Obstetric anal sphincter injury (OASIS) can be minimised with appropriate use of episiotomy[1]. Episcissors-60 were designed to improve the accuracy of episiotomy[2]. National Institute of Health and Care Excellence (NICE) in the UK have recommended research to address the uncertain efficacy and safety of Episcissors-60 in prevention of OASIS[3].
The aim of this systematic review is to evaluate the change in OASIS rate after introduction of Episcissors-60. We hypothesise that OASIS rate will reduce with introduction of Episcissors-60.

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), University of York (CRD42023462337). A literature search using MEDLINE, EMBASE and CINAHL databases was performed from inception to 31st August 2023, without limits. The MeSH terms used were ‘Episcissors*’, ‘Episcissors60’ and ‘Episcissors-60’. Included studies had a comparator group: historic (before-after) or parallel. Studies were screened by two independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Data were extracted for qualitative and quantitative synthesis using Review-Manager (RevMan5.4.1).

The initial literature search yielded 79 studies. After screening, a total of eight studies were included in both the systematic review and meta-analysis. Two studies were randomised, and the remainder were observational. Six studies were deemed high quality (≥7 Newcastle-Ottawa score). Six out of eight studies reported a reduction in OASIS with the introduction of Episcissors-60. The number of participants ranged from 63 to 18880. In all but one study, participants were mixture of normal vaginal deliveries and operative vaginal deliveries. The number of participants included in meta-analysis was 29052.

When data was pooled; there was a significant reduction in OASIS in the total number of vaginal deliveries (RD-0.02, 95%CI[-0.04,-0.01], p=0.009, I2=82%), and a significant change in the angle of post-suture episiotomy (MD 20.17, 95%CI[4.75,-35.58], p=0.01, I2=98%) with Epicissors-60. However, there was no significant difference in rate of OASIS in episiotomy deliveries (RD-0.02, 95%CI[0.05,0.00], p=0.10, I2=73%), nor in rate of episiotomy (RD0.01, 95%CI[-0.02,0.04], p=0.45 , I2=84%).
There was no significant difference in blood loss before and after introduction of Episcissors-60 (MD 2.62, 95%CI[-2.34, 7.57], p=0.3, I2=100%). Episiotomy incision length was significantly shorter in Standard scissors compared to Episcissors-60 (MD 1.91, 95%CI[0.72,-3.10], p=0.002, I2=87%).

Although this review did not observe a significant difference in OASIS rate in episiotomy deliveries or in episiotomy rate after introduction of Episcissors-60, it demonstrated a protective effect on OASIS rate in total vaginal deliveries.
Therefore, even though a direct effect was not evident, this may suggest that Episcissors-60 protective effect is mediated through a potential Hawthorne effect. A well-powered randomized controlled trial (RCT) is required to provide a definitive answer.

[1] Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis. Int Urogynecol J. 2016 Oct;27(10):1459-67. doi: 10.1007/s00192-016-2956-1. Epub 2016 Feb 19. PMID: 26894605; PMCID: PMC5035659.
[2] Freeman RM, Hollands HJ, Barron LF, Kapoor DS. Cutting a mediolateral episiotomy at the correct angle: evaluation of a new device, the Episcissors-60. Med Devices (Auckl). 2014 Feb 21;7:23-8. doi: 10.2147/MDER.S60056. PMID: 24570598; PMCID: PMC3933714.
[3] National Institute for Health and Care Excellence. Episcissors-60 for mediolateral episiotomy [MTG47]. National Institute for Health and Care Excellence; 2020. Available at: https://www. nice.org.uk/guidance/mtg47.

Continence 12S (2024) 101647
DOI: 10.1016/j.cont.2024.101647