CLINICIAN'S CORNER
Outcomes of Routine Episiotomy

A Systematic Review

Katherine Hartmann, MD, PhD; Meera Viswanathan, PhD; Rachel Palmieri, BS; Gerald Gartlehner, MD, MPH; John Thorp, Jr, MD; Kathleen N. Lohr, PhD

JAMA. 2005;293:2141-2148.

Context  Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use.

Objective  To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy.

Evidence Acquisition  We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality.

Evidence Synthesis  Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function - pain with intercourse was more common among women with episiotomy.

Conclusions  Evidence does not support maternal 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.

Author Affiliations: Center for Women's Health Research (Drs Hartmann and Thorp and Ms Palmieri), Department of Epidemiology, School of Public Health (Dr Hartmann and Ms Palmieri), Department of Obstetrics and Gynecology, School of Medicine (Drs Hartmann and Thorp), and Cecil G. Sheps Center for Health Services Research (Drs Hartmann and Gartlehner), University of North Carolina at Chapel Hill; Research Triangle Institute, Research Triangle Park, NC (Drs Viswanathan and Lohr).

I have been at a birth where the woman yelled, "Don't cut me!" and the doctor did it anyway (yes, assault)!

Several studies have proven that there is no advantage to routine use, but it is still done in ignorance. Eighty per cent of women who don't attend my classes (or a similarly well informed class) end up with this surgery and are told they needed it. (Docs call it a "snip" but it is actually an average of 2 inches long!!)

In actuality, only 2 - 3% of women need it. Does this mean that routine episiotomy should be an ethically acceptable alternative? NO WAY!!!! It is a violation of women in the same way that I believe RIC is a violation of little boys. (A mutilation? It can affect sex for the rest of their life, I know!!)

BTW, the American College of Obstetricians and Gynecologists states that it is not necessary for routine use, but 80% of doctors don't agree.

Darla the Doula, Certified Childbirth Educator (CCE)
website

Episiotomy is probably the #1 most unnecessary surgery performed on American women today. There is also much mythology surrounding the surgery and its indicators. Doctors tell women it's only a little snip (sound familiar?) and won't hurt a bit. Besides, it will not only keep their husband's happy during sex but will also prevent damage to the pelvic floor muscles, nerve tissue, prevent a horrendous laceration, and prevent uterine prolapse.

Virtually every obstetrical textbook repeats these myths. Fact is, not one of those statements holds up to medical scrutiny. Every study ever done proves that episiotomies cause permanent damage and weakness to the tissue, increases the rate of future uterine/bladder prolapse, causes perineal lacerations, and has a high rate of causing constant perineal pain. To make sure the new mother will have a vagina like before, the doctor frequently sews her up extra tight, which can cause lifelong pain. Many women will complain that dealing with episiotomy pain is more painful than giving birth. Studies vary but women report pain lasting over 1 year in 20-55% of all women who've have epsiotomies. Is there any wonder so many women become disinterested in sex?

Is episiotomy ever needed?

Of course, it can be a wonderful, life-saving procedure. However, it is abused in the US, with rates of over 80% in most hospitals. A homebirth midwife I know has performed two episiotomies in her career. Two women's births needed one; the other 850 births did not. Many doctors will say they don't routinely perform episiotomies, but do them only when needed. They frequently perform episiotomies on women without their consent. It is considered a standard procedure in obstetrics. If a doctor is questioned about it he will always say it was necessary to prevent complications or to speed up the birth because he thought the baby was in distress. If you want to read more, an excellent book is "Episiotomy And The Second Stage Of Labor" by Sheila Kitzinger.

The best way to avoid an episiotomy is to avoid an obstetrician.

- Camellia

Am J Obstet Gynecol 2001;185:444-50.

Episiotomy increases perineal laceration length in primiparous [first-birth] women

By Charles W. Nager MD, Jason P. Helliwell MD

Abstract
Objective: The aim of this study was to determine the clinical factors that contribute to posterior perineal laceration length.
Study Design: A prospective observational study was performed in 80 consenting, mostly primiparous women with term pregnancies. Posterior perineal lacerations were measured immediately after delivery. Numerous maternal, fetal, and operator variables were evaluated against laceration length and degree of tear. Univariate and multivariate regression analyses were performed to evaluate laceration length and parametric clinical variables. Nonparametric clinical variables were evaluated against laceration length by the Mann-Whitney U test.
Results: A multivariate stepwise linear regression equation revealed that episiotomy adds nearly 3 cm to perineal lacerations. Tear length was highly associated with the degree of tear (R = 0.86, R2 = 0.73) and the risk of recognized anal sphincter disruption. None of 35 patients without an episiotomy had a recognized anal sphincter disruption, but 6 of 27 patients with an episiotomy did (P < .001). Body mass index was the only maternal or fetal variable that showed even a slight correlation with laceration length (R = 0.30, P = .04).
Conclusion: Episiotomy is the overriding determinant of perineal laceration length and recognized anal sphincter disruption.

Acta Obstet Gynecol Scand. 2004 Apr;83(4):364-8.

Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial

By Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., Anthuber, C.

Abstract

Background. The indication of the restricted use of episiotomy at tears presumed to be imminent is not clear.

Methods. Randomized controlled trial with two perineal management policies. Use of episiotomy: (a) only for fetal indications and (b) in addition at a tear presumed to be imminent.

Participants: 146 primiparous [first-birth] women with an uncomplicated singleton pregnancy at >34 weeks of gestation. For the intention-to-treat analysis those 109 women were included who vaginally delivered a live full-term baby between January 1999 and September 2000: 49 women in group a, 60 in group b.

Outcome measures. Reduction of episiotomies, increase of intact perinea or only minor perineal trauma (intact perineum and first-degree tears), third-degree tears, anterior perineal trauma, perineal pain in the postpartum period, pH of the umbilical artery, Apgar scores, maternal blood loss.

Results. Episiotomy rates were 41% in group a and 77% in group b (p <0.001). Women in the restrictive policy group had a greater chance of an intact perineum (29% vs. 10%; p = 0.023) or only minor perineal trauma (39% vs. 13%; p = 0.003) and had significant lower pain scores postpartum at different activities. There were no statistically significant differences with regard to third-degree tears, anterior trauma, pre- and postpartum hemoglobin concentrations, Apgar scores and pH of the umbilical artery.

Conclusions. Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.

Childbirth Tear More Likely at Certain Hours: Study
Fri Jul 19

By Michelle Rabil

NEW YORK (Reuters Health) - Women giving birth during hospitals' busiest times of the day are more likely to have severe vaginal tearing than those who give birth at other times, study results suggest.

Procedures that increase the risk of severe vaginal tear include episiotomy (an incision to ease delivery of the baby's head), use of vacuum or forceps, or a drug-induced labor. Such procedures are performed more often between 10 AM and 10 PM than "off-peak" hours of 2 AM to 8 AM, according to the report in the Journal of Epidemiology and Community Health.

Researchers looked at records from over 37,000 live births in Philadelphia, Pennsylvania hospitals between 1994 and 1997. All of the women were admitted in active (non-induced) labor and at low risk for complications. Cases involving fetal distress, prolonged, obstructed or abnormal labor were excluded.

"This study raises the issue of unnecessary intervention, which at worst, increases the risk of negative outcomes for women," Dr. David Webb from the Philadelphia Department of Public Health ( news - web sites) told Reuters Health. "We need to know how widespread this practice is, beyond Philadelphia, as a matter of public health concern."

Approximately 10% of the deliveries involved the use of a vacuum, forceps or both. Of deliveries conducted without these instruments, episiotomy was performed in 27%, and drug-induced labor in 31%.

Mothers who gave birth during regular hours were 43% more likely to have an instrumentally-assisted delivery, 10% more likely to have an episiotomy, 86% more likely to have drug-induced labor, and 30% more likely to experience severe tearing, the report indicates.

These differences could not be explained by differences in mothers' backgrounds, insurance status, birth weight or length of labor. For example, there were about 41 cases of severe vaginal tearing in every 1,000 women who gave birth at 4 AM, compared with 58 such tears in every 1,000 women giving birth at 4 PM.

"Busy doctors in busy hospitals may have less tolerance for the time-consuming natural progression of labor and delivery during 'high-demand' hours, and thus are more willing during these times to perform procedures that hasten the labor and delivery process," Webb and co-author Dr. Jennifer Culhane of Thomas Jefferson University, Philadelphia, conclude.

Though additional studies are needed to confirm these findings in other populations, this study highlights the need for hospitals to identify staffing and other issues that "may be contributing to any avoidable, excess use of obstetric procedures," the researchers note.

SOURCE: Journal of Epidemiology and Community Health 2002;56:577-578.

Bangor Daily News (Maine)
August 14, 2013

Bangor man warns of rare flesh-eating infection that killed his wife days after childbirth

by Jackie Farwell,

BANGOR, Maine - Matt Nichols cradled his newborn daughter, Ruby Ann, in his arms Wednesday morning, gazing into her sleeping face.

When Matt, 29, accompanied his pregnant wife to Eastern Maine Medical Center on Aug. 1, he said he never could have imagined he'd raise their first child on his own after a vicious infection claimed the life of his wife just days after giving birth. Heather Nichols, healthy and also 29 years old, had carried little Ruby through a normal pregnancy. She'd researched the ins and outs of pregnancy and childbirth, preparing herself to become a mother.

After 20 hours of labor, Heather gave birth with Matt at her side. ...

But, as Matt explained, things soon took a turn for the worse after the young family returned home. Matt said Heather had undergone an episiotomy, a small surgical incision that enlarges the vaginal opening to assist with childbirth, and the swelling and pain, while expected, worsened overnight.

The next morning, she returned to the hospital expecting a prescription for some medication. But Heather never left.

As Matt, Heather and their loved ones would discover over the following days, Heather had contracted a rare and rapidly spreading bacterial infection called necrotizing fasciitis, he said. Commonly known as "flesh-eating bacteria," [or "galloping gangrene"] the infection ravages muscles, fat and skin tissue, typically entering the body through a break in the skin, such as a cut or scrape.

...

But Heather's condition rapidly worsened. After one operation to remove some of the decaying tissue, she still suffered from serious pain and swelling. ...

She died on Aug. 8.

...