Friday, January 24, 2014

The Evidence Says: Routine Episiotomies ~ Not Evidence based Practice

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):

  1. Median episiotomy predisposes to anal sphincter laceration, but studies conflict on whether mediolateral episiotomy increases risk or has no effect.
  2. Performing episiotomy for “imminent tear” does not decrease anal sphincter injury rates.
  3. Episiotomy has no effect on neonatal outcomes.
  4. Episiotomy causes more pain in the postpartum period than spontaneous tears.
  5. Episiotomy causes more healing complications than spontaneous tears.
  6. Episiotomy does not preserve pelvic floor functioning as measured by pelvic floor muscle strength, urinary incontinence, and anal incontinence.
  7. Studies consistently find episiotomy adversely affects sexual functioning.
  8. Episiotomy neither prevents nor relieves shoulder dystocia.
  9. 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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