Episiotomy Declining, Still Above Acceptable Rate in Brazil

Teresa Santos (in collaboration with Ilana Polistchuck, MD)

June 22, 2022

At one time, episiotomy was a routine procedure performed on women during childbirth. These days, however, it is increasingly used on a case-by-case basis. Research conducted in the municipality of Rio Grande, Rio Grande do Sul, Brazil, showed that the region's episiotomy rate decreased from 70.9% in 2007 to 19.4% in 2019.

The study authors were Juraci A. Cesar, MD, PhD, and Raúl A. Mendoza-Sassi, MD, PhD, from the Federal University of Rio Grande, Rio Grande, Rio Grande do Sul, Brazil (FURG), and Luana P. Marmitt, PhD, from the University of Western Santa Catarina (UNOESC). The findings, published in the Revista de Saúde Pública, are indeed positive. However, they also show that in most cases, the procedure had been performed on women at low risk for perineal laceration when, instead, it is a more appropriate option for women at high risk.

Medscape Portuguese Edition spoke with Cesar, the study's lead author. Cesar is a physician and professor at FURG and holds a master's and a doctorate in epidemiology.

A Marked Decline

Focusing on the years 2007, 2010, 2013, 2016, and 2019, the researchers noted that there were 12,914 births recorded in the municipality of Rio Grande. Of this total, 12,645 (98%) were successfully investigated.

The study showed that in the 5 years in question, 51.3% of women who delivered vaginally underwent episiotomy. An analysis of the data by year reveals that, while the episiotomy rate in 2007 was 70.9%, in 2019 it was 19.4% — a marked drop. That said, it is important to keep in mind that, according to the World Health Organization (WHO), the maximum acceptable rate is 10%.

According to Cesar, that drop was not connected to any one specific intervention. Instead, it probably resulted from a series of measures that had been implemented, as well as some fortunate events that occurred over a short period of time. Examples include the need to obtain the mother's written consent to carry out the procedure; the requirement to have a companion present; improvements in the region's hospital infrastructure — especially at FURG University Hospital, which is where most of the municipality's births take place; greater participation by the nursing team in terms of giving more support to the pregnant woman from her arrival at the hospital through the birth of her child; and the temporary closure of the delivery rooms and maternity ward at Santa Casa de Misericórdia Hospital in Rio Grande, where the episiotomy rate was about two times higher.

The researchers also identified the following factors significantly associated with episiotomy:

  • Younger age

  • Higher schooling

  • High household income

  • Primiparous

  • Attended by a private doctor during delivery

  • Oxytocin use

  • Forceps

  • Had a baby with a birth weight of at least 4000 g in this pregnancy

Do No Harm

In Cesar's opinion, episiotomy is meant to be used when the mother has a higher risk for perineal laceration. However, the study findings indicate that, in practice, the opposite has been happening. "There's a long road ahead in terms of switching that around so that the procedure will be carried out when indicated. And this is something that mothers and healthcare professionals are going to have to work on together," he said.

He believes that the unnecessary, excessive use of episiotomy does the patient more harm than good. "The basic principle of medical care is to do no harm — to not injure or cause harm to the patient," Cesar emphasized, explaining that, even if episiotomy is mostly being done on patients at lower risk, the fact remains that there's no justification for doing so and that, in most cases, the procedure is unnecessary. "This is why episiotomy must be discontinued as a routine practice, and a parsimonious practice implemented. Hence," he concluded, "the need to better train physicians and to provide guidance to mothers so that they'll be aware of the possible complications and side effects of the procedure."

This article was translated from the Medscape Portuguese edition.

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