Many women worldwide continue to undergo a painful procedure during childbirth that experts say should be used only in limited circumstances, according to a new report.
The procedure, called Episiotomy, involves making an incision to enlarge the vaginal opening during childbirth. Episiotomies were once performed routinely in the U.S. and elsewhere, in part because doctors believed it helped prevent vaginal tearing that can occur during delivery.
But in many countries, rates of episiotomy have fallen sharply since the 1980s, after mounting evidence began to show no benefit from routinely performing the 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.
Though Episiotomy is necessary in some cases to ensure a safe delivery, a range of professional medical organizations now agree that it should be used sparingly - in cases of fetal or maternal distress, for instance.
There is, however, no agreement on what constitutes an acceptable rate of Episiotomy. And in the new study, Canadian researchers found that rates vary widely from country to country, among regions within the same country, and even among providers in the same medical network.
Episiotomy rates are generally highest in Asia and Central and South America, while they are lowest in English-speaking countries and some European nations, the researchers report in the medical journal Birth.
Episiotomies were once routinely performed in an attempt to prevent tearing during labor, particularly to avoid tears that reach to the anus. The number of episiotomies performed remains high in the U.S., but there is now a great deal of controversy over whether they should be routine. Recent studies have shown that women who do not have an episiotomy might have a small tear, which is in most cases not worse than an episiotomy.
To perform an episiotomy, local anesthesia (numbing just the immediate area) is usually used. Just before the baby is born, the obstetrician makes an incision at the bottom of the vaginal opening. This enlarges the vaginal opening. The incision is closed after the baby and placenta have been delivered.
Sweden had the lowest rate, at less than 10 percent of vaginal births in 1999-2000. In contrast, it’s estimated that in Guatemala and Taiwan, all first-time mothers who delivered vaginally received an episiotomy.
In Western Europe, episiotomy rates for all vaginal deliveries ranged from 13 percent in England, in 2002-2003, to 87 percent in Spain, in 1995.
In the U.S., episiotomies were performed in one third of vaginal deliveries in 2000, the researchers found. But, as in Canada and other countries, the rate varied according to region; it was highest in the Northeast, at 38 percent, and lowest in the West, at 27 percent.
Exactly why episiotomy rates vary so widely among nations is unclear, the study’s lead author, Dr. Ian D. Graham told.
Expectations after surgery
An episiotomy usually heals without problems and may heal more quickly than a tear. It is also thought to help prevent vaginal stretching and to tighten the vagina after delivery.
Cultural ideas about women and about childbirth, such as the notion that it should be treated as a medical condition, could be at work, according to the researcher. In developing countries, he added, high episiotomy rates could also be the result of doctors “importing” a Western-style medical intervention because they see it as “more progressive” than traditional, low-tech births.
The fact that episiotomy rates vary substantially within countries - and, according to a number of international studies, within single institutions - is surprising, according to Graham.
“It does mean that the reasons for doing the episiotomies must be related to differences in the providers’ attitudes and practices,” he said.
In English-speaking countries, Graham noted, doctors should by now be well aware of guidelines calling for restricted use of episiotomy.
So, he said, women should ask their providers about their personal attitudes toward the procedure to ensure that those beliefs match their own.
SOURCE: Birth, September 2005.
Revision date: June 22, 2011
Last revised: by Andrew G. Epstein, M.D.