Review shows no benefit for routine episiotomy

Episiotomy, the incision used to widen the vaginal opening during delivery, should not be performed on a routine basis, according to a review of studies looking at this issue. Pregnant women treated with routine episiotomy do not fare better than other women plus they now have an incision that must heal.

Routine cutting of the vaginal opening was thought to make passage of the baby easier and prevent tears in the skin. Many believed this would promote better wound healing in the short term and reduce the risk of urinary or stool incontinence in the long term. However, the current findings provide no evidence to support any of these benefits.

The results reinforce the position held by the American College of Obstetricians and Gynecologists (ACOG) that routine episiotomy is unnecessary and may raise the risk of certain complications. This does not mean that episiotomy should never be performed, just not as a routine measure for all women undergoing vaginal delivery.

Despite the ACOG recommendation, it is estimated that up to 35 percent of vaginal deliveries involve routine episiotomy, lead author Dr. Katherine Hartmann, from the University of North Carolina at Chapel Hill. “I hope after our findings come out there will be a decline in use.”

“The findings suggest that for most major outcomes, routine use of Episiotomy is comparable to restrictive use,” Hartmann said. The difference lies with the fact that the former approach always involves an incision, whereas with the latter there is a good chance that an incision can be avoided, she explained.

The review, which is reported in the Journal of the American Medical Association, involved an exhaustive search of articles published between 1950 and 2004. Of 986 articles screened, the researchers identified 26 that met their inclusion criteria.

While the definition of routine episiotomy was virtually the same for all trials in the review, there was wide variability in the definition of restrictive episiotomy, Hartmann noted. Some studies used a very tight definition such as “don’t cut an episiotomy unless the baby is in trouble,” while others used a more lax definition such as “don’t cut an episiotomy unless you think you really need it.”

There was fair to good evidence that routine episiotomy was no better than restrictive episiotomy at limiting the severity of skin tears or reducing pain. For long-term outcomes, such as incontinence, the evidence was only rated as fair to poor, but still routine episiotomy seemed to provide no advantage.

Lastly, the authors found no evidence linking Episiotomy with preservation of sexual function. In fact, pain during intercourse was more common among women who underwent the procedure.

In contrast to the standard conclusion used in medical articles, Hartmann does not believe more studies are needed. “The literature is fairly convincing and there is very little precedent for using a procedure that doesn’t show benefit and has a risk of harm.”

SOURCE: Journal of the American Medical Association, May 4, 2005.

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