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Are episiotomies useful?

by Randall Neustaedter OMD

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A definitive review of the literature on episiotomy published in JAMA concluded that its routine use in births results in more harm than good. The authors comment that, “Despite decades of research, which many interpret as definitive evidence against routine episiotomy, little professional consensus has developed about the appropriateness of routine use.”

An episiotomy is a surgical incision of the mother’s perineum performed as the baby’s head emerges from the vaginal canal during birth intended to prevent tears of the perineal muscles. It is generally believed that these straight incisions are more easily repaired than tears. A total of 30-35 percent of vaginal births include episiotomy. However some clinicians perform episiotomies at more than 84 percent of births, and one study conducted from 1987-1992 documented an average episiotomy rate of 51 percent among spontaneous, uncomplicated term births. Wide use of episiotomy practice is due to the belief that women will have better outcomes as a result, less perineal injury and resulting pain, and less problems with sexual function and urinary incontinence. What we don’t hear is that perineal massage prior to birth and during birth can effectively prevent tears. What is hidden in these discussions is the advantage of episiotomy for doctors. It makes the birth quicker and easier for them.

These reviewers discovered that episiotomy did not prevent problems following the birth and in some cases created problems that may not have occurred otherwise. Most studies compared two groups, one group in which the obstetric health care practitioner restricted use of episiotomies, and a group with a liberal, routine use of episiotomies. Analyzing sexual function following episiotomy found that all measures of sexual function were equivalent by 3 months postpartum, except that pain with intercourse tended to be more common in women with episiotomy. When the investigators examined the outcome measures for the conditions that episiotomy is purported to prevent, they found no evidence that the procedure prevents urinary incontinence, pain, or fecal incontinence. In fact, women who had undergone episiotomy had reduced pelvic floor muscle strength compared with women with spontaneous tears.

The authors conclude, “Our systematic review finds no benefits from episiotomy.” They call for an immediate reduction in episiotomy use, likening the procedure to tonsillectomy in children. They suggest preventing 1 million episiotomies each year and reducing the episiotomy rate to less that 15 percent of spontaneous vaginal births.

Hartmann, K, et al. Outcomes of routine episiotomy: A systematic review. JAMA, May 4, 2005; 293 (17): 2141-48.

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