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

Five-year View

The risks of midline episiotomy seem clear. Studies of mediolateral episiotomy and its implications for severe perineal lacerations as well as long-term outcomes including dyspareunia, pelvic floor relaxation and prolapse are still needed. Any such investigation must include rigorous postpartum evaluations of the incisions to verify that they truly meet the definition of a 'mediolateral' incision. We anticipate that over the next 5 years, we will find a continued decline in episiotomy rates in the USA. Severe perineal lacerations are already tracked at the hospital level, and episiotomy rates are an obvious choice for third parties to track as a quality measure. These data may become publicly available (as hospital-wide laceration rates already are), and this increased scrutiny may provide an external incentive to providers to reduce unnecessary episiotomies.

The successful translation of evidence into clinical practice represents the most significant challenge for the coming 5 years. Interventions to aid the implementation of evidence-based guidelines may involve the utilization of simulation or quality improvement curricula to modify physician behavior. A growing body of evidence supports the impact of patient safety initiatives such as simulation or team training on the optimization of outcomes in obstetric emergencies such as shoulder dystocia or postpartum hemorrhage.[60,61] Many hospitals have implemented mandatory training programs which have reduced morbidity from these common obstetric events. Conceivably, this model could be applied to episiotomy. In addition, numerous studies, including a recent JAMA systematic review, have evaluated the impact of quality improvement curricula on provider knowledge and clinical outcomes.[62] While data provide varied results, models exist where curricula translate into improved clinical outcomes. Importantly, a quality improvement curriculum should expand clinicians' knowledge of and adherence to guidelines while providing a skill set for future self-directed implementation of change. Therefore, quality improvement curricula and simulation training may provide a novel means to not only implement evidence-based guidelines and improve patient care, but also provide a skill set that obstetricians could utilize to make similar practice modifications in the future.

With current evidence as our guide, the exhortation of Eason almost 20 years ago about attending a vaginal delivery still rings true: "don't just do something, sit there!".[63]


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