[ Editorials | Departments and Series | Index ]

VIEWPOINT

Should Use of Episiotomy Be Restricted?

Marianna Alperin, MD, MS; Kristiina Parviainen, MD

Episiotomy is one of the surgical procedures a woman is most likely to undergo during her lifetime.1 Since the 1980s, however, a growing body of literature discouraging routine episiotomy has resulted in a reduction of episiotomy use.2,3 Despite this trend, routine use of episiotomy among some practitioners and institutions remains alarmingly high.4 Why is this?

Many clinicians assert that meticulous repair of surgical episiotomy yields improved wound healing compared with unpredictable spontaneous laceration. This theory, however, has never been substantiated by empiric evidence.5 Episiotomy has been associated with increased blood loss at delivery, perineal scar breakdown, infection, pelvic pain, and dyspareunia.3 The “protective effect” of prophylactic episiotomy against severe (third- and fourth-degree) obstetric lacerations has also been disproved by studies highlighting increased incidence of severe lacerations with episiotomy.6,7 The resulting damage to internal and external anal sphincters can lead to devastating long-term sequelae, including fecal incontinence and rectovaginal fistulae.8 In addition, other studies have demonstrated that episiotomy increases perineal pain and dyspareunia when compared with spontaneous lacerations.9 Despite compelling evidence of limited (if any) benefit and potential harm, episiotomy use is still common.

We recently reported the impact of episiotomy beyond an index delivery, quantifying the effect of episiotomy on the risk of obstetric laceration in a subsequent vaginal delivery while controlling for other risk factors.4 Episiotomy was previously suggested to be associated with increased risk of obstetric lacerations in subsequent deliveries based on epidemiologic data; however, authors of that study were unable to account for other risk factors known to increase the risk of obstetric lacerations.10 Our study, consistent with previously published literature, again refuted the premise that episiotomy is protective against severe (third- and fourth-degree) lacerations: the incidence of severe laceration in the first delivery was 20.4% with episiotomy and 6.8% without. Additionally, repeat episiotomy in the second delivery again more than doubled the incidence of severe laceration (1.5% in women without episiotomy, compared to 3.6% in women with episiotomy).

Moreover, our findings support the assertion that healed tissue after trauma is weaker than uninjured tissue. After controlling for other known risk factors, our results indicate more than a 4-fold risk of perineal laceration in the second delivery attributable to episiotomy at first delivery. Thus, we demonstrated yet another detrimental aspect of episiotomy in that consequences of this procedure are not limited to the index delivery, but are perpetuated in subsequent vaginal deliveries.

Although spontaneous second-degree laceration and episiotomy would appear to confer similar relative risk for obstetric laceration in a subsequent delivery, the incidence of spontaneous second-degree laceration at first delivery was only 19% in our cohort, compared with a 59.7% rate of episiotomy. Thus, high rates of episiotomy at first delivery were responsible for increased risk of obstetric laceration in the second delivery in 40% of women in our series.

There are situations in which episiotomy is warranted. Episiotomy has a critical role in difficult instrumented deliveries, shoulder dystocia, and circumstances in which a non-reassuring fetal status must expedite delivery. In addition to delivering healthy babies, however, the labor attendant bears responsibility for minimizing perineum trauma, which includes judicious use of episiotomy. Previous studies established that a primary determinant for episiotomy use in obstetric practice is the health care professional, not patient characteristics.11,12 Concurrently, the rate of episiotomy in our cohort was significantly higher among private practitioner patients than those cared for by the resident service (67.6% vs 19.7%). This would suggest that provider bias—not obstetric factors—may be the most powerful predictor of episiotomy use.

Our study raises new concerns regarding episiotomy. Not only is there no proven benefit to this procedure, but episiotomy may also result in weakened tissue and render the patient more susceptible to injury in subsequent deliveries. We encourage health care professionals to weigh all the available evidence and to further restrict the use of episiotomy.

Neither author reports any actual or potential conflicts of interest in relation to this article.

back to top

Marianna Alperin, MD, MS, is Attending Urogynecologist, Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente, West Los Angeles, CA. Kristiina Parviainen, MD, is Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, PA.

References

1. Weber AM, Meyn L. Episiotomy use in the United States, 1979–1997. Obstet Gynecol. 2002;100(6):1177–1182.
2. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860–1980. Obstet Gynecol Surv. 1983;38(6):322–338.
3. Goldberg J, Holtz D, Hyslop T, Tolosa JE. Has the use of routine episiotomy decreased? Examination of episiotomy rates from 1983 to 2000. Obstet Gynecol. 2002;99(3): 395–400.
4. Alperin M, Krohn MA, Parviainen K. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery. Obstet Gynecol. 2008;111(6):1274–1278.
5. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol. 2000;95(3):464–471.
6. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(6):1905–1911.
7. Rodriguez A, Arenas EA, Osorio AL, Mendez O, Zuleta JJ. Selective vs. routine midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women. Am J Obstet Gynecol. 2008;198(3):285.e1–4
8. Haadem K, Dahlstrom JA, Ling L, Ohrlander S. Anal sphincter function after delivery rupture. Obstet Gynecol. 1987; 70(1):53–56.
9. Andrews V. Thakar R. Sultan AH. Jones PW. Evaluation of postpartum perineal pain and dyspareunia—a prospective study. Eur J Obstet Gynecol Reprod Biol. 2008;137(2): 152–156.
10. Dandolu V, Gaughan JP, Chatwani AJ, Harmanli O, Mabine B, Hernandez E. Risk of recurrence of anal sphincter lacerations. Obstet Gynecol. 2005;105(4):831-835.
11. Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Predictors of episiotomy use at first spontaneous vaginal delivery. Obstet Gynecol. 2000;96(2):214–218.
12. Hueston WJ. Factors associated with the use of episiotomy during vaginal delivery. Obstet Gynecol. 1996;87(6): 1001–1005.

back to top