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When is episiotomy warranted? What the evidence shows

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Selective episiotomy appears to offer a number of important benefits compared to routine use, but the debate endures. Dr. Repke reviews the evidence on outcomes and indications.


 

References

KEY POINTS
  • A Cochrane Database review concluded that restrictive episiotomy utilization is preferable to routine utilization. The review of 6 randomized trials found no differences in vaginal or perineal trauma, dyspareunia, or urinary incontinence between patients with and without episiotomy. Patients who had an episiotomy had less risk of anterior perineal trauma but an overall greater risk of posterior perineal trauma and other complications.
  • Shoulder dystocia, operative vaginal delivery, and a “short” perineal body have been presumed indications for episiotomy, although data are inadequate to support these claims.
  • The rationale for routine prophylactic episiotomy is to protect the pelvic floor, thereby minimizing the risk of urinary incontinence and pelvic floor dysfunction; however, episiotomy’s role in preventing such dysfunction remains to be established.
Systematic study has established that so-called routine episiotomy should be abandoned, and restrictive-use protocols should be developed that aim, initially, for a rate of less than 30%.1,2 Yet episiotomy (or more correctly, perineotomy) remains perhaps the most commonly performed surgical procedure in obstetrics.3 Its rate—more than 60% of vaginal deliveries in the United States—has not declined since Thacker and Banta’s landmark 1983 review.4

Although a large body of evidence indicates reassessment is in order, prophylactic episiotomy is a contentious issue. Indeed, it has been controversial ever since the procedure first became “routine” in the United States, in 1920. Still, advocates and dissenters share the same goal: to prevent severe perineal tears and their potential for urinary and fecal incontinence and sexual dysfunction.

This article reviews research findings that indicate:

  • Data are inadequate to recommend one method of episiotomy over another.
  • Timing of episiotomy to shorten the second stage of labor may be less relevant in an era of decreasing forceps utilization and without evidence of improved neonatal outcomes.5
  • Episiotomy, particularly midline episiotomy, remains the single greatest risk that a patient will sustain a third- or fourth-degree laceration. When such lacerations occur spontaneously, recovery is equivalent to episiotomy extension or deliberate proctoepisiotomy.

TABLE

Incidence of third- or fourth-degree laceration with and without episiotomy

NO. STUDIES COMPILEDNO. PATIENTS% WITH 3RD- OR 4TH-DEGREE LACERATION
Midline episiotomy1249,3956.5
No episiotomy1338,9611.4
Adapted from Thorp JM.3

Research does not support presumed indications

Episiotomy was first described in 1742 as a procedure that could assist the obstetrician in difficult vaginal deliveries.3 It was not until the work of DeLee6 and Pomeroy7 was published in 1920—coincident with deliveries beginning to move from home to hospital—that the procedure became “routine.” Still, some leaders in the field—specifically, J. Whitridge Williams of Johns Hopkins—vigorously dissented.8

Historically, episiotomy has been used to facilitate delivery in cases of protracted second stage, instrumented vaginal delivery, and suspected fetal compromise. However, data supporting episiotomy as a facilitating procedure are sparse, and evidence endorsing prophylactic episiotomy is largely anecdotal or descriptive.

Agreement is widespread that episiotomy is warranted under certain circumstances: Shoulder dystocia, operative vaginal delivery, and a “short” perineal body have been presumed indications. Data are inadequate to support these claims, however.

Shoulder dystocia. While it might seem to make sense to perform an episiotomy (or more likely, a proctoepisiotomy) in cases of shoulder dystocia, no data from controlled trials support this theory. Given the relative rarity of severe shoulder dystocia and the inability to conduct a truly randomized trial, physicians are left with only their clinical judgment as a guide in this circumstance.

Operative delivery. Many clinicians have advocated routine episiotomy before operative vaginal delivery, particularly with forceps. The intent is to increase the space available for delivery that has been diminished by the introduction of forceps. This rationale does not hold up as well for vacuum extraction; 1 study noted that when episiotomy is performed in cases of vacuum extraction, the likelihood of severe perineal trauma is increased.9

It has been reported10 that the greatest risk factor for both perineal trauma and third- or fourth-degree perineal laceration is episiotomy itself (TABLE), independent of mode of delivery (spontaneous or operative).

Short perineum. Many physicians, myself included, have performed episiotomies because they perceived that the perineum was short and that even a controlled delivery with optimal use of the Ritgen maneuver probably would not prevent a perineal laceration. That said, data on anal and flatus incontinence and postpartum sexual functioning suggest that spontaneous recovery from second-degree lacerations is no worse than recovery from midline episiotomy11,12 and, as stated, episiotomy itself is the leading risk factor for incurring a third- or fourth-degree extension—which imposes significantly greater recovery problems.

Two recent studies11,12 identified episiotomy as a specific, independent risk factor for fecal incontinence and delayed return of sexual activity postpartum. When matched for degree of perineal trauma, episiotomy without extension still resulted in poorer outcomes at 3 and 6 months postpartum than did spontaneous second-degree lacerations, suggesting that routine episiotomy not only fails to prevent, but may actually increase risk of perineal injury and impaired function.

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