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71 - Episiotomy
71 - Episiotomy
PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIAN–GYNECOLOGISTS
NUMBER 71, APRIL 2006
Episiotomy
Episiotomy is one of the most commonly performed procedures in obstetrics. In
This Practice Bulletin was 2000, approximately 33% of women giving birth vaginally had an episiotomy
developed by the ACOG Com- (1). Historically, the purpose of this procedure was to facilitate completion of
mittee on Practice Bulletins— the second stage of labor to improve both maternal and neonatal outcomes.
Obstetrics with the assistance
Maternal benefits were thought to include a reduced risk of perineal trauma,
of John T. Repke, MD. The in-
subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal
formation is designed to aid
practitioners in making deci- incontinence, and sexual dysfunction. Potential benefits to the fetus were
sions about appropriate obstet- thought to include a shortened second stage of labor resulting from more rapid
ric and gynecologic care. These spontaneous delivery or from instrumented vaginal delivery. Despite limited
guidelines should not be con- data, this procedure became virtually routine resulting in an underestimation of
strued as dictating an exclusive the potential adverse consequences of episiotomy, including extension to a
course of treatment or proce- third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia. The
dure. Variations in practice may purpose of this document is to examine the risks and benefits of episiotomy and
be warranted based on the to make recommendations regarding the use of this procedure in current obstet-
needs of the individual patient, ric practice.
resources, and limitations
unique to the institution or type
of practice.
Background
History
Episiotomy has been described in the medical literature for more than 300
years, but it was not until the 1920s, with the publication of papers by DeLee
(2) and Pomeroy (3), that more routine use of episiotomy became accepted.
However, there was certainly not unanimity about the utility of this approach at
that time (4). The shift to in-hospital deliveries in the 20th century was associ-
ated with decreased morbidity and an increase in the use of episiotomy and pro-
liferation of many other obstetric practices (eg, use of forceps, use of cesarean
delivery, use of anesthesia). More recently, in 1992 more than 1.6 million epi-
siotomies were performed in the United States, with a background cesarean
delivery rate of 22.3%. In 2003, 716,000 episiotomies were performed with a
background cesarean delivery rate of 27.5%, suggesting such infections are localized and may resolve with per-
that use of this procedure in obstetrics is decreasing (5, 6). ineal wound care. In rare cases, an abscess may form,
which will result in either the need for disruption of the
Techniques of Episiotomy repair to allow for evacuation of the abscess or sponta-
In general, two types of episiotomy have been described: neous breakdown of the repair. In extreme cases, infec-
the median (or midline or medial) episiotomy and the tions such as necrotizing fasciitis can cause maternal
mediolateral episiotomy. In the United States, the more death if not effectively evaluated and treated. In cases of
commonly used technique is the median episiotomy. It less severe infection with wound breakdown, several
gained popularity because it is easy to perform and to approaches can be used. For superficial breakdowns not
repair. Postpartum pain is reported to be reduced with involving the rectum or anal sphincter, expectant man-
this technique, as is postpartum dyspareunia (4). Median agement with perineal care may allow for spontaneous
episiotomy, however, is associated with a greater risk of healing to occur over a period of several weeks. For more
extension to include the anal sphincter (third-degree extensive breakdowns, or when the logistics of many fol-
extension) or rectum (fourth-degree extension) (7–10). low-up visits may be prohibitive, primary closure of the
Mediolateral episiotomy, an incision at least 45 defect may be attempted. Data suggest that early closure
degrees from the midline, is more commonly performed of episiotomy dehiscence in properly selected cases may
outside the United States and is favored by some because be appropriate (20). In rare cases, inadequately repaired
it maximizes perineal space for delivery while reducing episiotomies may lead to rectovaginal fistula formation
the likelihood of third- or fourth-degree extension (8, 11). (21). Repair of such defects can be challenging, depend-
Reported disadvantages of the mediolateral procedure ing on size and location, and should be repaired by some-
include difficulty of repair, greater blood loss, and, pos- one familiar with fistula repair techniques.
sibly, more early postpartum discomfort (4).
▲
endpoint of avoiding anal sphincter or rectal injury have Restricted use of episiotomy is preferable to routine
demonstrated that mediolateral episiotomy is superior to use of episiotomy.
▲
median episiotomy (9, 42, 43). However, there may be Median episiotomy is associated with higher rates of
other drawbacks to the use of mediolateral episiotomy, injury to the anal sphincter and rectum than is medio-
including increased perineal trauma not involving the lateral episiotomy.
sphincter (44). There does not appear to be evidence to
support a protective effect of mediolateral episiotomy The following recommendation and conclusion
with respect to subsequent development of genital pro- are based on limited or inconsistent scientific evi-
lapse (28). In addition, although the data are insufficient dence (Level B):
to determine the superiority of either approach, data do
▲
Mediolateral episiotomy may be preferable to medi-
suggest that both median and mediolateral episiotomies
an episiotomy in selected cases.
have similar outcomes, including pain from the incision
and time to resumption of intercourse (7).
▲ Routine episiotomy does not prevent pelvic floor
The timing of episiotomy has long been the subject damage leading to incontinence.
of debate (2, 3). There are no data to show that early epi-
siotomy results in decreased pelvic floor trauma. It has
been demonstrated that episiotomy, whether median or Proposed Performance
mediolateral, is associated with increased maternal blood Measure
loss at the time of delivery (45).
For patients with episiotomy, the percentage for whom the
Should episiotomy be routine or restricted in indication for episiotomy is included in the delivery notes
▲
clinical practice?
The best available data do not support liberal or routine References
use of episiotomy. Nonetheless, there is a place for epi-
1. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park
siotomy for maternal or fetal indications, such as avoid- MM. Births: final data for 2000. Natl Vital Stat Rep
ing severe maternal lacerations or facilitating or 2002;50(5):1–101. (Level II-3)
expediting difficult deliveries. According to a recent sys- 2. DeLee JB. The prophylactic forceps operation. Am J
tematic evidence review (24), although episiotomy is per- Obstet Gynecol 1920;1:34–44. (Level III)
formed in approximately 30–35% of vaginal births in the
3. Pomeroy RH. Shall we cut and reconstruct the perineum
United States, prophylactic use of episiotomy does not for every primipara? Am J Obstet Dis Women Child
appear to result in maternal or fetal benefit. Another sys- 1918;78:211–20. (Level III)
tematic review comparing routine episiotomy with 4. Thacker SB, Banta HD. Benefits and risks of episiotomy:
restrictive use reported that the group routinely using epi- an interpretive review of the English language literature,
siotomy had an overall incidence of 72.7%, versus 27.6% 1860-1980. Obstet Gynecol Surv 1983;38:322–38. (Level
in the restricted-use group (46). The restricted-use group III)
had significantly lower risks of posterior perineal trauma, 5. DeFrances CJ, Hall MJ, Podgornik MN. 2003 National
suturing, and healing complications, but a significant Hospital Discharge Survey. Advance data; No. 359.
Hyattsville (MD): National Center for Health Statistics;
increase in anterior perineal trauma. No statistically sig- 2005. Available at: http://www.cdc.gov/nchs/data/ad/ad
nificant differences were reported for severe vaginal or 359.pdf. Retrieved December 29, 2005. (Level II-3)
perineal trauma, dyspareunia, or urinary incontinence, 6. Martin JA, Hamilton BE, Sutton PD, Ventura SJ,
leading the reviewers to conclude that restrictive-use pro- Menacker F, Munson ML. Births: final data for 2003. Natl
tocols are preferable to routine use of this procedure. Vital Stat Rep 2005;54(2):1–116. (Level II-3)