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

Costs & Consensus

Only one study has looked at the costs associated with episiotomy practice.[35] This study examined the implications for cost of care in Argentina if a restrictive episiotomy policy was universally adopted. Using a decision-tree model, the authors concluded that in each of two Argentinean provinces, there was a potential cost reduction of US$11–20 per low-risk delivery if restrictive, rather than routine episiotomy, was adopted.

Given the large number of publications examining the risks and benefits of episiotomy, a Cochrane review was performed of the existing literature, first in 1999, and revised in 2004 and 2009.[36] The authors found that the majority of studies were of such poor quality that they could not be included. However, their review concluded that episiotomy did not decrease rates of urinary incontinence, pain or sexual dysfunction and increased the rates of perineal laceration, suture placement and perineal repair and wound complications. They found no benefits of episiotomy to the neonate. They also found that of the three studies that examined midline versus mediolateral episiotomy, none were of high enough quality to be included in their review, and no conclusions could be drawn about episiotomy type.

An additional review was published in JAMA in 2005.[34] By this time, in response to the growing concerns about the risks and complications of episiotomy, the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries. The JAMA review included a larger number of studies in their analysis than the Cochrane reviews, but came to identical conclusions. With regard to short-term outcomes, they concluded that episiotomy resulted in more pain, more need for pain medication and more severe lacerations than no episiotomy. With regard to long-term outcomes, they found the evidence was of poor quality, but that there was no improvement in urinary or fecal incontinence, no improvement in prolapse or sexual function, and greater dyspareunia with episiotomy. The authors concluded: "in the absence of benefit and with a potential for harm, a procedure should be abandoned. The majority of the data we have reviewed have been available for decades and thoughtfully reviewed by others. As in many discretionary procedures, practice patterns have been slow to change. However, in this instance, clinicians have been the primary agents to exercise choice to conduct or not conduct an episiotomy, rather than patients…evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had a lesser injury instead had a surgical incision".

With the publication of the JAMA and Cochrane meta-analyses, various professional bodies including the American College of Obstetricians and Gynecologists (ACOG; Washington DC, USA), the Royal College of Obstetricians and Gynaecologists (RCOG; London, UK), and the NICE (London, UK) have published consensus guidelines addressing episiotomy in current clinical practice. In 2006, ACOG published a Practice Bulletin concluding that median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than mediolateral episiotomy, and they recommended the restricted use of episiotomy in clinical practice (Level A evidence). They also concluded that routine episiotomy does not prevent pelvic floor damage leading to incontinence and that mediolateral episiotomy may be preferable to midline episiotomy when clinically indicated (Level B evidence).[30] NICE and RCOG published similar guidelines in 2007 recommending against routine episiotomy and advocating mediolateral episiotomy in clinically indicated cases. The NICE and RCOG guidelines also outline the recommended technique for performing a mediolateral episiotomy.[37]

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