Episiotomy Practice: Changes and Evidence-based Medicine in Action

Abstract and Introduction

Abstract

Episiotomy during vaginal delivery was first recommended in 1920 as a way to protect the pelvic floor from lacerations and protect the fetal head from trauma. It was rapidly adopted as a standard practice and has been widely used since then. However, over the last several decades, there has been a growing body of evidence that episiotomy does not provide these purported benefits and may contribute to more severe perineal lacerations and future pelvic floor dysfunction. In this review, we examine the evidence that led to changing episiotomy practices and the debate that has surrounded episiotomy. By doing so, we can not only evaluate this specific obstetric procedure, but also gain insights into the challenge of changing medical practice as new data emerge.

Introduction

Episiotomy is a surgical incision of the perineum performed to widen the vaginal opening for the delivery of an infant. An episiotomy is cut with scissors or a scalpel as the infant's head is crowning. Two types of episiotomy have been described, median and mediolateral. A median episiotomy is a vertical incision into the midline of the perineum from the posterior fourchette toward the anus. For a mediolateral episiotomy, the incision starts at the hymenal ring and extends downward at an angle of at least 45° from the midline.^[1] In general, median episiotomies are more commonly performed in the USA, while mediolateral episiotomies are more common in other parts of the world. The incision is then typically repaired after delivery of the placenta is completed.

The use of a surgical incision of the perineum during childbirth was first described in 1742.^[2] It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of mediolateral episiotomy for all deliveries in nulliparous women.^[3] DeLee argued, in very stark language, that allowing 'natural' childbirth so frequently resulted in damage to the woman and her child, that intervention was obligatory: "In fact, only a small minority of women escape damage, while 4% of babies are killed and an indeterminable number [are] injured … If you believe a woman after delivery should be as healthy [and] anatomically perfect as before … then you have to agree [that] labor is pathogenic". His rationales for episiotomy included shortening of the second stage, thereby reducing maternal exhaustion and blood loss, preservation of the pelvic floor, prevention of uterine prolapse and reducing the rates of short- and long-term damage to infants. These arguments proved to be very compelling to many obstetricians, and the practices soon became widespread.

In addition to DeLee's persuasiveness and his stature within the medical community, additional social factors may have increased acceptance of the practice. In the first four decades of the 20th Century, birth moved from the home into the hospital, and from lay attendants and midwives to the new specialty of obstetric physicians. This resulted in a rapid 'medicalization' of the birthing process, as physicians sought to study the process of childbirth, and intervene to improve maternal and fetal outcomes. This environment probably contributed to the rapid uptake of new interventions, including episiotomy.

Throughout the rest of the 20th Century, episiotomy was considered the standard of care by many American obstetric care providers. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparas.^[4] In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparas and 16–71% among multiparas.^[5] The purported short-term benefits for the parturient included its ease of repair compared with a spontaneous perineal laceration, improved postpartum pain and reduction in severe (third and fourth degree) lacerations. Additional long-term benefits were believed to accrue from decreasing the time that the perineum is stretched during birth, including prevention of pelvic floor relaxation, pelvic organ prolapse, sexual dysfunction, and urinary and fecal incontinence. The purported benefits to the neonate included prevention of asphyxia, cranial trauma, cerebral hemorrhage and mental retardation, as well as reduction in the incidence of shoulder dystocia.

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