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

Expert Commentary

There is little doubt that the use of midline episiotomy for vaginal delivery does not provide any significant benefit to the parturient, either in the immediate postpartum recovery period or in longer follow-up. Theoretical improvements in postpartum pain and healing have not been shown to occur, and, in fact, women who undergo episiotomy report more pain than women with spontaneous lacerations. Furthermore, there is no evidence that midline episiotomy prevents either urinary or fecal incontinence or pelvic organ prolapse. In contrast, midline episiotomy significantly increases the risk of third and fourth degree perineal lacerations and increases the risk of anal incontinence from the immediate postpartum recovery until at least 5 years after delivery. Finally, no benefit to the neonate has ever been demonstrated with the use of routine episiotomy.

At present, there are inadequate data to properly evaluate the safety and efficacy of mediolateral episiotomy to decrease severe perineal lacerations. The existing data are conflicting and based on retrospective studies or small prospective studies. Large-scale, prospective randomized trials are needed to determine if mediolateral episiotomy can reduce the risk of third and fourth degree lacerations in both spontaneous deliveries and operative vaginal deliveries.

The wide variations in episiotomy practice by provider type, hospital type and even time of day are among the most concerning findings. The fact that decisions about obstetric intervention are based more on characteristics of the accoucheur than the patient or the clinical situation is unacceptable. Multiple studies show an urgent need for targeted education of obstetric providers, particularly those outside of academia and those who have been in practice longer. However, education alone may be inadequate, as some providers may feel that their personal judgment carries more weight than data from the medical literature. In order to improve compliance with current guidelines, providers may need additional incentives to change their practice behaviors. One method would be to give obstetric providers feedback about their own episiotomy rates as well as comparative data. Some hospitals are already beginning to track these data for their own physicians.

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