CHAPEL HILL -- According to a systematic review of existing studies, to appear in the May 4 issue of the Journal of the American Medical Association, the surgical procedure known as an episiotomy, performed in up to 35 percent of U.S. vaginal births, usually provides no benefits.
Moreover, the researchers found that, in some cases, routine use of episiotomy causes more harm to mothers than avoiding its use. An episiotomy is an incision made at the vaginal opening during a birth. The intent, in most cases, is to mitigate the severity of the spontaneous tearing that sometimes occurs during childbirth and to facilitate proper anatomic repair. The procedure also may be performed in cases when the baby's safety is threatened and delivery needs to take place quickly. This study addressed routine use only, not emergencies.
In routine births, women without episiotomy were found to have less pain with faster resolution, and no greater or lesser risk of wound healing complications. In addition, the evidence showed that episiotomy did not protect women against urinary or fecal incontinence or pelvic organ prolapse in the first three months to five years following delivery.
"The literature we reviewed suggests that the outcomes with spontaneous tears, if they happen, are better than with episiotomy," said Dr. Katherine Hartmann, the lead author of the JAMA article. She noted that women are more likely to suffer the most severe types of tears, from the vagina into the rectum, when they have an episiotomy.
A key message from such findings, she added, is that a mother-to-be should talk to her doctor about her wishes regarding episiotomy during her prenatal care because it will be too late to have an informed discussion in the delivery room.
"You're in charge of what happens to you in your care. Your best bet to reach a clear understanding with your doctor about what this aspect of your birth will be like is to talk about it in advance."
Hartmann is assistant professor of obstetrics and gynecology in the University of North Carolina at Chapel Hill's School of Medicine and of epidemiology in UNC's School of Public Health. She also directs UNC's Center for Women's Health Research.
The JAMA article is based on work by a team of researchers from the RTI International-UNC Evidence-based Practice Center (EPC) working under contract to the Agency for Healthcare Research and Quality. The full evidence report, led by co-author Dr. Meera Viswanathan, senior health analyst at the RTI International, also concludes that any possible benefits of the procedure do not outweigh the fact that many women would have had less injury without the surgical incision.
The studies reviewed were consistent in demonstrating that routine episiotomy provided no benefit over restrictive episiotomy in terms of the severity of laceration, pain and pain medication use, the researchers said. Episiotomy also provided no benefit in terms of preventing problems such as fecal and urinary incontinence, or in reducing impaired sexual function. In fact, women who had an episiotomy were more likely later to have pain during intercourse than women who did not have the procedure.
The researchers concluded that the evidence does not support the benefits traditionally ascribed to routine episiotomy.
"In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision," they wrote.
Dr. John Thorp Jr., co-author of the article and a professor in UNC's department of obstetrics and gynecology and deputy director of the Center for Women's Health Research, has studied episiotomy for almost two decades.
"In most cases, episiotomy doesn't do any good, and it can harm women," Thorp said. "Why would one want a surgical procedure that's worthless?"
The rationale used to justify routine episiotomy, Thorp added, is that performing an episiotomy prevents more serious injury to the mother. It had been thought that a deliberate incision would heal more quickly and with fewer complications than a spontaneous tear, and that a woman who has an episiotomy would be less likely to have pelvic floor problems, such as fecal or urinary incontinence or impaired sexual function, later on.
By the 1930s, the procedure had become common in obstetrical practice. The procedure remains common today, occurring in more than 1 million of the roughly 4.2 million births nationwide each year. Among first-time mothers, 70 percent to 80 percent have an episiotomy, Thorp said.
However, studies published as early as 1983 began to question whether routine episiotomy actually provided the benefits credited to it. Thorp himself began to investigate the wisdom of routine episiotomy in the late 1980s.
"This is embedded in modern obstetrics," Thorp said, adding that episiotomy was introduced as part of the same movement in which the hospital, rather than the home, became the place where most babies are born. "Episiotomy was part of that package."
Other aspects of that "package," such as frequent use of general anesthesia and routine use of forceps during delivery, have since fallen out of favor due to advances in scientific understanding. However, Thorp said, many clinicians in practice today, who were trained to perform routine episiotomies as a standard of care, are reluctant to change.
In addition to Hartmann and Thorp, UNC researchers included Rachel Palmieri, a doctoral student in the School of Public Health's department of epidemiology and a graduate research assistant at the Center for Women's Health Research; and Dr. Gerald Gartlehner of UNC's Cecil G. Sheps Center for Health Services Research. Co-author Dr. Kathleen N. Lohr of RTI International is co-director of the EPC and research professor in the UNC School of Public Health's department of health policy and administration. Under its Evidence-based Practice Program, AHRQ develops scientific information for other agencies and organizations on which to base clinical guidelines, performance measures and other quality improvement tools. Use of episiotomy in obstetrical care was nominated as a topic for review by the American College of Obstetricians and Gynecologists.
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