Is tolerance of ambiguity creating an episiotomy skills gap

A cultural shift began in the late 1980s following evidence that routine versus selective episiotomy in vaginal births did not reduce the incidence of perineal trauma. The evidence was synthesised and incorporated into practice guidelines about 20 years later (Woolley 1995,Hartmann et al 2005). While a move to restrictive use of episiotomy reduced the incidence of episiotomy and of severe perineal trauma (Jiang et al 2017), its selective use is still advocated. The Obstetric Anal Sphincter Injury (OASI) care bundle, supported by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) and proposed in response to the growing rate of obstetric anal sphincter injuries, prescribes episiotomy when clinically indicated as one of its four evidence-based recommendations (Bidwell et al 2018,RCOG 2018). However, evaluation of the care bundle in practice has identified a widespread deskilling in episiotomy among the midwifery workforce (Bidwell 2018), who attend the majority of births in the UK (NHS Digital 2019)