Network meta-analysis of episiotomy approaches: comparing routine, restrictive, and non-episiotomy strategies and their effects on maternal and neonatal outcomes in primiparous patients.

BACKGROUND

Episiotomy, although occasionally required during labor, can result in postpartum discomfort, perineal trauma, and delayed healing. This study offers a comprehensive comparison of the safety and effectiveness of routine, restrictive, and non-episiotomy approaches on maternal and neonatal outcomes.

METHODS

We systematically searched PubMed, Web of Science, Scopus, and Cochrane. We included randomized clinical trials (RCTs), comparing routine, restrictive, and non-episiotomy approaches in primiparous pregnant women. We excluded non-randomized trials, conference abstracts, and observational studies. The Cochrane ROB tool 2 was employed to appraise the selected RCTs. We conducted our analysis using the “netmeta” package of RStudio software (v.4.3.0). Dichotomous outcomes were pooled as risk ratios (RR), while continuous outcomes were pooled as the mean differences (MD). We used the random effect model for all outcomes.

RESULTS

Sixteen studies, involving 10,738 patients, were included in the network meta-analysis. The findings revealed that the non-episiotomy group had a significantly higher risk of experiencing 1st-degree perineal tear compared to the routine episiotomy group (RR = 4.69, 95% CI [2.04; 10.74],  > 0.01). Similarly, the restrictive episiotomy group showed a significantly higher risk compared to the routine group (RR = 3.88, 95% CI [1.63; 9.26],  > 0.01). However, there were no significant differences observed between the routine, restrictive, and non-episiotomy groups regarding the duration of the 2nd stage of labor, postpartum perineal pain, and the occurrence of 2nd-, 3rd-, and 4th-degree perineal tears.

CONCLUSION

In conclusion, non-episiotomy approaches prove superior, with lower risks of complications compared to routine episiotomy. While restrictive episiotomy performs better than routine, it falls short of non-episiotomy methods. Therefore, non-episiotomy strategies are preferred, followed by restrictive episiotomy, with routine episiotomy being the least favorable. However, individual patient factors should guide treatment decisions, and further research is necessary to refine clinical practices.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s12978-025-02132-9.