Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article


During the past 20 years, many observational studies, randomized trials, and systematic reviews have appeared in the literature concerning outcomes of liberal versus restricted use of episiotomy. The Cochrane Database contains a meta-analysis of 4850 women in 6 clinical trials from 5 different countries.[30] This review has been available since 1997, thus, the information has been widely disseminated and is already well-known to many clinicians. In 2005, Hartmann et al.[31] updated this review but added only one clinical trial of 146 women, therefore the two reviews are in complete agreement. The assembled evidence indicates that episiotomies are to be avoided except in rare situations, such as extreme fetal jeopardy. No benefits accompany the routine use of episiotomies, and women who receive them have more genital tract trauma, require more suturing, and have more persistent perineal pain after childbirth. Further, no long-term benefits follow episiotomy, such as improved sexual function, fewer bowel or urinary symptoms, or a stronger pelvic floor. As such, routine episiotomy causes more harm than benefit.

While episiotomy rates have declined in the United States, approximately 25% of all vaginal births still are accompanied by this procedure.[8] Rates vary according to geographic location.[7] Rates also vary by the birth attendant, with the lowest rates found in midwifery practices.[15] Clinicians in academic centers have been shown to have lower rates than those in private practice settings.[32] Rates below 15% have been advocated as immediately possible.[31] Currently, some academic centers have extremely low rates (<1% for all clinicians, including midwives, obstetricians, and family physicians), demonstrating that episiotomies are almost never truly indicated.[29]


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