Changes in Episiotomy Practice: Evidence-based Medicine in Action

Justin R Lappen; Dana R Gossett

Disclosures

Expert Rev of Obstet Gynecol. 2010;5(3):301-309. 

In This Article

Episiotomy & Long-term Clinical Outcomes

At the same time that the evidence was building regarding episiotomy as a cause of severe perineal lacerations, there existed separate lines of investigation into the sequelae of these lacerations as well as other long-term outcomes related to episiotomy.

Various studies have evaluated the impact of severe obstetric lacerations on the subsequent development of rectal incontinence. Several studies have demonstrated increased rectal incontinence during the first postpartum year in women with severe obstetric lacerations.[18–20] However, recently published studies provide additional evidence for long-term consequences of severe lacerations in regard to rectal incontinence. Fritel et al. published survey results from a randomized trial comparing 'routine' versus 'restrictive' episiotomy and noted more frequent incontinence of flatus at 4 years postpartum in the 'routine' group.[21] A study from the Netherlands in 2007 reported a 15- and 25-year follow-up on a small cohort of women with anal sphincter disruption during vaginal delivery. Of women with severe obstetric lacerations, 15% reported bowel incontinence compared with less than 1% of controls.[22] Sorensen followed women for 5–10 years after delivery, and found that women with a fourth degree laceration were significantly more likely to have persistent incontinence of flatus and loose stools.[23] Examination of these women revealed markedly lower sphincter pressures with squeeze. In 1998, Poen and colleagues found that even after 'successful' repair of a third degree laceration, approximately 40% of women had anal incontinence after 5 years.[24]

In addition to the sequelae related to severe obstetric laceration, various studies have evaluated other consequences of episiotomy, including dyspareunia and sexual dysfunction, urinary incontinence and pelvic floor relaxation or prolapse. The largest study with long-term clinical outcome data is the West Berkshire Perineal Management Trial published by Sleep and Grant in 1987.[25] This trial randomized 1000 women to restricted versus liberal episiotomy during spontaneous vaginal delivery at a single center. Follow-up data were collected by survey at 3 years postpartum and the responses of 674 women were available for analysis. No statistically significant difference in the rate of dyspareunia or urinary incontinence was noted. Rockner and colleagues conducted the only other study with long-term outcomes data and reported no difference in the risk of urinary incontinence between women with and without episiotomy at 4 years postpartum.[26]

Several other studies provide intermediate-term clinical outcome data (between 3 and 12 months postpartum) regarding the impact of episiotomy on the development of dyspareunia, urinary incontinence or pelvic floor dysfunction. In a large prospective study, Klein et al. found that both immediately after delivery and at 3 months postpartum, women with median episiotomies reported more perineal pain than those with either an intact perineum or a spontaneous laceration.[27] Sexual function was better among women with intact perineums or spontaneous tears, and worse among women with episiotomies or severe (third or fourth degree) lacerations. The Argentine trial noted increased pain in the 'routine' episiotomy group and a large prospective trial study by Sartore et al. reported increased perineal pain and dyspareunia in patients with mediolateral episiotomy.[15,28] Various other small studies have made similar observations.[29,30]

The aforementioned study by Klein also evaluated urinary symptoms and pelvic muscle relaxation and noted no difference in urinary incontinence or prolapse between women with and without median episiotomy. However, electromyographic examination of the pelvic floor musculature demonstrated that women with either median episiotomy or severe perineal laceration had less recovery of muscle strength after delivery compared with women with intact perineums or first or second degree spontaneous lacerations. Sartore et al. conducted a prospective trial of 519 primaparous patients 3 months after term singleton spontaneous vaginal delivery.[28] Exclusion criteria included third and fourth degree perineal lacerations, pre-existing urinary or anal incontinence, or history of vaginal or anal surgery. Women with mediolateral episiotomy were compared with women with an intact perineum or spontaneous first or second degree perineal laceration. Rates of urinary incontinence and prolapse were similar in both groups; however, mediolateral episiotomy was associated with lower pelvic muscle floor strength both by digital exam and vaginal manometry.

Conversely, a recent commentary by DeLancey highlights a possible protective effect of mediolateral episiotomy on the risk of subsequent pelvic floor dysfunction.[31] In 2006, Kearney et al. published a case–control study of magnetic resonance images of the levator ani muscles in continent nulliparous women compared with women reporting de novo stress urinary incontinence that was persistent beyond 6 months postpartum and reproducible on physical examination. This study demonstrated that levator ani injury during vaginal delivery was associated with the subsequent development of stress urinary incontinence and pelvic floor dysfunction.[32] In the conclusion of this study, the authors reference two large cohort studies from the 1940s to 1950s that provide evidence of a significant decrease in the risk of levator ani damage and need for prolapse surgery with appropriately timed mediolateral episiotomy.[20,33] They conclude that mediolateral episiotomy may serve as a preventative strategy to decrease the risk of pelvic floor dysfunction by protecting against levator ani disruption at the time of delivery.

Therefore, uncertainty still exists regarding the long-term clinical outcomes and sequelae of episiotomy. Unfortunately, most studies report short- or intermediate-term outcomes and do not provide data beyond the first postpartum year. In fact, in a 2005 systematic review of episiotomy published in the Journal of the American Medical Association (JAMA), only two of the studies analyzed provide data beyond 1 year postpartum, leading the authors to conclude that "the overall level of evidence on long-term sequelae … is fair to poor".[34]

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