Does Anyone Still Do Routine Episiotomies?
Abstract & Commentary
By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationship to this field of study.
It is unclear how many practitioners around the world use routine episiotomy today as a way to avoid third and fourth degree lacerations. There certainly was a period of time when episiotomy was a routine practice in nulliparas. Most of the studies addressing any possible benefit of episiotomy were conducted prior to 1995, when the frequency of its utilization had diminished appreciably.
In the city of Medellin, Columbia, it has been commonplace to use routine medial episiotomy to "prevent" perineal trauma. In this setting, Rodríguez et al designed a randomized trial to compare maternal outcomes of patients having routine midline episiotomy vs those who had "selective" episiotomy.1 Two hundred and twenty-three patients were randomized during the second stage of labor to have a midline episiotomy, which consisted of a 4 cm incision in the perineum and a 4 to 6 cm cut through the vaginal mucosa. Another 223 patients were allocated to the "selective" group. These patients had the above incision only if the operator felt that a perineal laceration was inevitable if not done, or where there was fetal distress, shoulder dystocia, or a forceps delivery. Immediately post-delivery each patient had her perineum inspected by an objective attending not involved in the research.
The results, published in the recent issue of the American Journal of Obstetrics & Gynecology, showed that routine episiotomies certainly did not prevent lacerations. Third and fourth degree lacerations occurred in 14.6% of the "routine" group vs 6.8% of the selected group (9.9% vs 4.5% for third-degree and 4.5% vs 2.3% for fourth degree lacerations). Interestingly, minor complications such as periurethral tears and superficial lacerations were more common in the "selective" group. Last, 24.3% in the "selective" group wound up having episiotomies, and in 85% of these cases the reason was "impending laceration." Most importantly, 86% of the lacerations in the "selective" category occurred in the group having the incisions.
Commentary
Liberal use of episiotomy came about because of the notion that if a patient is at risk for a laceration, it is better to control the situation with an intended incision, rather than to await an uncontrolled, more extensive, laceration. Some older studies have shown that routine episiotomy is associated with a higher rate of lacerations, but what is different about the Rodríguez study is that it was randomized and, for the first time, showed that 86% of the lacerations in the "selective" group occurred in those in whom the providers did the procedure to avoid them.
Goldberg at al2 examined trends in the use of episiotomy at Thomas Jefferson Hospital in Philadelphia and found that the overall rates of episiotomy fell from 69.9% in 1983 to 19.4% in 2000. I could not find current statistics on the prevalence of the episiotomies in the United States, but I did find data not only showing higher rates of immediate perineal morbidity but longer discomfort times, delayed bonding, and increased rates of dyspareunia. A phrase that surfaced described episiotomy as "the unkindest cut of all."
There probably is a place for episiotomy on occasion —for example, to shorten the second stage in fetal distress—but liberal use of, and certainly routine use of, the midline episiotomy should be discouraged.
References
- Rodriguez A, et al. Am J Obstet Gynecol. 2008;198:285.e1-285.e4.
- Goldberg J, et al. Obstet Gynecol. 2002;99:395-400.
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