The Role of Episiotomy in Prevention and Management of Shoulder Dystocia: A Systematic Review

Importance: Shoulder dystocia is an obstetric emergency with potential catastrophic outcomes. Objective: To perform a systematic literature review examining the effectiveness of episiotomy in the prevention and management of shoulder dystocia during vaginal birth. Evidence Acquisition: Search was conducted by a research librarian in MEDLINE, Web of Science, Cochrane Library, and SCOPUS databases using the terms "episiotomy" and "shoulder dystocia," with no language or time restrictions. Two investigators independently selected original researches examining the effects of episiotomy on shoulder dystocia and its neonatal andmaternal outcomes. Relevant articles were accessed in full text, including manual search of the references. We contacted authors of studies with insufficient or unclear data. Because of clinical and methodological diversity of the studies, meta-analysis was not performed. Results: Fourteen articles met the inclusion criteria, encompassing a total of 9769 shoulder dystocia cases. Only 1 study effectively evaluated the role of episiotomy in shoulder dystocia prevention, yielding a nonsignificant result. Three articles assessed neonatal consequences of shoulder dystocia, one of them linking episiotomy to higher risk of neonatal injury. Two of the 3 studies evaluating maternal outcomes showed that episiotomy is related to increased risk of advanced perineal tears. Overall quality of evidence was rated as very low. Conclusions and Relevance: Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completion of this educational activity, the reader will be better able to analyze the paucity of existing literature examining the role of episiotomy in the prevention and management of shoulder dystocia, discuss the crucial issues in exploring the subject including uniform definition of shoulder dystocia and the report of episiotomy timing, and assess the knowledge needed to determine whether to perform episiotomy in deliveries with increased risk of shoulder dystocia, such as in cases of macrosomic fetus.