Changes in Episiotomy Practice: Evidence-based Medicine in Action

Justin R Lappen; Dana R Gossett


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

In This Article

Acceptance & Resistance among Practitioners

There has been a steady decline in overall rates of episiotomy in the USA over the last four decades, and growing consensus in the literature that midline episiotomy was more harmful than beneficial, culminating in the Cochrane reviews and the JAMA article. However, new recommendations for restrictive use of episiotomy have not been universally accepted. A number of studies have shown that increasingly, the most important predictor of whether or not a woman has an episiotomy at delivery is who attends her delivery.

In 2000, Robinson and colleagues reviewed 1576 deliveries at the Brigham and Women's Hospital (MA, USA) between 1994 and 1995.[38] They found that at this major academic institution there were wide differences in episiotomy rates based on the type of provider performing the delivery. Specifically, midwives had the lowest rates at 21%, academic faculty physicians had an intermediate rate of 33% and private physicians had a rate of 56%. No obstetric or demographic characteristics explained this difference in episiotomy practice. The strongest predictor of whether or not a woman underwent episiotomy was the type of provider who attended her delivery. No information was provided about the training of midwives with respect to episiotomy.

In 2004, Howden and colleagues reviewed a much larger number of deliveries at an academic women's hospital over a 5-year period from 1995 to 2000.[39] In all, they reviewed 27,702 deliveries with over 15,000 episiotomies. During the 5-year study period, the overall episiotomy rate declined from 59.7 to 45%. More striking than this, however, was the difference between academic faculty and residents and their private counterparts. Among the academic physicians, the average rate of episiotomy was 17.7%, and among private obstetricians it was 67.1%. After using logistic regression to control for demographic and obstetric characteristics of the two groups of patients, the authors concluded that having a private obstetrician attend a woman's delivery increased her risk of episiotomy more than sevenfold.

In 2006, another study compared private and academic deliveries at Lehigh Valley (USA) during 2001.[40] In approximately 1000 deliveries over a 6-month period, the rates of episiotomy were 6% among patients delivered by the academic/resident service, and 26% among patients delivered by private obstetricians. The authors further stratified physicians by years in practice, and found that doctors in practice more than 15 years had higher rates of episiotomy than those in practice less than 15 years (32 vs 22%, respectively).

All of these studies were conducted within academic medical centers, and the fact that private physicians in practice at these centers were failing to adopt evidence-based delivery practices was concerning. In 2008, Gossett and Dunsmoor addressed the practice patterns of physicians in the community hospital setting.[41] In this review of almost 3000 deliveries from 2004 to 2005, the authors found that the overall rate of episiotomy declined from 21 to 18%. More notable was the wide variation in individual provider episiotomy rates, which ranged from 2 to 43%. In this study, provider characteristics more strongly predicted episiotomy use than patient characteristics. Most predictive was a strong, linear correlation between years in practice and episiotomy rates. Providers in practice 10 years or less had episiotomy rates of approximately 15%, those in practice 11–20 years had rates of approximately 25% and those in practice over 20 years had rates of approximately 35%. Another interesting finding in this study was that women who were delivered by their primary physician, rather than a different physician on night call, were significantly less likely to undergo episiotomy (OR: 0.43). The authors concluded that individual provider characteristics, rather than patient characteristics or clinical scenario, were most important in determining whether or not a woman received an episiotomy.

A few more studies provide interesting insights into decision-making about episiotomy. Webb and Culhane showed a clear temporal pattern of episiotomy and other obstetric interventions.[42] Episiotomies and other interventions to expedite delivery such as operative vaginal delivery were most likely to be performed mid-day, and least likely in the middle of the night. The authors posit that physicians may have multiple demands on their time during the day, and may therefore feel more pressure to accomplish delivery more quickly than they do at night. The same authors also found that episiotomy rates varied widely by hospital (from 20 to 73%), and that rates of severe perineal lacerations correlated with episiotomy rates (from 4 to 13%).[43]

All of these studies concluded that additional education of obstetric providers, perhaps targeting nonacademic physicians, or those in practice longer, might decrease episiotomy use and decrease the complications associated with high episiotomy rates.


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