Clinical CommentaryMuch ado about a little cut: is episiotomy worthwhile?
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
References (14)
The prophylactic forceps operation
Am J Obstet Gynecol
(1920)- et al.
Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation
Am J Obstet Gynecol
(1994) Shall we cut and reconstruct the perineum for every primipara?
Am J Obstet
(1918)- Carroli G, Belizan J, Stamp G. Episiotomy policies in vaginal births. In: Neilson JP, Crowther CA, Hodnett ED, Hofmeyr...
- et al.
Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies
Obstet Gynecol
(1991) - et al.
Changes in the management of labour1. Length and management of the second stage
CMAJ
(1987) - et al.
Delayed pushing with lumbar epidural analgesia in labour
Br J Obstet Gynaecol
(1983)
Cited by (40)
Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study
2011, International Journal of Nursing StudiesCitation Excerpt :Previously, physicians were taught that episiotomy was a routine and effective procedure for a safe birth (Belizan and Carroli, 1998; Graham, 1997; Klein et al., 1995). Routine episiotomy was questioned during the late 1970s and 1980s (Carroli et al., 1999; Weeks and Kozak, 2001) and fell out of favor in the 1990s (Eason and Feldman, 2000). The factors behind this change included a rise in women's health awareness, the natural childbirth movement, professional competition, and evidence-based practice (Tseng, 2005).
Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth
2007, Journal of Midwifery and Women's HealthCitation Excerpt :The extent and complexity of genital tract trauma is directly related to the amount of suturing required and to subsequent perineal pain. Thus, more trauma equals greater morbidity after birth.9–11 Although some clinicians have adopted the practice of not suturing lacerations that exclude the anal sphincter and rectum, this approach has not been systematically evaluated in studies of adequate size and with sufficient long-term follow-up.33
A comparison of "hands off" versus "hands on" techniques for decreasing perineal cacerations during birth
2006, Journal of Midwifery and Women's HealthEpisiotomy: Beliefs, practice and the impact of educational intervention
2005, European Journal of Obstetrics and Gynecology and Reproductive BiologyEpisiotomy and vaginal trauma
2005, Obstetrics and Gynecology Clinics of North AmericaThe Role of Episiotomy in Emergency Delivery
2023, Practical Guide to Simulation in Delivery Room Emergencies