismail K. (2013). Prevalence, pathophysiology and current management of dehisced perineal wounds following childbirth. British Journal of Midwifery. 21 (3): 160-171. https://doi.org/10.12968/bjom.2013.21.3.160

16. Dudley L, Kettle C, Waterfield J, Ismail KM. (2017). Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study. BMJ open. 7 (2): e013008. https://doi.org/10.1136/bmjopen-2016-013008; PMid:28188152 PMCid:PMC5306502

17. Edwards R, Harding KG. (2004). Bacteria and wound healing. Current opinion in infectious diseases. 17 (2): 91-96. https://doi.org/10.1097/00001432-200404000-00004; PMid:15021046

18. Eming SA, Krieg T, Davidson JM. (2007). Inflammation in wound repair: molecular and cellular mechanisms. Journal of Investigative Dermatology. 127 (3): 514-525. https://doi.org/10.1038/sj.jid.5700701; PMid:17299434

19. Frykberg RG. (2015). Challenges in the treatment of chronic wounds. Advances in wound care. (New Rochelle). 4 (9): 560-582. https://doi.org/10.1089/wound.2015.0635; PMid:26339534 PMCid:PMC4528992

20. Gjødsbøl K, Christensen JJ, Karlsmark T, Jørgensen B, Klein BM, Krogfelt KA. (2006). Multiple bacterial species reside in chronic wounds: a longitudinal study. International wound journal. 3 (3): 225-231. https://doi.org/10.1111/j.1742-481X.2006.00159.x; PMid:16984578 PMCid:PMC7951738

21. Golebiewska EM, Poole AW. (2015). Platelet secretion: From haemostasis to wound healing and beyond. Blood reviews. 29 (3): 153-162. https://doi.org/10.1016/j.blre.2014.10.003; PMid:25468720 PMCid:PMC4452143

22. Gravett CA, Gravett MG, Martin ET, Bernson JD, Khan S, Boyle DS et al. (2012). Serious and life-threatening pregnancy-related infections: opportunities to reduce the global burden. 9 (10): e1001324. https://doi.org/10.1371/journal.pmed.1001324; PMid:23055837 PMCid:PMC3467240

23. Gün İ, Doğan B, Özdamar Ö. (2016). Long-and short-term complications of episiotomy. Turkish journal of obstetrics and gynecology. 13 (3): 144. https://doi.org/10.4274/tjod.00087; PMid:28913110 PMCid:PMC5558305

24. Heres M, Pel M, Elferink-Stinkens P, Van Hemel O, Treffers P. (1995). The Dutch obstetric intervention study – variations in practice patterns. International Journal of Gynecology & Obstetrics. 50 (2): 145-150. https://doi.org/10.1016/0020-7292(95)02424-B; PMid:7589749

25. Honnegowda TM, Kumar P, Udupa EGP, Kumar S, Kumar U, Rao P. (2015). Role of angiogenesis and angiogenic factors in acute and chronic wound healing. Plastic and Aesthetic Research. 2: 243-249. https://doi.org/10.4103/2347-9264.165438

26. Huang S-P, Wu M-S, Shun C-T, Wang H-P, Hsieh C-Y, Kuo M-L et al. (2005). Cyclooxygenase-2 increases hypoxia-inducible factor-1 and vascular endothelial growth factor to promote angiogenesis in gastric carcinoma. Journal of biomedical science. 12 (1): 229-241. https://doi.org/10.1007/s11373-004-8177-5; PMid:15864753

27. Jallad K, Steele SE, Barber MD. (2016). Breakdown of perineal laceration repair after vaginal delivery: a case-control study. Female pelvic medicine & reconstructive surgery. 22 (4): 276-279. https://doi.org/10.1097/SPV.0000000000000274; PMid:27054788

28. James GA, Swogger E, Wolcott R, Pulcini Ed, Secor P, Sestrich J et al. (2008). Biofilms in chronic wounds. Wound Repair and regeneration. 16 (1): 37-44. https://doi.org/10.1111/j.1524-475X.2007.00321.x; PMid:18086294

29. Jetten N, Roumans N, Gijbels MJ, Romano A, Post MJ, de Winther MP et al. (2014). Wound administration of M2-polarized macrophages does not improve murine cutaneous healing responses. PloS one. 9 (7): e102994. https://doi.org/10.1371/journal.pone.0102994; PMid:25068282 PMCid:PMC4113363

30. Jiang H, Qian X, Carroli G, Garner P. (2017). Selective versus routine use of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews: 2. https://doi.org/10.1002/14651858.CD000081.pub3; PMid:28176333

31. Johnson A, Thakar R, Sultan AH. (2012). Obstetric perineal wound infection: is there underreporting? British journal of Nursing. 21 (5): S28-S35. https://doi.org/10.12968/bjon.2012.21.Sup5.S28; PMid:22489339

32. Jones K, Webb S, Manresa M, Hodgetts-Morton V, Morris RK. (2019). The incidence of wound infection and dehiscence following childbirth-related perineal trauma: A systematic review of the evidence. European Journal of Obstetrics & Gynecology and Reproductive Biology. 240: 1-8. https://doi.org/10.1016/j.ejogrb.2019.05.038; PMid:31202973

33. Kaiser P, Wächter J, Windbergs M. (2021). Therapy of infected wounds: overcoming clinical challenges by advanced drug delivery systems. Drug Delivery and Translational Research. 11 (4): 1545-1567. https://doi.org/10.1007/s13346-021-00932-7; PMid:33611768 PMCid:PMC8236057

34. Kalan L, Grice EA. (2018). Fungi in the wound microbiome. Advances in wound care. 7 (7): 247-255. https://doi.org/10.1089/wound.2017.0756; PMid:29984114 PMCid:PMC6032664

35. Kingsley K, Huff J, Rust W, Carroll K, Martinez A, Fitchmun M et al. (2002). ERK1/2 mediates PDGF-BB stimulated vascular smooth muscle cell proliferation and migration on laminin-5. Biochemical and biophysical research communications. 293 (3): 1000-1006. https://doi.org/10.1016/S0006-291X(02)00331-5; PMid:12051759

36. Kirketerp-Møller K, Jensen PØ, Fazli M, Madsen KG, Pedersen J, Moser C et al. (2008). Distribution, organization, and ecology of bacteria in chronic wounds. Journal of clinical microbiology. 46 (8): 2717-2722. https://doi.org/10.1128/JCM.00501-08; PMid:18508940 PMCid:PMC2519454

37. Kokanalı D, Ugur M, Kuntay Kokanalı M, Karayalcın R, Tonguc E. (2011). Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Archives of gynecology and obstetrics. 284 (2): 275-280. https://doi.org/10.1007/s00404-010-1620-0; PMid:20680312

38. Kolaczkowska E, Kubes P. (2013). Neutrophil recruitment and function in health and inflammation. Nature reviews immunology. 13 (3): 159-175. https://doi.org/10.1038/nri3399; PMid:23435331

39. Lavaf M, Simbar M, Mojab F, Majd HA, Samimi M. (2018). Comparison of honey and phenytoin (PHT) cream effects on intensity of pain and episiotomy wound healing in nulliparous women. Journal of Complementary and Integrative Medicine. 15: 1. https://doi.org/10.1515/jcim-2016-0139; PMid:28981445

40. Li J, Chen J, Kirsner R. (2007). Pathophysiology of acute wound healing. Clinics in dermatology. 25 (1): 9-18. https://doi.org/10.1016/j.clindermatol.2006.09.007; PMid:17276196

41. Lucas T, Waisman A, Ranjan R, Roes J, Krieg T, Müller W et al. (2010). Differential roles of macrophages in diverse phases of skin repair. The Journal of Immunology. 184 (7): 3964-3977. https://doi.org/10.4049/jimmunol.0903356; PMid:20176743

42. Lund NS, Persson LK, Jangö H, Gommesen D, Westergaard HB. (2016). Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 207: 193-199. https://doi.org/10.1016/j.ejogrb.2016.10.013; PMid:27865945

43. Mantovani A, Sica A, Locati M. (2005). Macrophage polarization comes of age. Immunity. 23 (4): 344-346. https://doi.org/10.1016/j.immuni.2005.10.001; PMid:16226499

44. Martin P, Leibovich SJ. (2005). Inflammatory cells during wound repair: the good, the bad and the ugly. Trends in cell biology. 15 (11): 599-607. https://doi.org/10.1016/j.tcb.2005.09.002; PMid:16202600

45. Mori H-M, Kawanami H, Kawahata H, Aoki M. (2016). Wound healing potential of lavender oil by acceleration of granulation and wound contraction through induction of TGF-β in a rat model. BMC complementary and alternative medicine. 16 (1): 1-11. https://doi.org/10.1186/s12906-016-1128-7; PMid:27229681 PMCid:PMC4880962

46. NICE. (2014). Intrapartum care: care of healthy women and their babies during childbirth. URL: https://www.nice.org.uk/guidance/cg190.

47. Nikpour M, Delavar MA, Khafri S, Ghanbarpour A, Moghadamnia AA, Esmaeilzadeh S et al. (2019). The use of honey and curcumin for episiotomy pain relief and wound healing: A three-group double-blind randomized clinical trial. Nursing and Midwifery Studies. 8 (2): 64.

48. Owens C, Stoessel K. (2008). Surgical site infections: epidemiology, microbiology and prevention. Journal of hospital infection. 70: 3-10. https://doi.org/10.1016/S0195-6701(08)60017-1; PMid:19022115

49. Percival SL. (2004). Biofilms and their potential role in wound healing. Wounds. 16: 234-240.

50. Pergialiotis V, Vlachos D, Protopapas A, Pappa K, Vlachos G. (2014). Risk factors for severe perineal lacerations during childbirth. International Journal of Gynecology & Obstetrics. 125 (1): 6-14. https://doi.org/10.1016/j.ijgo.2013.09.034; PMid:24529800

51. Perkins E, Tohill S, Kettle C, Bick D, Ismail K. (2008). Women's views of important outcomes following perineal repair. BJOG. 115 (1): 67-253.

52. Prosser SJ, Barnett AG, Miller YD. (2018). Factors promoting or inhibiting normal birth. BMC pregnancy and childbirth. 18 (1): 1-10. https://doi.org/10.1186/s12884-018-1871-5; PMid:29914395 PMCid:PMC6006773

53. Rodero MP, Licata F, Poupel L, Hamon P, Khosrotehrani K, Combadiere C et al. (2014). In vivo imaging reveals a pioneer wave of monocyte recruitment into mouse skin wounds. PLoS One. 9 (10): e108212. https://doi.org/10.1371/journal.pone.0108212; PMid:25272047 PMCid:PMC4182700

54. Rogers R, Leeman L, Borders N, Qualls C, Fullilove AM, Teaf D et al. (2014). Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women. BJOG: An International Journal of Obstetrics & Gynaecology. 121 (9): 1145-1154. https://doi.org/10.1111/1471-0528.12571; PMid:24548705 PMCid:PMC4565727

55. Rusavy Z, Karbanova J, Kalis V. (2016). Timing of episiotomy and outcome of a non‐instrumental vaginal delivery. Acta obstetricia et gynecologica Scandinavica. 95 (2): 190-196. https://doi.org/10.1111/aogs.12814; PMid:26563626

56.Sandin‐Bojö AK, Kvist LJ. (2008). Care in labor: a Swedish survey using the Bologna Score. Birth. 35 (4): 321-328. https://doi.org/10.1111/j.1523-536X.2008.00259.x; PMid:19036045

57. Schierle CF, De la Garza M, Mustoe TA, Galiano RD. (2009). Staphylococcal biofilms impair wound healing by delaying reepithelialization in a murine cutaneous wound model. Wound repair and regeneration. 17 (3): 354-359. https://doi.org/10.1111/j.1524-475X.2009.00489.x; PMid:19660043

58. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K et al. (2003). Wound bed preparation: a systematic approach to wound management. Wound repair and regeneration. 11: S1-S28. https://doi.org/10.1046/j.1524-475X.11.s2.1.x; PMid:12654015

59. Segel GB, Halterman MW, Lichtman MA. (2011). The paradox of the neutrophilˈs role in tissue injury. Journal of leukocyte biology. 89 (3): 359-372. https://doi.org/10.1189/jlb.0910538; PMid:21097697 PMCid:PMC6608002

60. Shaw TJ, Martin P. (2016). Wound repair: a showcase for cell plasticity and migration. Current opinion in cell biology. 42: 29-37. https://doi.org/10.1016/j.ceb.2016.04.001; PMid:27085790

61. Siddiqui AR, Bernstein JM. (2010). Chronic wound infection: facts and controversies. Clinics in dermatology. 28 (5): 519-526. https://doi.org/10.1016/j.clindermatol.2010.03.009; PMid:20797512

62. Sultan A, Thakar R, Ismail K, Kalis V, Laine K, Räisänen S et al. (2019). The role of mediolateral episiotomy during operative vaginal delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology. 240: 192-196. https://doi.org/10.1016/j.ejogrb.2019.07.005; PMid:31310920

63. Swanson T, Angel D. (2022). International wound infection instutute wound infection in clinical practice update principles of best practice. Wounds International. 24 (8): 33.

64. Takeo M, Lee W, Ito M. (2015). Wound healing and skin regeneration. Cold Spring Harbor perspectives in medicine. 5 (1): a023267. https://doi.org/10.1101/cshperspect.a023267; PMid:25561722 PMCid:PMC4292081

65. Theocharidis G, Veves A. (2020). Autonomic nerve dysfunction and impaired diabetic wound healing: The role of neuropeptides. Autonomic Neuroscience. 223: 102610. https://doi.org/10.1016/j.autneu.2019.102610; PMid:31790954 PMCid:PMC6957730

66. Vale de Castro Monteiro M, Pereira GMV, Aguiar RAP, Azevedo RL, Correia-Junior MD, Reis ZSN. (2016). Risk factors for severe obstetric perineal lacerations. International urogynecology journal. 27 (1): 61-67. https://doi.org/10.1007/s00192-015-2795-5; PMid:26224381

67. Velnar T, Bailey T, Smrkolj V. (2009). The wound healing process: an overview of the cellular and molecular mechanisms. Journal of international medical research. 37 (5): 1528-1542. https://doi.org/10.1177/147323000903700531; PMid:19930861

68. Vestweber D. (2015). How leukocytes cross the vascular endothelium. Nature Reviews Immunology. 15 (11): 692-704. https://doi.org/10.1038/nri3908; PMid:26471775

69. Wager L, Leavesley D. (2015). MicroRNA regulation of epithelial-to-mesenchymal transition during re-epithelialisation: assessing an open wound. Wound Practice & Research: Journal of the Australian Wound Management Association. 23 (3): 132-142.

70. Waldman R. (2019). ACOG Practice Bulletin No. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstetrics & Gynecology. 133 (1): 185. https://doi.org/10.1097/AOG.0000000000003041; PMid:30575652

71. WHO. (2016). WHO recommendations for prevention and treatment of maternal peripartum infections. URL: https://www.who.int/publications/i/item/9789241549363.

72. Wiseman O, Rafferty AM, Stockley J, Murrells T, Bick D. (2019). Infection and wound breakdown in spontaneous second‐degree perineal tears: An exploratory mixed methods study. Birth. 46 (1): 80-89. https://doi.org/10.1111/birt.12389; PMid:30136338

73. Wolcott RD, Rhoads DD, Dowd SE. (2008). Biofilms and chronic wound inflammation. Journal of wound care. 17 (8): 333-341. https://doi.org/10.12968/jowc.2008.17.8.30796; PMid:18754194

74. Xue M, Jackson CJ. (2015). Extracellular matrix reorganization during wound healing and its impact on abnormal scarring. Advances in wound care. 4 (3): 119-136. https://doi.org/10.1089/wound.2013.0485; PMid:25785236 PMCid:PMC4352699

75. Zaidi A, Green L. (2019). Physiology of haemostasis. Anaesthesia & Intensive Care Medicine. 20 (3): 152-158. https://doi.org/10.1016/j.mpaic.2019.01.005

76. Zhuk SI, Holianovskyi O, Hryshchenko O, Dubossarska Yu, Zhylka N, Kaminskyi V et al. (2022). Unifikovanyy̆ klinichnyy̆ protokol pervynnoï, vtorynnoï (spetsializovanoï), tretynnoï (vysokospetsializovanoï) medychnoï dopomohy «Fiziolohichni polohy». Zdorov'ia Ukrainy. Tematychnyi nomer «Akusherstvo, Hinekolohiia, Reproduktolohiia». 1-2: 16-23.