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Routine Episiotomy: To Cut or Not to Cut Hollie S. Moyer Midwives College of Utah August 13, 2012

ROUTINE EPISIOTOMY Routine Episiotomy: To Cut or Not to Cut

Modern maternity care is not as scientific as consumers are led to believe. Many common practices and procedures are merely hypotheses and unproven ideas, and yet care providers somehow have the authority to use them without being questioned. As Lothian (2009) writes in her empowering article for pregnant women, Every pregnant woman needs to know that the standard maternity care is not evidence-based and, therefore, the health-care provider and place of birth will influence the care she receives in powerful ways (p. 49). Routine induction, elective cesarean section, unnecessary use of augmentation, electronic fetal monitoring, and routine episiotomy are merely a handful of the many approaches to birth that are not backed by science. In particular, no evidence supports the practice of routine episiotomy as beneficial to mother and baby. It increases risk of perineal trauma and maternal morbidity and should therefore be abandoned with preference being given to natural birthing positions and processes, with episiotomies restricted solely to situations of fetal distress. Sir Fielding Ould was the first to describe episiotomy in 1742 when he recommended the procedure in labors that were dangerously prolonged due to an extremely tight vaginal opening (Bartscht and DeLancey, 2004). From its first mention, episiotomy was a last resort to be used very rarely and only in emergencies. Nothing is found on use of the procedure in the United States until over a century later when a small mediolateral episiotomy was cut for young eclamptic women with unusually difficult labors (Bartscht and DeLancey). The use of episiotomy changed in the 1920s when J.B. DeLee in the American Journal of Obstetrics and Gynecology touted the procedure as one that preserved the perineal floor and could restore the vaginal canal to near perfect (Bartscht and DeLancey, 2004, para. 3). Underlying DeLees encouragement of episiotomy was his view of labor as a decidedly

ROUTINE EPISIOTOMY pathologic process for which he saw the need to make it as short as possible (para. 4). In the decades after DeLee, episiotomies became routine under the premise, according to Cohain

(2008), that all women needed suturing after first births and that tearing was worse than cutting (p. 24). This claim was unfounded at the time and continues to be to this day. Despite the existence of many thoughtfully reviewed studies, the opinions of various obstetricians have been the main source of influence in common practice involving episiotomy. A systematic review of current practices by Hartmann, Viswanathan, Palmieri, et al. (2005), found that, episiotomy use is heavily driven by local professional norms, experiences in training, and individual practitioner preference rather than variation in the needs of individual women at the time of vaginal birth (p. 2142). Instead of evidence-based, woman-centered practice this is obstetrician-preferred practice. Although the outcomes differ slightly studies overwhelmingly show that episiotomy does not do what it is believed to do, namely reduce the risk of perineal injury, improve perineal healing, prevent birth injury in babies, or reduce sexual pain and incontinence (Lothian, et al., 2007, p. 32). According to Cohain (2008), Episiotomy was found to be associated with more damage than tearing: more third degree extensions, more anal muscle damage, more short and long-term fecal incontinence, more bleeding, more pain, more short-term and long-term sexual discomfort and dissatisfaction. (p. 24) The review by Hartmann, et al. (2005) agrees concluding that none of the studies found routine episiotomy to lessen pain. In fact, restrictive, not routine, use of episiotomy was associated with less perineal pain across all activities assessed in each study (p. 2144). As Cohain points out, The biggest risk factor for perineal damage on subsequent births is a previous episiotomy (p.


24). Let us state the obvious: an episiotomy is an intentional injury to the perineum and therefore increases the likelihood of further perineal injury. Ironically, supporters of routine use of episiotomy argue that it decreases the likelihood of third and fourth degree tears. Evidence shows the opposite to be true. The Cochrane review by Carroli and Belizan (2004), as well as the review by Hartmann, et al. (2005) reported more thirdand fourth- degree lacerations where episiotomy was used liberally or routinely. A randomized study done in the 1980s found that routine episiotomy increased the risk of anal sphincter and rectal injuries and made it impossible for a woman to give birth with little to no perineal damage (Hartmann, et al., p. 2141). Neither does evidence support the belief that episiotomy protects pelvic floor musculature, reduces the likelihood of incontinence, or improves sexual function. Women who have had episiotomies have long-term reduction of pelvic floor muscle strength and require more time to regain pelvic floor muscle function after birth (Hartmann, et al., 2005). Urinary and fecal incontinence is more influenced by heredity than it is by natural tearing in childbirth. The evidence shows that instead of reducing the risk of incontinence, episiotomy doubles the risk (Hartmann, et al.). This review also found that women with episiotomies may be more likely to delay intercourse after childbirth and, when intercourse resumes, find it more painful (p. 2147). Routine episiotomy is not doing what its advocates have set out to accomplish. Better outcomes may be attained if birth professionals were to trust the natural progression of birth, encourage birth positions that are gentler on the perineum, and greatly restrict the use of episiotomy. Womens bodies were created to give birth. The idea that birth is somehow pathologic or unnatural is absolutely counter-intuitive. Since it is part of the design of the female body to be able to open up and deliver an infant, obstetricians and midwives would do well to trust the

ROUTINE EPISIOTOMY natural progression and the power within a womans body. Lothian, et al., (2007) reminds us,

Unless there is a clear medical reason for an intervention, interfering with the natural process of labor and birth is not likely to be beneficial and actually may be harmful (p. 29). Even the training we have received may lead us in false directions if we are not careful to assess outcomes. Jensen (2005), a midwife, came to this realization: Much of what I was trained to do to prevent episiotomies and lacerations actually caused swelling and underlying trauma to the tissue. When I left that tissue alone to do what it does beststretch for birthmy episiotomy rate dropped to almost zero and my laceration rate dropped [from 33%] to 5%. (p. 49) We must know the limits of our knowledge, the incompleteness of our training, and respect the mystery of birth. Part of respecting and trusting birth requires that we trust the women giving birth. By allowing them to move into whatever position is most comfortable we open ourselves to the possibility of witnessing how innate birth really is. If the birthing woman is unsure of what position to take, as is likely in a culture where lithotomy has been the only option for decades, the birth attendant can suggest various upright positions. Despite the frequent use of the semirecumbent position, evidence has shown this position to be associated with perineal trauma (Soong, et al., 2005, p. 165). Instead of horizontal positions, one should encourage more upright positions or on all-fours. According to Soong, et al., the advantages of these positions include use of gravity to assist maternal effort, more effort, more efficient uterine contractions, and less [aortocaval] compression (p. 165). The only way to prevent episiotomies is to stop doing them altogether. Birth practitioners ought to eagerly adapt such non-invasive approaches as maternal

ROUTINE EPISIOTOMY birth position changes, reserving the use of the scalpel only for situations in which fetal wellbeing is endangered. This paper has shown that episiotomy was established under the false premises that all

women need suturing after vaginal birth and that cutting is less damaging than tearing. Evidence does not support the assumed maternal benefits of routine episiotomy. As Hartman, et al. (2005) found in their analysis of several studies on this topic, Outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision (p. 2141). We conclude that routine episiotomy should be abandoned. Instead, birth practitioners should allow birth to happen naturally without unnecessary intervention, encourage women to take birth positions that evidence has shown reduce the risk of lacerations, and restrict the use of episiotomy except in cases where it is necessary to ensure fetal well-being. With these measures we hope to see better outcomes for mothers and babies.

ROUTINE EPISIOTOMY References Bartscht, K. D., and DeLancey, J. O.L. (2004). Episiotomy. In J. Sciarra (Ed.), Gynecology and Obstetrics (Volume 2, Chapter 69). Retrieved from Carroli, G., and J. Belizan. (2004). Episiotomy for vaginal birth. In the Cochrane Library. Issue 2. (Eds) John Wiley and Sons Ltd, Chichester. Cohain, J. S. (2008, Spring). Episiotomy, hospital birth and cesarean section: Technology gone haywire. Midwifery Today, pp. 24-25.

Hartmann, K., M. Viswanathan, R. Palmieri, G. Gartlehner, J. Thorp, Jr., and K.N. Lohr. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), pp. 2141-2148. Jensen, K. (2005, Autumn). Preventing episiotomies. Midwifery Today, p. 49. Lothian, J. A., D. Amis, and J. Crenshaw. (2007). Care practice #4: No routine interventions. Journal of Perinatal Education, 16(3), pp. 29-34. Lothian, J.A. (2009). Safe, healthy birth: What every pregnant woman needs to know. The Journal of Perinatal Education, 18(3), pp. 48-54. Soong, B., and M. Barnes. (2005). Maternal position at midwife-attended birth and perineal trauma: Is there an association? Birth, 32(3), pp. 164-169.