Examining the Evidence
Q Is routine episiotomy justified?
<huc>A</huc> The answer is a resounding “No.” Episiotomy can worsen outcomes when women who would have had no incision are subjected to the procedure.
Consider this observation, now more than 100 years old:
Episiotomy… is practiced in the belief that the vulvar opening, if sufficiently enlarged by the incisions, will not tear farther, or that in any case the laceration will occur in the continuation of the incisions, whose clean-cut edges will heal more readily than the irregular spontaneous tears. Personally, I see no advantage in the procedure, as my experience is that ordinary perineal tears will heal almost uniformly if properly sutured and cared for.
—J. Whitridge Williams1
Since that opinion was published, many would claim, medicine has evolved from an anecdotal discipline to a more evidence-based science. Ironically, it has taken a systematic, evidence-based review of articles from a 54-year period to determine what Williams discerned anecdotally at the turn of the 20th century.
Details of the study
Hartmann et al reviewed 26 trials from 1950 to 2004, each of which included at least 40 participants. For short-term maternal outcomes, they restricted their review to randomized clinical trials. When long-term outcomes were assessed, they included nonrandomized trials and prospective cohorts.
Short-term outcomes included third- and fourth-degree lacerations, pain, wound healing, and blood loss. Long-term outcomes included incontinence, pelvic floor defects, and sexual function.
The findings: Immediate maternal outcomes were not improved with routine episiotomy. Though we lack long-term follow-up into the age range most likely to have pelvic floor sequelae, episiotomy does not appear to prevent fecal and urinary incontinence or pelvic floor relaxation, or to preserve sexual function.
A resounding chorus
These findings exactly mirror those of a Cochrane review by Carroli and Belizan.2 Both reviews make it clear that routine episiotomy is outdated.
While some uses for episiotomy remain—such as hastening delivery in the setting of a nonreassuring fetal tracing or shoulder dystocia—the procedure of incising the perineum prior to delivery of the baby’s head should be limited to indicated instances only and should never be performed routinely.