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Routine Episiotomy Needs To Be Discouraged

A number of high quality trials provide strong evidence that episiotomy should not be performed routinely during labor yet it remains common practice in more than 40 percent of deliveries in the United States.

"This suggests the need for further educational interventions on how to attend deliveries in primiparous women without using episiotomy," declares Dr Amy Denham, and Dr Valerie King from the Department of Family Medicine, University of North Carolina at Chapel Hill, North Carolina.

The clinicians point out that the episiotomy was initially based on theoretical benefit, but with little evidence supporting claims that it prevented severe perineal lacerations or pelvic floor dysfunction. However, evidence-based medicine has called the practice into question with the suggestion that episiotomy increases the risk of third- and fourth-degree lacerations.

"A recent Cochrane review of six randomized controlled clinical trials comparing routine versus restricted use of episiotomy showed that episiotomy was associated with more second-degree perineal trauma, without significant differences in dyspareunia, severe perineal trauma, or severe pain," the clinicians point out. Similar results were seen in either mediolateral episiotomy or midline episiotomy.

In their trial, Drs Denham and King enrolled 80 pregnant women, mean age 26.4 years, at term who had not had previous vaginal deliveries. The 62 who went on to have vaginal deliveries were included in the analysis. A majority (92 percent) had prenatal care, most (88 percent) had epidural analgesia, about one fourth (28 percent) had forceps or vacuum-assisted delivery, and a few had malpresentations. A decision whether to perform an episiotomy was left to clinical judgement.

Among the 62 patients in the final analysis, 76 percent had a perineal laceration, with a median length of 4 cm. Five patients (8 percent) had a third-degree laceration, and one patient (2 percent) had a fourth-degree laceration. Approximately half of the patients (44 percent) had an episiotomy. The mean laceration length was 3 cm longer for patients who had an episiotomy (4.9 cm versus 1.9 cm).

When assisted deliveries were excluded from the analysis, the association between episiotomy and laceration length remained significant.

The researchers concluded that the study "provides weak evidence that episiotomy increases perineal laceration length in primiparous women. Earlier higher-quality trials provide strong evidence that episiotomy should not be performed routinely. Its use should be restricted to situations in which specific clinical indications exist."
The Journal of Family Practice, December 2001, Vol. 50, No. 12. "Does episiotomy increase perineal laceration length in primiparous women?"

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