National trends of episiotomy in non-instrumental vaginal deliveries (2013-2022): A multi-data source approach

Episiotomy and obstetric anal sphincter injuries (OASIS) are recognized indicators of intrapartum care quality. The aim of this study was to assess episiotomy trends in non-instrumental vaginal deliveries across all Portuguese public maternities over the last decade. Rates of third- and fourth-degree perineal lacerations were also evaluated.

A retrospective secondary data analysis was conducted using data from an official national health entity, including all non-instrumental vaginal deliveries in the Portuguese National Health Service between January 1, 2013 and December 31, 2022. Information on episiotomy and third- and fourth-degree perineal lacerations was extracted. Descriptive statistics were presented using absolute and relative frequencies. Linear regression was used to assess trends. Additional national databases were consulted to validate findings, and data quality was assessed using the intraclass correlation coefficient (ICC). A significance level of 5% was considered.

Of 689 908 registered deliveries, 490 322 (71%) were vaginal, and 361 887 (52%) were non-instrumental vaginal deliveries. Among the latter, the episiotomy rate was 42.5%. A significant decrease was observed in episiotomy rates, from 63% in 2013 to 21% in 2022, (P < 0.001), accompanied by a significant increase in third-degree perineal lacerations (0.15% to 0.31%, P < 0.001), while fourth-degree perineal lacerations remained stable (0.03% to 0.02%, P = 0.001).

A restrictive episiotomy policy was increasingly adopted in Portugal over the last decade. Although rare, third-degree perineal lacerations increased during this period. Further research is needed to determine optimal intrapartum care practices regarding episiotomy use. Standardized data coding and improved access to anonymized national datasets are essential for accurate monitoring and cross-country comparability.