Gruesome birthing practice of no routine use

Routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother, according to a review of scientific evidence sponsored by HHS’ Agency for Healthcare Research and Quality (AHRQ). Episiotomy is the surgical cutting of the perineum—the skin between the vaginal opening and the anus—and is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. The findings are published in this week’s issue of the Journal of the American Medical Association.

The review, conducted by AHRQ’s Evidence-based Practice Center at RTI-International-University of North Carolina at Chapel Hill and Raleigh, found that routine episiotomy, common in many practice settings, did not achieve any of the goals it is commonly believed to achieve. When providers restricted their use of episiotomy, women were more likely to give birth without perineal damage, less likely to need suturing, and more likely to resume intercourse earlier.

Women who experienced spontaneous tears without episiotomy had less pain than women with episiotomies. Complications related to the healing of the perineum were the same with or without episiotomy.

In addition, the evidence showed that episiotomy did not protect women against urinary or fecal incontinence, pelvic organ prolapse or difficulties with sexual function in the first three months to five years following delivery. No research described the long-term impact of episiotomy later in adult life when incontinence is most likely to occur.

“The routine use of episiotomy has been standard for years, with apparently limited research to support it,” said Carolyn M. Clancy, M.D., director of AHRQ. “This evidence could help many women with uncomplicated births avoid a procedure that is of no benefit to them.”

The evidence report concludes that any possible benefits of the procedure do not outweigh the fact that many women would have had less injury without the surgical incision. The scope of the review did not include neonatal outcomes, and therefore the report cannot comment on possible benefits of episiotomy for the babies.

Researchers also studied the evidence for suture materials and techniques of repairing the perineum following episiotomy or tear. Some evidence suggested that a two-stage repair, which closes the underlying layers of tissue but leaves the perineal skin unsutured, is more beneficial than the traditional three-stage method, which sutures the perineal skin. In addition, the continuous, subcuticular method of suturing may be superior to the interrupted, transcutaneous method. Finally, polyglycolic acid sutures may have an advantage over chromic catgut with regard to perineal pain and healing.

Evidence was either inconsistent or did not support the use of other materials such as rapidly absorbed sutures, treated chromic catgut, and silk sutures. Further research, including rigorous clinical trials that compare complete approaches to repair, is needed to determine the impact of alternative materials such as tissue adhesive and to resolve the inconsistencies in the current literature.

The topic was nominated by the American College of Obstetricians and Gynecologists, which intends to translate the findings into clinical practice guidelines for OB/GYNs. The executive summary of the report, entitled Use of Episiotomy in Obstetrical Care: A Systematic Review, is available on the Web at www.ahrq.gov/clinic/epcsums/epissum.htm.

The full report is available at www.ahrq.gov/downloads/pub/evidence/pdf/episiotomy/episob.pdf (PDF file, 3.5 MB). Printed copies also will be available by calling AHRQ’s Publications Clearinghouse at 1-800-358-9295.


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