Routine Episiotomies

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  THE HISTORY: Mothering Magazine "Avoiding an episiotomy"

  The American College of Obstetricians and Gynecologists (ACOG) estimates that as many as ninety percent of women giving birth to their first child in a hospital will have an episiotomy, despite ACOG's official position that "the routine use of episiotomy is not now recommended as a standard practice."Among births occurring at home or at a birthing center tinder the care of a midwife, the episiotomy rate for first-time mothers is estimated at about ten to fifteen percent.

  Medical literature first described episiotomies in 1741 as a surgical technique performed to enlarge the vagina so that forceps could be inserted high into the pelvis, thereby assisting in the birth of the baby. At that time it was also widely believed, without any research to support such claims, that episiotomies would prevent gynecological and fetal injuries during birth, such as tearing, damage to the pelvic floor muscles, and fetal brain trauma or injury. While this may have been true for rare instances of unusually long, difficult labor likely to end with such injuries, by the 1930s episiotomies had become routine for all births in hospitals.

  It was also during the late 1920s and early 1930s that [...] most mothers giving birth in hospitals were anesthetized [...] with a pharmaceutical triple-whammy of morphine, an amnesic drug called scopolamine, and finally a dose of ether or chloroform.(2) This procedure left women unconscious during birth and therefore unable to push their babies out, necessitating routine episiotomies and the use of forceps high in the pelvis.

  Although criticism of medicated childbirth took root in the 1950s, it was not until the 1970s that the widespread use of medication and interventions in childbirth were called into question. At that time, the popularity of childbirth preparation methods such as Bradley and Lamaze, gave rise to a widely-supported natural childbirth movement.

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  ANTI: About.com "Episiotomy"

  Dr. JM Thorp, in "Episiotomy: Can its routine use be defended?", says, "There is little evidence to support routine use of episiotomy. This procedure may well increase the incidence of third- and fourth-degree lacerations.

  The American College of Obstetricians and Gynecologists say that episiotomy "is not always necessary" and "should not be considered routine." However, estimates claim that the episiotomy rate in the United States is sixty-five to ninety-five percent, depending on the parity (number of babies previous born).

  [...]

  The fact is, that medical research has not proven any of these benefits. In fact, in many of the cases, the opposite is actually true. Episiotomies can actually cause harm.

  "Review of the literature on episiotomy indicates the likelihood that it is over-used, with shaky justification at best. It seems reasonable to infer that a median episiotomy has no great advantage over a first- (into the skin) or second-degree (into the underlying muscle) laceration when there are no overriding fetal indications."

  Episiotomies are not always necessary, and there is much you can do to lessen your chances of having this surgical incision.

  Remember, as with any medical procedure, there is always a time and a place where it is a valid option.

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  ANTI: Childbirth.org "Will Natural Tearing Heal Better than an Episiotomy?

  Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it. All the authoritative pronouncements in favor of episiotomy descend from a seventy-five-year-old article (DeLee 1920) that produced not a shred of evidence in its support. Most recently, Williams Obstetrics (Cunningham, MacDonald, and Gant 1989) states, "The reasons for [episiotomy's] popularity among obstetricians are clear. It substitutes a straight, neat surgical incision for the ragged laceration that otherwise frequently results. It is easier to repair and heals better than a tear." Human Labor and Birth (Oxorn-Foote 1986) adds that it averts "brain damage" by "lessen[ing] the pounding of the head on the perineum." An earlier edition of William's Obstetrics (Pritchard, MacDonald, and Gant 1985) claims that it reduces the incidence of cystocele (a herniation of the posterior bladder through the anterior rectal wall), rectocele (a herniation of the anterior rectal wall through the posterior vaginal wall), and stress incontinence (involuntary loss of urine in response to laughing, sneezing, etc., although the 1989 edition admits this benefit is unproved). ...read the full article

  Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it. All the authoritative pronouncements in favor of episiotomy descend from a seventy-five-year-old article (DeLee 1920) that produced not a shred of evidence in its support. Most recently, Williams Obstetrics (Cunningham, MacDonald, and Gant 1989) states, "The reasons for [episiotomy's] popularity among obstetricians are clear. It substitutes a straight, neat surgical incision for the ragged laceration that otherwise frequently results. It is easier to repair and heals better than a tear." Human Labor and Birth (Oxorn-Foote 1986) adds that it averts "brain damage" by "lessen[ing] the pounding of the head on the perineum." An earlier edition of William's Obstetrics (Pritchard, MacDonald, and Gant 1985) claims that it reduces the incidence of cystocele (a herniation of the posterior bladder through the anterior rectal wall), rectocele (a herniation of the anterior rectal wall through the posterior vaginal wall), and stress incontinence (involuntary loss of urine in response to laughing, sneezing, etc., although the 1989 edition admits this benefit is unproved).

  Obstetricians presume spontaneous tears do worse damage, but now that researchers have gotten around to looking, every study has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.

  By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual disatisfaction after childbirth (the concern was the male partner, of course, hence, the once-popular "husband's knot," an extra tightening during suturing that made many women's sex lives a permanent misery), urinary incontinence, and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies.

  Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete.

  Meanwhile, as the authors of this chapter's "Reality" quotation point out, episiotomy, like any other surgical procedure, carries the risk of blood loss, poor wound healing, and infection.

  In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs. click to close

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  ANTI: Mayo Clinic "Episiotomy: Can you deliver a baby without one?"

  An incision extending the opening of the vagina — an episiotomy — was once a routine part of childbirth. But episiotomies aren't always necessary.

  An episiotomy was once a routine part of childbirth. It was thought that an episiotomy would help prevent more extensive vaginal tears and heal better than a natural tear. The procedure was also thought to reduce the risk of incontinence after childbirth and keep the bladder and rectum from drooping into the vagina.

  Sounds reasonable, but researchers have found that routine episiotomies don't prevent these problems after all. In fact, routine episiotomies offer no benefits. Recovery is uncomfortable, and sometimes the surgical incision is more extensive than a natural tear would have been.

  Researchers say there's no need for a routine episiotomy, but the procedure is still warranted in some cases. For example, your doctor may recommend an episiotomy if extensive vaginal tearing appears likely, if your baby is in an abnormal position or if your baby needs to be delivered quickly. ...read the full article

  From "Episiotomy: Can you deliver a baby without one?"

  An incision extending the opening of the vagina — an episiotomy — was once a routine part of childbirth. But episiotomies aren't always necessary.

  An episiotomy was once a routine part of childbirth. It was thought that an episiotomy would help prevent more extensive vaginal tears and heal better than a natural tear. The procedure was also thought to reduce the risk of incontinence after childbirth and keep the bladder and rectum from drooping into the vagina.

  Sounds reasonable, but researchers have found that routine episiotomies don't prevent these problems after all. In fact, routine episiotomies offer no benefits. Recovery is uncomfortable, and sometimes the surgical incision is more extensive than a natural tear would have been.

  Researchers say there's no need for a routine episiotomy, but the procedure is still warranted in some cases. For example, your doctor may recommend an episiotomy if extensive vaginal tearing appears likely, if your baby is in an abnormal position or if your baby needs to be delivered quickly.

  To soften the vaginal tissues for delivery, some health care providers suggest massaging the area between the vaginal opening and anus (perineal massage) in the last weeks of pregnancy. Although there are no guarantees — and you don't have to do it if the idea makes you uncomfortable — stretching the tissues may reduce vaginal trauma during delivery.

  It's important to go into labor with an open mind. It will take time for the baby to stretch the vaginal tissues to allow delivery. Count on your doctor to respect your wishes about episiotomy — and to let you know when it's the safest option for you or your baby. click to close

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  ANTI: ACOG "ACOG Recommends Restricted Use of Episiotomies"

  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."

  Recent studies show that common indications for episiotomy were based on limited data. Additionally, there was a general underestimation of potential adverse consequences associated with the procedure, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and painful sex. 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.

  "In the case of episiotomy, as with all medical and surgical therapies, we need to continually evaluate what we do and make appropriate changes based on the best and most current evidence available," said the document's author, ACOG Fellow John T. Repke, MD. "We should avoid the pitfall of letting anything in medicine become 'routine' and therefore, outside the realm of review and critical analysis."

ADDITIONAL LINKS

• Childbirth.org "Perineal Massage," excerpt from William and Martha Sears The Birth Book

• Lamaze Institute for Normal Birth "Systematic Review Finds No Benefit to Routine Episiotomies"

• University of North Carolina Health Care System "There's No Need for Routine Episiotomy"

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