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Practice Guidelines Issued for Use of Episiotomy

April 6, 2006 — The American College of Obstetrics and Gynecology (ACOG) has prepared practice guidelines for use of episiotomy, which are published in the April issue of Obstetrics & Gynecology. The authors note that this is one of the most commonly performed procedures in obstetrics; approximately 33% of women giving birth vaginally in 2000 had an episiotomy.

"Historically, the purpose of this procedure was to facilitate completion of the second stage of labor to improve both maternal and neonatal outcomes," write John T. Repke, MD, and colleagues from the ACOG Committee on Practice Bulletins. "Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor resulting from more rapid spontaneous delivery or from instrumented vaginal delivery."

The guidelines were designed to assist practitioners in making decisions about appropriate obstetric and gynecologic care, but they should not be construed as dictating an exclusive course of treatment or procedure. Individual patient needs, and resources and limitations of each institution or type of practice may necessitate variations in practice.

"The purpose of this document is to examine the risks and benefits of episiotomy and to make recommendations regarding the use of this procedure in current obstetric practice," the authors write. "Despite limited data, this procedure became virtually routine resulting in an underestimation of the potential adverse consequences of episiotomy, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia."

Level A recommendations and conclusions, based on good and consistent scientific evidence, are that restricted use of episiotomy is preferable to routine use and that median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than is mediolateral episiotomy.

Level B recommendations and conclusions, based on limited or inconsistent scientific evidence, are that mediolateral episiotomy may be preferable to median episiotomy in selected cases and that routine episiotomy does not prevent pelvic floor damage leading to incontinence. As a performance measure, the panel recommends the percentage of patients for whom the indication for episiotomy is included in the delivery notes.

Although the indications for episiotomy vary and are based largely on clinical opinion, the procedure may be indicated in cases where it is necessary to expedite delivery in the second stage of labor or where spontaneous laceration is likely. However, evidence is lacking to support these indications.

"Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure," the authors write. "Restrictive use of episiotomy appears to reduce the likelihood of perineal lacerations."

A systematic review of routine vs restrictive episiotomy found no evidence to support episiotomy in preventing pelvic floor damage leading to incontinence. Whether episiotomy adds to immediate postpartum pain is still unclear. In prospective cohort studies, women who did or did not have episiotomy had no differences in dyspareunia or resumption of intercourse at 3 months.
Several trials have reported on different techniques of perineal closure aimed at reducing postpartum pain and promoting rapid healing, but larger trials are needed to draw any definite conclusions.

Proposed fetal benefits of episiotomy include cranial protection, especially for premature infants; reduced perinatal asphyxia and fetal distress; higher Apgar scores, less fetal acidosis, and fewer complications from shoulder dystocia, but few data are available to support these claims. The presumed effect of episiotomy on shortening the second stage of labor has also not been demonstrated conclusively.

Median episiotomies are associated with higher risk of extension into the rectum and compromise of the external anal sphincter muscle, and mediolateral episiotomies are associated with greater postpartum pain, more blood loss, greater difficulty in repair, and more dyspareunia, especially when compared with spontaneous tears. Because of the potential for greater expansion of the pelvic floor with mediolateral episiotomy, this procedure may theoretically help lower the risk for incontinence.

"Although the data are insufficient to determine the superiority of either approach, data do suggest that both median and mediolateral episiotomies have similar outcomes, including pain from the incision and time to resumption of intercourse," the authors conclude. "The best available data do not support liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications, such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries."Obstet Gynecol. 2006;107:957-962

Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
Compare median vs mediolateral episiotomy.
Evaluate potential indications for the routine use of episiotomy.
Clinical Context
Episiotomy has been used routinely for approximately 80 years, but the best technique of episiotomy and its clinical benefits remain largely unknown. The current Practice Bulletin from ACOG summarizes some of the known and perceived differences between median and mediolateral episiotomies. The median episiotomy is the more popular technique used in the United States, reflecting its relative ease in execution and repair compared with the mediolateral technique. However, median episiotomy is more likely than mediolateral episiotomy to promote a third-degree or fourth-degree extension of the laceration. Meanwhile, mediolateral episiotomy may be preferred to median episiotomy because it creates more perineal space for delivery. There are little data to indicate that one type of episiotomy is superior to the other in terms of the risk for genital prolapse or recovery after delivery.

The current Practice Bulletin highlights other clinical outcomes of episiotomy.

Study Highlights
Although the use of episiotomy appears to have fallen slightly between 1992 and 2003, it is still performed in approximately 33% of vaginal deliveries.
In either median or mediolateral episiotomy, a 2-layered closure can improve postpartum pain and healing complications vs a 3-layer closure. A minimally reactive polyglycolic acid derivative suture is recommended to reduce wound inflammation.
Common complications of episiotomy include bleeding and infection. For superficial wound breakdown, the authors recommend conservative treatment with perineal care. However, wound complications involving the anal sphincter or rectum may require surgical closure.
There are no evidence-based indications for episiotomy, which has traditionally been used in cases of complicated second stage of labor, such as shoulder dystocia or nonreassuring fetal heart rate pattern, or cases judged to present a high risk for spontaneous laceration. The use of episiotomy appears mostly based on anecdotal evidence.
Limited vs more liberal use of episiotomy appears to be associated with a reduced risk for perineal lacerations. Also, median episiotomy was the most significant risk factor for third- or fourth-degree lacerations in one study.
Episiotomy has not been definitively demonstrated to reduce the risk for urinary or anal incontinence, genital prolapse, or pelvic floor damage.
Women with either an episiotomy or a similar degree of perineal laceration generally complain of similar levels of postpartum pain, and return to sexual activity occurs at approximately the same pace.
There is little evidence that episiotomy improves any fetal outcomes, including its use in common situations, such as shoulder dystocia. Research has not consistently demonstrated that episiotomy reduces the duration of the second stage of labor.
Overall, the authors found good and consistent scientific evidence that the restricted use of episiotomy is preferable to routine use of episiotomy and that median episiotomy is associated with higher rates of anal sphincter and rectum injury vs mediolateral episiotomy. They found limited or inconsistent evidence that mediolateral episiotomy may be preferred to median episiotomy in some situations and that routine episiotomy does not protect against pelvic floor damage leading to incontinence.
Pearls for Practice
Median episiotomy may be easier to perform and repair than mediolateral episiotomy, but it is associated with an increased risk of third- and fourth-degree extension. Both types of episiotomy appear similar in outcomes of postpartum recovery and genital prolapse.
There is no evidence-based indication for the routine use of episiotomy.



News Author
Laurie Barclay, MD
is a freelance reviewer and writer for Medscape.


Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Author
Charles P. Vega, MD
Charles Vega, MD, Associate Clinical Professor; Residency Program Director, Family Medicine, University of California-Irvine, Orange, California


Disclosure: Charles Vega, MD, FAAFP, has disclosed that he has received grants for educational activities from Pfizer.

Clinical Reviewer
Gary Vogin, MD
Senior Medical Editor, Medscape


Disclosure: Gary Vogin, MD, has disclosed no relevant financial relationships.

Medscape Medical News 2006. ©2006 Medscape
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