Clinical Commentary
Much ado about a little cut: is episiotomy worthwhile?

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Abstract

Methods to prevent perineal trauma during childbirth include avoiding episiotomy and forceps delivery and slowing delivery of the head to allow the perineum time to stretch. Each intervention can lengthen the second stage of labor and change the biophysical stresses on infants and the pelvic floor. Available evidence supports the belief that the interventions are safe for infants and do not lead to significant short- or long-term maternal morbidity. We should abandon the conventional teaching that a longer second stage and perineal stretching are harmful. Routine episiotomy is no longer advisable. Forces that might inhibit physicians from practicing evidence-based techniques of obstetric delivery include time pressures, malpractice concerns, lack of experience with slow perineal stretching, and an interventionist practice pattern. Changes in practice can be effectively introduced through consumer pressures, opinion leaders, and in teaching institutions, by house staff.

Section snippets

Is an intact perineum bad for infants?

There is no evidence that delivery practices that avoid perineal trauma are correlated with low Apgar scores, birth trauma, or cerebral palsy. Passing through the bony pelvis might sometimes be traumatic for fetuses, but there is certainly no evidence that soft tissues of the perineum damage fetal brains.

Does restricting episiotomy, compared with routine episiotomy, lead to lower Apgar scores? In all six randomized controlled trials of episiotomy policy3 the answer was no. The trials did not

Is an intact perineum bad for the mother?

Childbirth-induced damage to the pelvic floor (muscle dehiscence, denervation injury, and fascial avulsion) is again receiving much attention in the gynecologic literature. Preventing trauma to mothers’ perineums during childbirth is worthwhile only if it is of short- and long-term benefit to mothers. Historically, it was assumed that perineal trauma should be prevented. The 19th century medical literature contains many fascinating papers detailing techniques to avoid perineal tears, which came

What explains the excessive use of episiotomy even now?

Routine episiotomy remains common even in teaching institutions. “Who cares about a little cut?” was a frequent comment from obstetricians participating in Klein’s episiotomy trial. They felt that avoiding episiotomy was possible, but that the benefits were trivial. Given the evidence, there should be widespread abandonment of routine episiotomy and renewed interest in investigating delivery techniques to keep the perineum intact. We believe there are potent reasons why practice has not

Where do we go from here?

Changing common practice involves a cultural change. Leavitt, in her historical analysis of childbirth practices in North America,13 stated that in each generation, the concerns of women for safer, less painful, more humane childbirth have shaped research and practice. Research data and practice guidelines are not sufficient to induce change. In institutions, research is translated into the practices of attending staff by opinion leaders and residents, who serve as vectors transmitting what

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