Episiotomy use should be minimized: new guidelines

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Episiotomies should not be performed on a routine basis, but there are situations in which the procedure is necessary, according to new practice guidelines by the American College of Obstetricians and Gynecologists (ACOG).

An episiotomy is an incision to enlarge the vaginal opening during childbirth. Episiotomies have been performed routinely in the U.S. and elsewhere, in part because doctors believe that it helps prevent vaginal tearing during delivery and that the procedure can shorten the second stage of labor.

But mounting evidence shows no benefit from routinely performing this procedure. The incision takes weeks to heal, during which time walking, using the bathroom and even sitting can be painful. At worst, episiotomy can lead to a laceration in the anal sphincter, a difficult-to-repair tear that can cause long-term incontinence.

After a review of studies on this procedure, Dr. John T. Repke, and colleagues from ACOG, found that episiotomies generally did not make labor, delivery or recovery easier for the mother.

In addition, episiotomy was associated with substantial and probably underestimated, risks, such as serious tissue tears, anal sphincter problems, and painful intercourse.

Still, the guidelines, which are published in the medical journal Obstetrics & Gynecology, point out that there are situations in which episiotomy may be appropriate, such as to prevent a severe lacerations or to speed up a difficult delivery.

Based on “good and consistent” evidence, the guidelines recommend restricted, rather than routine, use of episiotomy. They also found there was a lower risk of anal sphincter and rectal injury when the incision is made at an angle (mediolateral episiotomy) rather than vertically (median episiotomy).

Based on “limited or inconsistent” evidence, the guidelines suggest that mediolateral episiotomy may be preferable to the median approach in selected cases. In addition, routine episiotomy does not prevent incontinence related to pelvic floor damage.

“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,” Repke said in a statement. “We should avoid the pitfall of letting anything in medicine become ‘routine’ and therefore, outside the realm of review and critical analysis.”

SOURCE: Obstetrics and Gynecology, April 2006.

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