One
item many women try to include in their birth plan is an
episiotomy.
Episiotomy
has been at the center of controversy for a number of years. The following
appears on the website of the American College of Obstetricians and
Gynecologists:
“The use of episiotomy during labor
should be restricted, with physicians encouraged to use clinical judgment to
decide when the procedure is necessary, according to a new Practice Bulletin
published by The American College of Obstetricians and Gynecologists (ACOG) in
the April issue of Obstetrics & Gynecology. According to ACOG, "The best available data
do not support the liberal or routine use of episiotomy. Nonetheless, there is
a place for episiotomy for maternal or fetal indications such as avoiding
severe maternal lacerations or facilitating or expediting difficult deliveries."
(ACOG Practice
Bulletin #71, 2006)
And according to
the ICEA Position Paper on Episiotomy:
“Data suggest that women who have an
episiotomy do not have significantly improved labor, delivery, and recovery
compared with those who do not have one. Without sufficient data to develop
evidence-based criteria for performing episiotomies, clinical judgment remains
the best guide to determine when its use is warranted, according to ACOG.”
(ICEA PositionPaper: Episiotomy, 2013; ACOG Practice Bulletin #71, 2006)
While the ACOG
bulletin has not been updated in eight years, the data is still the same. Yet
why do physicians continue to use episiotomies routinely? In their landmark book (should be a text and
required reading of every and all birth professionals), Romano and Goer (Romano
and Goer, 2012) state that prophylactic episiotomy champion Joseph DeLee (in
the 1920 inaugural issue of the American Journal of Obstetrics and Gynecology) “admitted
that while he lacked evidence for the benefits of his recommendations, adding
he believed he probably would be able to produce some eventually, but at the
same time he disparaged statistics as a basis for forming judgements.”
With countless
journal articles and studies demonstrating the lack of evidence to routine
episiotomy, the question still remains. Is it due to the drive-thru style of
labor and birth seen globally? Does
episiotomy fit into that style and further facilitate convenience? Only
physicians can truly answer that question.
But here is what
we DO know (Romano and Goer, 2012):
- Median episiotomy
predisposes to anal sphincter laceration, but studies conflict on whether
mediolateral episiotomy increases risk or has no effect.
- Performing episiotomy
for “imminent tear” does not decrease anal sphincter injury rates.
- Episiotomy has no
effect on neonatal outcomes.
- Episiotomy causes
more pain in the postpartum period than spontaneous tears.
- Episiotomy causes
more healing complications than spontaneous tears.
- Episiotomy does
not preserve pelvic floor functioning as measured by pelvic floor muscle
strength, urinary incontinence, and anal incontinence.
- Studies
consistently find episiotomy adversely affects sexual functioning.
- Episiotomy neither
prevents nor relieves shoulder dystocia.
- Anal lacerations rarely recur at subsequent births provided no median episiotomy is done.
Additionally, studies (deSilva, 2012) have shown that the use of oxytocin and semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. Recommendations for full upright positioning and avoiding oxytocin could reduce the need for episiotomy and risk of lacerations/perineal trauma.
Research references:
Cassado, J. et al.
(2013) Does episiotomy protect against injury of the levator ani muscle in
normal vaginal delivery. Neurourlogy and
Urodynamics.
deSilva, F.M. et. al.
(2012) Risk factors for birth-related perineal trauma: a cross-sectional study
in a birth centre. Journal of Clinical Nursing. Aug 21(15-16):2209-18.
Romano, A. and Goer, H. (2012), Optimal
Care in Childbirth: The Case for a Physiologic Approach. Classic Day Publishing.
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