Episiotomy Trends

It has been several years since the American College of Obstetricians and Gynecologists (ACOG) issued
a statement renouncing routine episiotomy -- a procedure that involves making an incision into the
perineum, the area between the vagina and the anus, to ease delivery. Prompting the statement was a
review of past studies that overwhelmingly shows that the cut poses serious risks to women and offers
few benefits, according to an article published in the group's journal, Obstetrics and Gynecology.

ACOG's position wasn't new then, and neither was the article's conclusion: That episiotomy increases a
woman's chance for everything from painful infections to persistent sexual problems. And, yet, laboring
women admitted to hospitals still have a greater than 40 percent chance of undergoing this dubious
procedure when they deliver. Despite two decades of data discrediting the safety and usefulness of
episiotomies, doctors keep performing them and women keep paying the price.

Episiotomy has been a mainstay of obstetrical practice since the 1920s, when leading doctors declared
that cutting the perineum was best for Baby and Mom, says Ian Graham, Ph.D., assistant professor of
medicine at the University of Ottawa and author of Episiotomy: Challenging Obstetric Interventions.
Despite a lack of good data, doctors claimed the incision not only protected against tears,
incontinence, and weakened pelvic-floor muscles, but also made delivery easier on the baby.
Now episiotomies are a habit that medicine just can't seem to kick. One reason: They conveniently
speed up delivery. In fact, Emma Stephens*, a Chicago mother, believes her doctor's vacation plans
may have played an unwarranted role in the decision to perform an episiotomy during the birth of her
daughter. "After I had been pushing for less than 20 minutes, she said that the skin was stretched
paper-thin and that she had no option," even though there were no indications that the baby was in
trouble, Stephens says. Getting sewn up delayed that all-important first meeting. "Worse still, it was
horribly painful for weeks," she says. "I remember having to take these long baths while the baby was
crying and wanting to nurse."

Many physicians perform episiotomies for no better reason than it's what they learned to do in medical
school. Others simply may not have kept abreast of the critical evidence. What's more, some older
practitioners tend to be slower in changing their techniques, says Dr. Graham. And to be fair,
interpreting fetal heart rates can be difficult during delivery and many doctors just want to get the
baby out quickly and safely, says Erica Eason, M.D., an associate professor of obstetrics and gynecology
at the University of Ottawa.

However, the bottom line is that this procedure really only needs to be done under certain conditions.
According to Dr. Eason, an episiotomy is warranted when the baby is in distress; when forceps or a
vacuum extractor is used; when the baby is breech, or when the baby's head has emerged from the
birth canal but his shoulders are stuck. Otherwise, the perineal tissue should be allowed to stretch on
its own. Even if there is tearing (which is possible), the wound is likely to be less severe, says Dr.
Eason.
Surprises in new OB practice trends:
Episiotomy rate drops 60%,
repeat cesareans almost double
Janelle Yates
Senior Editor

Use of episiotomy fell by 60% between 1997 and 2008, according to the latest statistical brief on
childbirth-related hospitalizations from the Agency for Healthcare Research and Quality
(AHRQ).1 Other significant changes were noted, as well. For example, the use of forceps to aid
delivery declined by 32%, from 14% to 10%.

In addition:

The number of hospital stays for childbirth fell by 300,000 between 2007 and 2008from
4.5 million to 4.2 million. (The annual number of childbirth stays had previously been
increasing by about 2% a year, starting in 1999.) Nevertheless, childbirth remained the
most common reason for hospitalization, accounting for 11% of all hospital stays and $18.9
billion in hospital costs5% of all inpatient hospital costs.
An increase in repeat cesarean delivery, from 8% to 14% of all childbirths, was
accompanied by a decrease in the rate of vaginal birth after cesarean (VBAC), which fell to
1% of all deliveries in 2008
The rate of cesarean delivery varied by insurance coverage, with uninsured women less
likely to undergo it (28%), compared with privately insured women (34%) and those on
Medicaid (31%)
The average childbirth hospital stay involving cesarean delivery with no complications cost
hospitals an average of $5,700; when complications occurred, the cost rose to $7,600. In
contrast, a vaginal childbirth stay without complications cost hospitals an average of
$3,400, and it cost $4,400 when complications occurred. Although it was uncommon,
vaginal delivery that involved an operating room procedure (such as operative forceps or
vacuum delivery) had the highest average cost: $9,400.
Forty percent of all childbirth stays were billed to Medicaid; 53% to private insurers; 4%
were uninsured; and the rest were charged to other payers.
Roughly 36% of all childbirth hospital stays in 2008 occurred in the South, 16% in the
Northeast, 26% in the West, and 23% in the Midwest.
 JAMA Study on Routine Episiotomy

Advice for pregnant

women on how to
avoid routine
episiotomy

Katherine Hartmann and colleagues have published a new systematic review about effects of routine
episiotomy on women. It is important for pregnant women and their caregivers to understand lessons
from this research, detailed below. Please see also Childbirth Connection's clear, simple advice for
pregnant women on how to avoid routine episiotomy.

What did the new episiotomy study do?

The new study used a rigorous systematic review approach to summarize the best available research
about effects of routine episiotomy on mothers. Episiotomy is a surgical cut that is often made just
before birth to enlarge the opening of the vagina. This practice has been widely used for many
decades in the belief that it offers benefits to mothers.

What did the researchers conclude?

The researchers found that routine episiotomy offers mothers no benefits and is associated with
harms.

Depending on the circumstances, the literature reviewed found that routine episiotomy increased:

need for stitching

experience of pain and tenderness

healing period

likelihood of leaking stool or gas (bowel incontinence)

pain with intercourse.

Midline episiotomy, the standard in North America, is a cut straight back into the perineum (see pelvic
floor and episiotomy pictures below, or find more information on the effect of episiotomy on the pelvic
floor). With this type of cut, women are vulnerable to tissue tears that extend into or through the anal
muscle.

What are some concerns about tears that extend into or through the anal
muscle?
This type of trauma increases women's risk of harm due to

pain and discomfort

prolonged healing
 infection

pain with intercourse

bowel incontinence, both feces and gas

decreased sexual function

pressure for cesarean in future birth.

Are concerns about effects of routine episiotomy new?

No. The evidence has been clear and consistent for many years. Numerous past reviews have come to
similar conclusions.

Why are so many episiotomies being performed on women when the best
research has shown that they are harmful?
Despite compelling research evidence, many maternity care providers still use this procedure liberally.
This happens for many reasons. These include:

high-intervention standards for childbirth

practice style and values of individual providers

practice style and values in specific birth settings

influence of colleagues

influence of medical education.

Women themselves may not be aware of the harms caused by episiotomies and their lack of benefit.
And providers may not obtain women's informed consent or informed refusal for the procedure.

How often are episiotomies used with vaginal birth?

The episiotomy rate has been falling off for some time in the U.S. However, when Childbirth
Connection carried out its national U.S. Listening to Mothers surveyamong women who had given birth
from 2000 to 2002, 35% of mothers with a vaginal birth had experienced episiotomy.

Episiotomy rates vary dramatically across providers and hospitals. So, choice of caregiver and choice
of birth setting affect a woman's likelihood of this and other labor interventions.

What is a good rate of episiotomy?

Authors of the JAMA study recommend that the U.S. could immediately achieve a rate below 15% of
vaginal births. Providers with a conservative practice style have rates well below 15%. Midwives
generally have the lowest rates, followed by family physicians and obstetricians.
How can a pregnant woman avoid a routine episiotomy?
In this environment, a woman should not assume that she will only get an episiotomy if it is
necessary. Apart from an urgent need to hasten a birth, there is no clear justification for episiotomy.
Childbirth Connection has gathered tips to help women avoid routine or unnecessary episiotomies.

Is episiotomy a factor in the supposed "harms of vaginal birth"?

Episiotomy is just one of the practices that contribute to the supposed "harms of vaginal birth".
Research has identified concerns about other practices that may be widely used with vaginal birth. In
addition to episiotomy, other practices that appear to increase risk of harm to the pelvic floor include
pushing and giving birth on the back, forceful staff-directed pushing, use of forceps or vacuum
extraction, pressing on the abdomen (by a staff member) during pushing, and epidural analgesia. Use
of these practices could be greatly reduced, to the benefit of birthing women.

There is growing talk among professionals and in the media about supposed hazards of vaginal birth.
In a large review of the best science, Childbirth Connection did not find a single study that minimized
harmful management practices to try to understand whether vaginal birth in itself poses harm. It is
wrong at this time to conclude that vaginal birth is harmful. Due to many increased harms associated
with major surgery, an appropriate solution is to improve the way providers manage vaginal birth
rather than shifting to cesarean section without medical need.
 Approach to Episiotomy
INTRODUCTION

Episiotomy refers to a surgical incision of the female perineum performed by the accoucheur at the time
of parturition. It is usually performed with scissors when the perineum is stretched and distended, just
prior to crowning of the fetal head. The purpose is to increase the diameter of the soft tissue pelvic outlet,
thereby preventing perineal lacerations, facilitating delivery, and reducing the time for expulsion of the
infant.

PREVALENCE OF EPISIOTOMY

Episiotomy is one of the most common operations performed on women [1]. Changing trends in
obstetrical practice over time have influenced the decision to perform an episiotomy and resulted in a
decreasing prevalence of the procedure (60.9 percent of vaginal deliveries in 1979 versus 24.5 percent in
2004) [2]. The prevalence of episiotomy is highest in Latin America and lower in Europe [3], with reported
rates varying widely from 1 percent (Sweden) to 80 percent (Argentina) [4,5].

The decision to perform an episiotomy appears to be influenced by the type of obstetrical provider.
Specifically, private practitioners and faculty providers are more likely than midwives to use this procedure
(four-fold and two-fold higher, respectively) [6-8]. Maternal position, parity, and use of epidural anesthesia
also appear to play a role in the decision to perform episiotomy. An upright or lateral maternal childbirth
position is associated with fewer episiotomies than the supine or lithotomy positions [9], while epidural
anesthesia and primiparity may increase the incidence [6,10,11]. Episiotomy is more common with
operative than spontaneous vaginal deliveries (71 versus 33 percent) [1].

RATIONALE FOR EPISIOTOMY

The purported benefits of episiotomy include [3,12]:

Reduction in third and fourth degree tears

Ease of repair and improved wound healing
Preservation of the muscular and fascial support of the pelvic floor
Reduction in neonatal trauma, such as with the premature infant (soft cranium) or macrosomic
infant (shoulder dystocia)
Reduction in dystocia by increasing the diameter of the soft tissue outlet
Expedited delivery of fetuses with nonreassuring fetal heart rate tracings