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Episiotomy: Ritual Genital Mutilation in Western Obstetrics
The practice of routinely cutting the perineum during hospital
deliveries in the United States, episiotomy, has been shown to be
the principal risk factor for severe tearing during delivery,
which is the injury that it is supposed to prevent. Nonetheless
American obstetricians continue to overuse this procedure ten
times more often than is called for. Episiotomy is also a major
risk factor for infection, loss of sexual pleasure, and
incontinence. Women who have been subjected to episiotomies take
longer to heal from delivery, even compared to women who have
Given the completely unscientific, ritual approach
obstetricians have to this practice, it illuminates the Western
outrage over ritual genital mutilation of girls and women in East
Africa, which also has many painful and disabling sequelae. Just
as we reach out in solidarity with African feminists to stop
genital mutilation in Africa, we need to stop the iatrogenic, unscientific practice of episiotomy in American obstetrics.
Outcomes of Routine Episiotomy A
Katherine Hartmann, MD, PhD; Meera Viswanathan, PhD;
Rachel Palmieri, BS; Gerald Gartlehner, MD, MPH;
John Thorp, Jr, MD; Kathleen N. Lohr, PhD
Evidence Synthesis Fair to good evidence from clinical
trials suggests that immediate maternal outcomes of routine
episiotomy, including severity of perineal laceration, pain,
and pain medication use, are not better than those with
restrictive use. Evidence is insufficient to provide
guidance on choice of midline vs mediolateral episiotomy.
Evidence regarding long-term sequelae is fair to poor.
Incontinence and pelvic floor outcomes have not been
followed up into the age range in which women are most
likely to have sequelae. With this caveat, relevant
studies are consistent in demonstrating no benefit from episiotomy
for prevention of fecal and urinary incontinence or pelvic
floor relaxation. Likewise, no evidence suggests that
episiotomy reduces impaired sexual function—pain with
intercourse was more common among women with episiotomy.
Conclusions Evidence does not support maternal benefits
traditionally ascribed to routine episiotomy. In fact,
outcomes with episiotomy can be considered worse since
some proportion of women who would have had lesser injury
instead had a surgical incision.
Procedure On Women In Labor Adds Risk
Study Urges Halt To Episiotomies
By Rob Stein
Washington Post Staff Writer
Wednesday, May 4, 2005; A01
One of the most common surgical procedures performed in the United
States -- an incision many pregnant women receive to reduce the risk of
tissue tears during delivery -- has no benefits and actually causes more
complications, according to the most comprehensive analysis to evaluate
Contradicting the long-accepted rationale for the procedure, called
an episiotomy, the analysis found that it increases the risk of tissue
tears, leading to more pain, more stitches and a longer recovery after
childbirth. In addition, an episiotomy increases the risk of sexual
difficulties later and does not reduce the risk of incontinence, the
federally sponsored study found.
As a result, the researchers concluded, routine use of the procedure
undergone by more than 1 million U.S. women each year should be
discontinued, and the incision should be considered only to speed
delivery when the health of the baby is at risk.
"The evidence is clear: Routine use of episiotomy is not supported by
research and should stop," said Katherine E. Hartmann, director of the
Center for Women's Health Research at the University of North Carolina
at Chapel Hill, who led the analysis published in today's issue of the
Journal of the American Medical Association. "Women need to know this
information so they can talk with their care providers before they are
Other experts agreed, saying the procedure is an example of a broader
problem in medicine: Many practices that became common before their
effectiveness was tested have become ingrained by tradition and continue
to be practiced well after their usefulness has been questioned by
"Routine episiotomy clearly is not necessary," said Laura Riley,
director of labor and delivery at Massachusetts General Hospital in
Boston who chairs the obstetrics practice committee for the American
College of Obstetricians and Gynecologists. "This is a message that's
been out there that's clearly taken a long time to get universally
accepted and universally implemented."
The new analysis was conducted for the Agency for Healthcare Research
and Quality, a federal agency that conducts influential evaluations of
medical procedures, at the request of the college amid growing
frustration that the procedure was still being done routinely despite
strong evidence questioning its usefulness, Hartmann said.
"There was a sense that without attention being focused on this, we
might be stuck with these very high rates for a very long time," she
An episiotomy is an incision that doctors make in the perineum -- the
skin between the opening of the vagina and anus. The idea is that the
incision will make delivery of a child easier and that a deliberate
surgical incision will heal more quickly and with fewer complications
than tears that occur spontaneously, minimizing the risk of sexual
problems and other complications, such as incontinence. Because the
procedure has been in widespread use since the 1930s, it has been
subject to careful evaluation only fairly recently.
The number of episiotomies began to decrease in the United States in
the 1980s when studies started raising questions about their value. But
the procedure is still estimated to be performed in about one-third of
all vaginal births -- more than 1 million of the estimated 4.2 million
vaginal births that occur each year, making it more common than
hysterectomies and Caesarean section deliveries. The rate varies widely
around the country, but overall about 70 to 80 percent of first-time
mothers undergo episiotomies.
For the study, Hartmann and colleagues scoured the medical literature
for all studies on the subject between 1950 and 2004, finding 986. The
researchers then identified 45 studies that provided the best data,
including 26 that provided the most useful information on benefits and
risks, and pooled that information for the new analysis.
Based on that data, the researchers found that women who had not
undergone the procedure were no more likely to experience spontaneous
tears during childbirth than those who had. In fact, those who underwent
the procedure appeared somewhat more prone to tears, the researchers
"If you have a piece of fabric, it doesn't tear well until you get it
started. The episiotomy can have that effect of actually being the
starting place for a tear," Hartmann said.
As a result, women who have had episiotomies tend to need more
stitches and experience more pain after childbirth, the researchers
found. Women who underwent episiotomies had a 26 percent higher risk of
Moreover, women who had episiotomies were no less likely to
experience urinary or fecal incontinence in the three months to five
years after delivery, the study found. Rather, women with episiotomies
were twice as likely to suffer fecal incontinence in the first three
Those with episiotomies were also 53 percent more likely to suffer
pain during intercourse three months after delivery.
"There's a lot of unnecessary suffering occurring to women because of
the use of episiotomies," said Carol Sakala of the Maternity Center
Association, a private, nonprofit group based in New York. "It's really
Sakala noted that the rate of Caesarean section deliveries has been
increasing in the United States, in part because of women's fears of
complications from vaginal deliveries. Unnecessary episiotomies may be a
key contributing factor to those complications, she said.
"We need to send a very clear message to women and their providers,"
Sakala said. "The evidence clearly says that performing routine
episiotomies offers none of the benefits that have been presumed in the
past and in many cases offer severe harm."
Episiotomy Use in
the United States, 1979–1997
Anne M. Weber, Leslie Meyn
Obstetrics and Gynecology 2002;100:1177-1182.
Although the episiotomy rate declined from 1979 to 1997, the rate in
1997 of 39 per 100 vaginal deliveries is higher than scientific
Surgical Cut in Childbirth Still Too Common-Report
By Jacqueline Stenson
NEW YORK (Reuters Health) - The number of women in childbirth who
receive episiotomies--incisions to widen the birth canal--is declining
but still too high, researchers say. Nationwide figures estimate
that episiotomies were performed in 39% of vaginal deliveries in 1997,
down from 65% in 1979.
"I expected the number to decrease, but I was hoping to see it
decrease even more," said study author Dr. Anne Weber, an associate
professor of obstetrics and gynecology at the University of Pittsburgh
School of Medicine.
There is no consensus on what the ideal episiotomy rate should be,
but current evidence indicates that "rates higher than 20% couldn't
be justified," Weber told Reuters Health.
And some studies have found that even lower rates--of 10% or
less--resulted in good outcomes for both mothers and babies, she noted
in the study, published in the December issue of Obstetrics and
So why are so many episiotomies still performed? "People who
were trained in an era when routine episiotomy was standard have not
changed their practices," Weber said.
About two decades ago some doctors began questioning whether every
woman having a vaginal delivery needed an episiotomy, but the practice
really came under fire in the last decade, she noted.
"Routine episiotomy does not offer advantages to the patient and
actually offers disadvantages," she said. The most severe are anal
sphincter lacerations that can result in long-term fecal incontinence
and the inability to control gas in as many as half of patients who
experience these lacerations.
When a doctor makes the incision, that cut may continue tearing on
its own and rip into anal tissue, Weber explained. Such severe,
difficult-to-fix damage is much less likely when the vaginal opening
tears naturally, she said.
In the study, anal sphincter lacerations occurred in 1 in 12 women
who received episiotomies compared with 1 in 26 who did not. Weber said
most doctors would probably agree that an episiotomy is warranted when
the baby is stuck in the birth canal and at risk for respiratory
distress because the head has been delivered but the chest has not. But
beyond that, there are a lot of gray areas. For instance, many doctors
still do episiotomies when they use forceps or vacuum devices to help
deliver babies, but episiotomies for this purpose are declining and
physicians do not agree on whether the practice is beneficial, she said.
The new study results were derived from the National Hospital
Discharge Survey, a federal database of a sampling of US
hospitals. Findings also showed that younger women, white women
and those with private insurance were among the groups most likely to
While there are no national episiotomy figures beyond 1997, the rate
has probably continued to decline, Weber said, noting that some regional
studies show a more recent, persistent downward trend.
Alternative Birth Methods on Traditional Birth Management.
Eberhard J, Geissbuhler V. Fetal Diagn Ther 2000
Because of popular demand for more natural childbirth, a new concept was
introduced in 1991 in our clinic. It consisted of careful monitoring and
birth management, restrictive use of invasive methods, and free choice of
different birth methods including waterbirths and other alternative birth
methods. ....The episiotomy rate has dropped from a previous rate higher
than 80% to a rate lower than 15%.
choice? The impact of private health insurance on episiotomy rates in
Australian hospitals. Shorten A, Shorten B. Midwifery
Objective: to assess the extent to which variations in episiotomy rates in
Australian hospitals are justified by clinical variables and to further
explore the relationships between episiotomy, insurance status, perineal
trauma and outcomes for babies....Results: after controlling for clinical
and other factors privately insured women were estimated to be up to twice
as likely to experience episiotomy as publicly insured women. This
difference most plausibly reflects differences in labour management styles
between obstetricians and midwives.
risk factors for stress urinary incontinence: a population-based study(1).
Persson J, Wolner-Hanssen P, Rydhstroem H. Obstet Gynecol
2000 Aug 23;96(3):440-445.
We linked three national, Swedish, population-based registries with the use
of unique personal identification numbers.... All women born between 1932
and 1977 and operated on for stress urinary incontinence between 1987 and
1996 were identified from the Hospital Discharge Registry. Diabetes
mellitus, body mass index (BMI), age at first delivery, parity, birth
weight, and epidural analgesia were positively associated with incontinence
surgery. In contrast, cesarean delivery, forceps/vacuum extraction, and episiotomy
were negatively associated with incontinence surgery.
of episiotomy use at first spontaneous vaginal delivery. Robinson
JN, Norwitz ER, Cohen AP, Lieberman E. Obstet Gynecol 2000
We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries
in nulliparas at Brigham & Women's Hospital between December 1, 1994 and
July 31, 1995....The overall rate of episiotomy was 40.6% (640 of 1576).
Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%)
and private providers (55.6%) (P =. 001). After controlling for confounding
factors with logistic regression, private practice provider was the
strongest predictor of episiotomy use (OR, 4.1; 95% CI, 3.1, 5.4) followed
by faculty provider (OR, 1.7; 95% CI, 1.1, 2.5), prolonged second stage of
labor (OR, 1.8; 95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6; 95% CI, 1.1,
2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8).
perineal lacerations during vaginal delivery: the University of Miami
experience. Angioli R, Gomez-Marin O, Cantuaria G,
O'sullivan MJ. Am J Obstet Gynecol 2000 May;182(5):1083-5.
For 50,210 women in the seven year study, episiotomy and the type of
episiotomy as well as birth weight, assisted vaginal delivery, and older
maternal age were identified as independent risk factors associated with
third- and fourth-degree perineal lacerations... Older patients who are
being delivered of a first child are at higher risk for severe laceration.
Midline episiotomy and assisted vaginal delivery should therefore be avoided
in this population whenever possible, especially in the presence of a large
episiotomy rates: impact on perineal outcomes.
Low LK, Seng JS, Murtland TL, Oakley D. J Midwifery Womens Health
Recent, large, randomized, controlled trials of the effects of episiotomy on
perineal damage have confirmed that episiotomy is associated with an
increased risk of damage to the perineum. Yet episiotomy remains the most
common surgical procedure women undergo... Multivariate findings indicate
that in the absence of episiotomy, rates of perineal integrity were highest
among clinicians who usually had the lowest rate of episiotomy use. When an
episiotomy was done, rates of third- and fourth-degree extensions were
highest among clinicians who used episiotomy most frequently. This finding
challenges the idea that clinicians who were very experienced with the use
of episiotomy would avoid complications such as extensions.
for vaginal birth. Carroli G, Belizan J.
Cochrane Database Syst Rev 2000;(2):CD000081.
Compared six studies comparing restrictive use of episiotomy with routine
use of episiotomy; restrictive use of mediolateral episiotomy versus routine
mediolateral episiotomy; restrictive use of midline episiotomy versus
routine midline episiotomy; and use of midline episiotomy versus
mediolateral episiotomy. Compared with routine use, restrictive episiotomy
involved less posterior perineal trauma, less suturing and fewer healing
complications. Restrictive episiotomy was associated with more anterior
perineal trauma. There was no difference in severe vaginal or perineal
trauma; dyspareunia; urinary incontinence or several pain measures.
Restrictive episiotomy policies appear to have a number of benefits compared
to routine episiotomy policies. There is less posterior perineal trauma,
less suturing and fewer complications, no difference for most pain measures
and severe vaginal or perineal trauma, but there was an increased risk of
anterior perineal trauma with restrictive episiotomy.
of caregivers for care during pregnancy and childbirth. Hodnett
ED. Cochrane Database Syst Rev 2000;(2):CD000062.
Compared to usual care, women who had continuity of care from a team of
midwives were less likely to be admitted to hospital antenatally and more
likely to attend antenatal education programs. They were also less likely to
have drugs for pain relief during labour and their newborns were less
likely to require resuscitation. No differences were detected in Apgar
scores, low birthweight and stillbirths or neonatal deaths. While they were
less likely to have an episiotomy, women receiving continuity of care were
more likely to have either a vaginal or perineal tear. They were more likely
to be pleased with their antenatal, intrapartum and postnatal care.
out routine episiotomies, Canadian researchers say," Medical
Post, 36(26), July 18, 2000.
Episiotomy: Challenging Obstetric Interventions
by Ian D. Graham
Carroli G, Belizan J, Stamp G. Episiotomy
for vaginal birth (Cochrane Review).
In: The Cochrane Library, Issue
3, 1999. Oxford: Update Software. A
meta-analysis performed on the studies collected in the
Cochrane Pregnancy and Childbirth Group trials register.
Six studies were included. In the routine episiotomy
group, 72.7% (1752/2409) of women had episiotomies, while
the rate in the restrictive episiotomy group was 27.6%
(673/2441). Compared with routine use, restrictive
episiotomy involved less posterior perineal trauma
(relative risk 0.88, 95% confidence interval 0.84 to
0.92), less suturing (relative risk 0.74, 95% confidence
interval 0.71 to 0.77) and fewer healing complications
(relative risk 0.69, 95% confidence interval 0.56 to
0.85). Restrictive episiotomy was associated with more
anterior perineal trauma (relative risk 1.79, 95% 1.55 to
2.07). There was no difference in severe vaginal or
perineal trauma (relative risk 1.11, 95% confidence
interval 0.83 to 1.50); dyspareunia (relative risk 1.02,
95% confidence interval 0.90 to 1.16); urinary
incontinence (relative risk 0.98, 95% confidence interval
0.79 to 1.20) or several pain measures. Results for
restrictive versus routine mediolateral versus midline
episiotomy were similar to the overall comparison. Reviewers'
conclusions: Restrictive episiotomy policies
appear to have a number of benefits compared to routine
episiotomy policies. There is less posterior perineal
trauma, less suturing and fewer complications, no
difference for most pain measures and severe vaginal or
perineal trauma, but there was an increased risk of
anterior perineal trauma with restrictive episiotomy.
Tragedy of Routine Episiotomy", from
Henci Goer's Obstetric Myths Versus
Research Realities, 1995.
Gentlebirth's Page on Perineal
Protection / Avoiding Tears and Episiotomy
Episiotomies -- Medical
Myth versus Reality, Cheri
Van Hoover, C.N.M.
Woolley RJ. Benefits
and risks of episiotomy: A review of the English-language
literature since 1980. Part I and II.
Obstet Gynecol Survey 1995; 50:806-820. Conclusion:
The English-language literature published since 1980 on
the benefits and risks of episiotomy can be summarized as
follows: Episiotomies prevent anterior perineal
lacerations (which carry minimal morbidity), but fail to
accomplish any of the other maternal or fetal benefits
traditionally ascribed, including prevention of perineal
damage and its sequelae, prevention of pelvic floor
relaxation and its sequelae, and protection of the
newborn from either intracranial hemorrhage or
intrapartum asphyxia. In the process of affording this
one small advantage, the incision substantially increases
maternal blood loss, the average depth of posterior
perineal injury, the risk of anal sphincter damage and
its attendant long-term morbidity (at least for midline
episiotomy), the risk of improper perineal wound healing,
and the amount of pain in the first several postpartum
Renfrew MJ. Hannah W. Albers L. Floyd E. [Mother and
Infant Research Unit, University of Leeds, United
Kingdom. ] Practices that minimize trauma to the genital
tract in childbirth: a systematic review of the
literature. [Review] Birth. 25(3):143-60, 1998 Sep.
BACKGROUND: Trauma to the genital tract commonly occurs
at birth, and can cause short- and long-term morbidity.
Clinical measures to reduce its occurrence have not been
fully identified. METHODS: A systematic review of the
English language literature was conducted to describe the
current state of knowledge on reduction of genital tract
trauma before planning a large randomized controlled
trial of ways to prevent such trauma. Randomized trials
and other published reports were identified from relevant
databases and hand searches. Studies were reviewed and
assessed using a structured format. RESULTS: A total of
77 papers and chapters were identified and placed into 5
categories after critical review: 25 randomized trials, 4
meta-analyses, 4 prospective studies, 36 retrospective
studies, and 8 descriptions of practice from textbooks.
The available evidence is conclusive in favor of
restricted use of episiotomy. The contribution of
maternal characteristics and attitudes to intact perineum
has not been investigated. Several other topics warrant
further study, including maternal position, style of
pushing, and antenatal perineal massage. Strong opinions
and sparse data exist regarding the role of hand
maneuvers by the birth attendant for perineal management
and birth of the baby. This became the topic of the
planned randomized controlled trial, which was completed;
results will be published soon. CONCLUSIONS: The case
for restricting the use of episiotomy is conclusive. Several
other clinical factors warrant investigation, including
the role of hand maneuvers by the birth attendant in
preventing birth trauma. A large randomized controlled
trial will report on this topic.
Wood J. Amos L. Rieger N. [Department of Obstetrics
and Gynaecology, Flinders Medical Centre, Adelaide, South
Australia. ] Third degree anal sphincter tears: risk
factors and outcome. Australian & New Zealand Journal
of Obstetrics & Gynaecology. 38(4):414-7, 1998 Nov.
The aim of this retrospective study was to determine the
incidence, risk factors and anal symptoms related to
third degree tears after vaginal delivery. There were
9,631 vaginal deliveries during the 5-year period
studied, with 116 (1.2%) having a third degree tear.
Statistically significant risk factors for a third degree
tear were primiparity, forceps delivery, episiotomy,
fetal birth-weight greater than 4,000 g and increased
duration of the second stage of labour. Eighty four of
the 116 women were able to be interviewed, and 21 (25%)
had anal symptoms related to the tear. Only 3 women had
sought help for their symptoms. Twelve women experienced
anal incontinence and 2 more required delayed repair of
the anal sphincter for incontinence. Third degree tears
are a major cause of perinatal and postnatal morbidity.
Attention needs to be directed to the prevention of such
tears by awareness of the women at risk and to better
follow-up and counselling of the women sustaining a tear.
Fatton B. Jacquetin B. [Unite d'urogynecologie Centre
hospitalo-universitaire Maternite de l'Hotel-Dieu,
Clermont-Ferrand. ] [Pelvic and perineal sequelae of
delivery]. [Review] [French] Revue du Praticien.
49(2):160-6, 1999 Jan 15. Vaginal delivery especially
with dystocia, may result in relaxation or disruption of
fascial and ligamentous supports of pelvic organs. The
relationship between first childbirth and obstetric
trauma is strong but additional pregnancies and
deliveries are aggravating factors as well as ageing and
hormonal effects of the menopause. These anatomic changes
are contributing to the development of stress urinary
incontinence, anal incontinence and genital prolapse. Preventing
obstetric trauma needs changes in current obstetric
practice: reduction in the episiotomy rate, use of vacuum
extractor in preference to forceps. General
practitioners can help at the time of postnatal control
by making a full clinical evaluation of pelvic floor
damage, referring women for further investigation and
asking them about postnatal sexual difficulties.
Postpartum perineal physiotherapy is indicated for women
at risk: pelvic floor congenital weakness instrumental
delivery, postpartum urinary and/or anal incontinence.
Williams FL. du V. Florey C. Mires GJ. Ogston SA.
[Department of Epidemiology and Public Health, University
of Dundee, Ninewells Hospital and Medical School. ]
Episiotomy and perineal tears in low-risk UK
primigravidae. Journal of Public Health Medicine.
20(4):422-7, 1998 Dec. BACKGROUND: The aim of the
study was to determine the rates and to describe the risk
factors for episiotomy and perineal tears in low-risk
primigravidae. METHOD: A cross-sectional survey of 101
randomly selected NHS hospitals in the UK was carried out
between February 1993 and January 1994. Subjects were 40
consecutive low-risk primigravidae in each hospital. The
main outcome measures were number and reasons for
episiotomy, and number and degree of perineal tears.
RESULTS: A large proportion of women (83 per cent)
experienced some form of perineal trauma. Forty per cent
of the women had an episiotomy only, 6 per cent an
episiotomy and perineal tear, and 37 per cent perineal or
other tears without episiotomy. The main reasons for
performing an episiotomy were foetal distress (27 per
cent), impending tear (25 per cent) and delay of the
second stage of labour (21 per cent). Fifty-nine per cent
of women with a delayed second stage had a spontaneous
vaginal delivery and 41 per cent required instrumental
assistance. The likelihood of having an episiotomy
increased with the duration of the second stage of
labour, irrespective of type of delivery. Episiotomy
rates varied appreciably throughout regions and hospitals
in the United Kingdom, ranging from 26 to 67 per cent.
There was also a large regional variation in the rates of
perineal trauma; generally, high rates of one outcome
were associated with low rates of the other. Compared
with white women, women from the Indian sub-continent
were almost twice as likely and those from the Orient
almost five times as likely to have an episiotomy. CONCLUSIONS:
The magnitude of the geographical variation suggests a
lack of uniformity in indications for performing
episiotomies and that guidelines for performing
episiotomies may need to be reviewed. The rates of
episiotomy in women from the Indian sub-continent and
Orient were very high compared with those for white
women, and this requires clarification and explanation,
as they are contrary to rates experienced in these ethnic
groups in other countries.
Bomfim-Hyppolito S. [Universidade Federal do Ceara,
Fortaleza, Brazil. ] Influence of the position of the
mother at delivery over some maternal and neonatal
outcomes. International Journal of Gynaecology &
Obstetrics. 63 Suppl 1:S67-73, 1998 Dec. OBJECTIVE:
Evaluate possible advantages or disadvantages of the
sitting over the horizontal position during the second
stage of labor. DESIGN AND METHODS: Clinical trial
randomly selecting 127 volunteers for the sitting
position and 121 for the horizontal position during the
second stage of labor. Duration of the second stage and
of expulsion of the placenta, vulvo vaginal and perineal
lacerations, blood lost and Apgar score were evaluated.
RESULTS: There was a non-significant decrease of 3.4 min
in the duration of the second period in the vertical
position in comparison with the horizontal position.
There was a similar difference in the duration of
delivery of the placenta, but also non-significant. Blood
loss was slightly greater among women delivering in
vertical position, but the difference did not reach
significance. Breastfeeding did not show any influence on
blood loss and on the time for delivering the placenta. The
incidence of perineal trauma was 44.1% for vertical
position and 47% for horizontal position in the whole
group and of 47.8% and 71.2% in the group with history of
episiotomy. This last difference was statistically
significant. The results of this study are in the line of
other studies that suggest some advantages and possible
disadvantages of the vertical position. CONCLUSIONS:
Mothers should be given the choice of the posture to be
assumed during parturition. The supine position should
not be imposed and episiotomy should not be a routine.
McCandlish R. Bowler U. van Asten H. Berridge G.
Winter C. Sames L. Garcia J. Renfrew M. Elbourne D.
[National Perinatal Epidemiology Unit, Oxford, UK. ] A
randomised controlled trial of care of the perineum
during second stage of normal labour. British Journal of
Obstetrics & Gynaecology. 105(12):1262-72, 1998 Dec.
OBJECTIVE: To compare the effect of two methods of
perineal management used during spontaneous vaginal
delivery on the prevalence of perineal pain reported at
10 days after birth. DESIGN: Randomised controlled trial.
SETTING: Two English maternity care units. SAMPLE: 5471
women who gave birth between December 1994 and December
1996. METHODS: At the end of the second stage of labour
women were allocated to either the 'hands on' method, in
which the midwife's hands put pressure on the baby's head
and support ('guard') the perineum; lateral flexion is
then used to facilitate delivery of the shoulders, or the
'hands poised' method, in which the midwife keeps her
hands poised, not touching the head or perineum, allowing
spontaneous delivery of the shoulders. MAIN OUTCOME
MEASURE: Perineal pain in the previous 24 hours reported
by women in self-administered questionnaire 10 days after
birth. RESULTS: Questionnaires were completed by 97% of
women at 10 days after birth. 910 (34.1%) women in the
'hands poised' group reported pain in the previous 24
hours compared with 823 (31.1%) in the 'hands on' group
(RR 1.10, 95% CI 1.01 to 1.18: absolute difference 3%,
0.5% to 5%, P = 0.02). The rate of episiotomy was
significantly lower in the 'hands poised' group (RR 0.79,
99% CI 0.65 to 0.96, P = 0.008) but the rate of manual
removal of placenta was significantly higher (RR 1.69,
99% CI 1.02 to 2.78; P = 0.008). There were no other
statistically significant differences detected between
the two methods. CONCLUSION: The reduction in pain
observed in the 'hands on' group was statistically
significant and the difference detected potentially
affects a substantial number of women. These results
provide evidence to enable individual women and health
professionals to decide which perineal management is
Hagymasy L. Gaal J. [Department of Obstetrics and
Gynaecology, Borsod-Abauj-Zemplen County Hospital,
Miskolc, Hungary. ] A comparative study of vertical and
horizontal deliveries in the presence and with the
assistance of the woman's partner.Journal of
Psychosomatic Obstetrics & Gynecology. 19(2):98-103,
1998 Jun. The authors are the first in Hungary to
have applied the method of vertical delivery with the
husband's or partner's presence in the delivery room.
This is part of the authors' family-centered delivery
program at the Maternity Ward of Borsod-Abauj-Zemplen
County Hospital, Miskolc. A comparison of 321 births was
carried out, which included 158 vertical deliveries and
163 horizontal deliveries. During both vertical and
horizontal deliveries, the husband or partner was present
in the delivery room. The comparison included the
mother's biometrics and social characteristics, as well
as the circumstances of the delivery and the clinical
parameters of the newborns. Certain stages of delivery in
the vertical position took a shorter period of time
compared to horizontal delivery, but the differences were
not significant. Episiotomies were carried out in
fewer cases of vertical deliveries, and significant
injuries due to the lack of an episiotomy in the case of
vertical deliveries were not detected. The parameters
characterizing the clinical state of the newborns were
the same in both groups. The answers given to
questionnaires supported the favorable psychological
effects of a vertical delivery. The authors hope that
vertical delivery, as a possible alternative, will find
its place in obstetric practice in Hungary.
Lorenz N. Nougtara A. Garner P. [Support Centre for
International Health, Swiss Tropical Institute, Basel,
Switzerland. ] Episiotomy in Burkina Faso. Tropical
Doctor. 28(2):83-5, 1998 Apr. Episiotomy is a common
obstetric intervention in many countries of the world,
although little is known about rates in African
countries. In recent years, the effectiveness of routine
episiotomy to prevent severe tears and neonatal asphyxia
has been questioned, and evidence shows that the
procedure results in considerable maternal morbidity.
This study estimates episiotomy rates in Burkina Faso. A
high proportion of primigravidae (46%) received an
episiotomy when trained midwives attended the delivery; a
level which indicates the procedure has to be regarded as
routine practice. The episiotomy rate was lower (26%) in
primigravidae delivered by auxillary midwives. This
proportion is closer to recommended selective approaches
derived from good research summaries. The tear
rate in women assisted by midwife and auxiliary staff was
similar, suggesting that women tear even when the
procedure is performed. These results indicate that
obstetricians and midwives in Burkina Faso should
critically appraise whether routine episiotomy should be
abandoned. The introduction of a labour chart is
a good vehicle to introduce a policy on avoiding
Cravchik S. Munoz DM. Bortman M. [Hospital Neuquen,
Servicio de Obstetricia, Argentina. ] [Indications for
episiotomy at public maternity clinics in Nequen,
Argentina]. [Spanish] Pan American Journal of Public
Health. 4(1):26-31, 1998 Jul. Indications for
performing episiotomy during vaginal births are a
controversial topic requiring worldwide review. In
Neuquen Province, Argentina, when standards for low-risk
childbirth were developed in 1995, they included the
provision to limit episiotomies to cases at high risk for
spontaneous laceration. The present retrospective cohort
study was designed for comparing the criteria applied in
1996 as indications for episiotomy in public maternity
services of Neuquen Province, as well as the effect of
parity and other variables on its frequency. The
Perinatal Data System yielded 7,513 medical records for
review, which represented 70% of all the institutional
births during the year. Of these records, 830 dealing
with cesarean sections did not qualify for the study. The
remaining 6,683 records were divided into eight groups
according to hospital location. Episiotomy incidence
rates were estimated for those eight groups and the
Poisson regression was applied in order to adjust for
birthweight, number of siblings, mother's age, and type
of birth presentation and outcome. Taking the Neuquen
Hospital data as baseline because of its higher
complexity and large number of births taking place there,
two hospitals had episiotomy incidence rates equal to 70%
(95% CI: 62%-79%) and 67% (95% CI: 57%-78%) of the
Neuquen Hospital rates. Two other hospitals had incidence
rates which were higher by 28% (95% CI: 13%-45%) and 17%
(95% CI: 2-35%), while the remaining hospitals showed no
significant differences. Stratified regression by number
of previous vaginal births showed parity to be the
strongest influencing variable on indications for
episiotomy. Rates for nulliparous women showed no
differences by hospital, but rates for primiparous women
did, with even stronger differences shown for multiparous
women. The authors concluded that all institutions
included in the study performed episiotomies as a
virtually routine procedure on nulliparous women, that
there are significant differences in their indications
for primiparous women, and that those differences
increase along with parity. These differences seem to
show that maternity clinics in the Province of Neuquen
vary widely in their criteria for episiotomy indications.
Kaczorowski J. Levitt C. Hanvey L. Avard D. Chance G.
[Department of Family Medicine, Facultyy of Health
Sciences, McMaste University, Hamilton, Ont., Canada. ] A
national survey of use of obstetric procedures and
technologies in Canadian hospitals: routine or based on
existing evidence?. Birth. 25(1):11-8, 1998 Mar.
BACKGROUND: The objective of this national survey was to
describe the routine use of procedures and technologies
in Canadian hospitals providing maternity care, and to
determine the extent to which current use was consistent
with the existing evidence and recommended guidelines for
maternal and newborn care. METHODS: Representatives of
572 hospitals providing maternity care across Canada were
sent questionnaires in the spring and summer of 1993; 523
(91.4%) responded. The primary outcome measures consisted
of the self-reported use of obstetric procedures and
technologies (perineal shaves, enemas/suppositories,
intravenous infusions, initial and continuous electronic
fetal heart monitoring, episiotomy rates). Hospitals were
grouped according to location, size (number of live
births per year), and university affiliation status.
RESULTS: The hospitals in the Prairie provinces, in
Quebec, and in the Atlantic provinces were significantly
less likely than those in Ontario to restrict their use
of perineal shaves and enemas to women on admission in
labor. Small hospitals were significantly more likely
than large hospitals ( 1000 live births) to restrict
their use of intravenous infusions, and initial and
continuous electronic fetal monitoring. The
university-affiliated and nonteaching hospitals were
significantly less likely than the university teaching
hospitals to have episiotomy rates of less than 40
percent for primiparous women. Small hospitals were more
likely than large hospitals to report episiotomy rates of
less than 20 percent for multiparous women. CONCLUSIONS:
Considerable variations occur in the routine use of
obstetric procedures and technologies in Canadian
hospitals providing maternity care, according to hospital
location, size, and university affiliation status.
Despite the existing evidence suggesting that the routine
use of these practices and procedures is both unnecessary
and potentially harmful, a significant number of Canadian
hospitals continued to use them routinely in 1993.
Way S. [Institute of Health and Community Studies,
University of Bournemouth, UK. ] Social construction of
episiotomy. [Review] Journal of Clinical Nursing.
7(2):113-7, 1998 Mar. This article explores the
meaning of episiotomy. A review of the literature
examines the definition, procedure, perceptions and
outcomes of episiotomy to create a better understanding
for those using or experiencing its practice. The article
highlights that episiotomy means more than just a cut in
the perineum. Episiotomy means different things to
different individuals and groups, the meaning being
socially constructed depending on social context,
professional background and personal experience. It is
concluded that midwives need to understand what an
episiotomy means to women, and that through research
midwives need to develop their own body of knowledge of
childbirth from the viewpoints of those who are actually
Haadem K. [Review of the literature on advantages and
disadvantages: episiotomy: only limited protection against
ruptures--time for a revision?]. [Swedish] Lakartidningen.
95(40):4354-8, 1998 Sep 30. A review of the
literature on the pros and cons of episiotomy suggests that it
should be used restrictively. Although there is a general
agreement that episiotomy is protective against anterior perineal
tears, no evidence has been found to support the belief that it
is protective against anal sphincter muscle tears, pelvic muscle
damage or urinary incontinence in the parturient or intracranial
haemorrhage or intrapartum asphyxia in the newborn. Women
undergoing episiotomy are characterised by greater blood loss in
conjunction with delivery, and there is a risk of improper wound
healing and increased pain during the early puerperium. The
prevalence of episiotomy in Sweden has been declining over the
past 20 years, and is now approximately five per cent among
multiparae and fifteen per cent among primiparae.
Maduma-Butshe A. Dyall A. Garner P. Routine episiotomy
in developing countries. Time to change a harmful practice
[editorial]. BMJ. 316(7139):1179-80, 1998 Apr 18.
Kaczorowski J. Levitt C. Hanvey L. Avard D. Chance G.
A national survey of use of obstetric procedures and technologies
in Canadian hospitals: routine or based on existing evidence?.
Birth. 25(1):11-8, 1998 Mar. BACKGROUND: The objective
of this national survey was to describe the routine use of
procedures and technologies in Canadian hospitals providing
maternity care, and to determine the extent to which current use
was consistent with the existing evidence and recommended
guidelines for maternal and newborn care. METHODS:
Representatives of 572 hospitals providing maternity care across
Canada were sent questionnaires in the spring and summer of 1993;
523 (91.4%) responded. The primary outcome measures consisted of
the self-reported use of obstetric procedures and technologies
(perineal shaves, enemas/suppositories, intravenous infusions,
initial and continuous electronic fetal heart monitoring,
episiotomy rates). Hospitals were grouped according to location,
size (number of live births per year), and university affiliation
status. RESULTS: The hospitals in the Prairie provinces, in
Quebec, and in the Atlantic provinces were significantly less
likely than those in Ontario to restrict their use of perineal
shaves and enemas to women on admission in labor. Small hospitals
were significantly more likely than large hospitals (> 1000
live births) to restrict their use of intravenous infusions, and
initial and continuous electronic fetal monitoring. The
university-affiliated and nonteaching hospitals were
significantly less likely than the university teaching hospitals
to have episiotomy rates of less than 40 percent for primiparous
women. Small hospitals were more likely than large hospitals to
report episiotomy rates of less than 20 percent for multiparous
women. CONCLUSIONS: Considerable variations occur in the
routine use of obstetric procedures and technologies in Canadian
hospitals providing maternity care, according to hospital
location, size, and university affiliation status. Despite the
existing evidence suggesting that the routine use of these
practices and procedures is both unnecessary and potentially
harmful, a significant number of Canadian hospitals continued to
use them routinely in 1993.
North Dakota's Genital
Integrity Law, passed in 1995, prohibits the cutting of
genitals of minors. If a young woman chose to take her episiotomy
to court in North Dakota, she would likely win. For more
Ciolli P, et al. "[Episiotomy: can its habitual use be
defended? A study of 100 puerperae and a group of gynecologists
and midwives]". Minerva Ginecol. 1997 May 1; 49(5): 187-191.
Italian. The authors studied vaginal delivery with and
without episiotomy, during the period 1993-1994. The aim of this
study was to examine 100 puerperal women and a group of
gynecologists and midwives, to evaluate the benefits and risks of
routinely used medical procedures, and to understand the rational
of the procedure and put in evidence the indications on which
decisions were based. RESULTS: This study does not indicate
that episiotomy offers a clear benefit to primipara in terms of
decreased numbers of risk factors, while it is indicated in
laborious vaginal delivery. The opinion of sanitary operators
about this procedure is favourable especially for primiparas, but
however this does not necessarily mean that more routine
episiotomy can be justified.
Maier JS, et al. "Nurse advocacy for selective versus
routine episiotomy. " Journal of Obstetric Gynecologic
Neonatal Nursing. 1997 Mar 1; 26(2): 155-161. Although
episiotomy is one of the most commonly performed surgeries,
little scientific support exists for this procedure. Furthermore,
the suggested advantages of routine episiotomy are challenged
easily and the surgery is not without risks. Adverse effects
arising from episiotomy include an increased incidence of severe
lacerations, blood loss, pain, delayed healing, dyspareunia,
psychologic trauma, and medical cost. Nurses can assist women in
avoiding perineal trauma resulting from unnecessary episiotomy
through patient education, patient advocacy, and direct care.
Handa VL, Harris TA, Ostergard DR "Protecting the
pelvic floor: obstetric management to prevent incontinence and
pelvic organ prolapse" Obstetrics and Gynecology 1996
Sep;88(3): 470-478 . OBJECTIVES: To review the literature
regarding the effects of childbirth on the muscles, nerves, and
connective tissue of the pelvic floor, review the evidence to
support an association between childbirth and anal incontinence,
urinary incontinence, and pelvic organ prolapse; and present
recommendations for the prevention of these sequelae. DATA
SOURCES: Sources were identified from a MEDLINE search of
English-language articles published from 1984 to 1995. Additional
sources were identified from references cited in relevant
research articles. METHODS OF STUDY SELECTION: We studied
articles on the following topics: anatomy of the pelvic floor
association of childbirth with neuromuscular injury,
biomechanical and morphologic alterations in muscle function, and
connective tissue structure and function; the long-term effects
of childbirth on continence and pelvic organ support; and the
effects of obstetric interventions on the pelvic floor.
TABULATION, INTEGRATION, AND RESULTS: Articles were reviewed and
summarized. An overview of the structure and function of the
pelvic floor was developed to provide a context for subsequent
data. Childbirth was found to be associated with a variety of
muscular and neuromuscular injuries of the pelvic floor that are
linked to the development of anal incontinence, urinary
incontinence, and pelvic organ prolapse. Risk factors for pelvic
floor injury include forceps delivery, episiotomy, prolonged
second-stage of labor, and increased fetal size. Cesarean
delivery appears to be protective, especially if the patient does
not labor before delivery. CONCLUSION: The pelvic floor plays an
important role in continence and pelvic organ support.
Obstetricians may be able to reduce pelvic floor injuries by
minimizing forceps deliveries and episiotomies, by allowing
passive descent in the second stage, and by selectively
recommending elective cesarean delivery.
Lede RL, Belizan JM, Carroli G "Is Routine Use of
Episiotomy Justified?" American Journal of Obstetrics &
Gynecology. vol 174 No 5 May 1996: 1399-1402. Episiotomy, one
of the most common surgical procedures, was introduced in
clinical practice in the eighteenth century without having strong
scientific evidence of its benefits. Its use was justified by the
prevention of severe perineal tears, better future sexual
function, and a reduction of urine and fecal incontinence. With
regard to the first assumption, the evidence that is based on
five randomized controlled trials shows a 9% reduction in severe
perineal tears in the selective use of episiotomy, but this
effect fluctuates between a 40% reduction and a 38% increase. In
relation to long-term effects, women in whom management includes
routine use of episiotomy have shown poorer future sexual
function, similar pelvic floor muscle strength, and similar
urinary incontinence in comparison with women in whom episiotomy
is used in a selective manner. In summary, there is no reliable
evidence that routine use of episiotomy has any beneficial
effect; on the contrary, there is clear evidence that it may
cause harm such as a greater need for surgical repair and a
poorer future sexual capability. In view of the available
evidence the routine use of episiotomy
should be abandoned and episiotomy rates > 30% do not seem
Woolley R.J. "Benefits and risks of episiotomy: a
review of the English-language literature since 1980. Parts I and
II." Obstet Gynecol Surv 1995 Nov;50(11):806-835. The
professional literature on the benefits and risks of episiotomy
was last reviewed critically in 1983, encompassing material
published through 1980. This paper reviews the evidence
accumulated since then. It is concluded that episiotomies prevent
anterior perineal lacerations (which carry minimal morbidity),
but fail to accomplish any of the other maternal or fetal
benefits traditionally ascribed, including prevention of perineal
damage and its sequelae, prevention of pelvic floor relaxation
and its sequelae, and protection of the newborn from either
intracranial hemorrhage or intrapartum asphyxia. In the process
of affording this one small advantage, the incision substantially
increases maternal blood loss, the average depth of posterior
perineal injury, the risk of anal sphincter damage and its
attendant long-term morbidity (at least for midline episiotomy),
the risk of improper perineal wound healing, and the amount of
pain in the first several postpartum days. Mediolateral and, to a
lesser degree, midline episiotomies substantially increase the
amount of blood loss at delivery; in fact, simple avoidance of
episiotomy may be the most powerful means the delivery attendant
has to prevent excessive intrapartum hemorrhage. The long-term
morbidity of the anal sphincter damage induced by episiotomy,
particularly midline, has generally been underestimated in both
its frequency and severity. Other potential fetal and maternal
complications of episiotomies, although rare, are numerous and
serious. The overall degree of risk that accompanies this
procedure could only be justified by a clear and overriding
benefit, which does not appear to exist.
Hueston, M.D. "Factors Associated With the Use of
Episiotomy During Vaginal Delivery" Obstetrics &
Gynecology, Vol 87 No 6 June 1996: 1001-1005. OBJECTIVE: To
examine factors associated with the performance of episiotomy.
METHODS: A retrospective review was performed on 8647 deliveries
during 1991 and 1992 at five medical centers. Episiotomy rates
were compared based on variables involving patient demographics,
obstetric condition, and physician factors for the 6458 vaginal
deliveries in the sample. Logistic regression modeling using
variables associated in bivariate analysis was performed to
examine independent effects of each variable. RESULTS: Several
characteristics of the patient, her clinical status, and
physician factors were all associated with episiotomy use. The
strongest independent predictors of episiotomy were nulliparity
(odds ratio [OR] 4.10, 95% confidence interval [CI] 3.59-4.68)
and the use of forceps (OR 5.03, 95% CI 3.39-7.46) or vacuum
extraction (OR 3.78, 95% CI 2.36-6.04). Provider specialty and
the site of care were also associated independently with
episiotomy. Episiotomy use was also associated with major
perineal lacerations and an increased length of hospital stay. CONCLUSION:
Although differences in episiotomy rates mainly reflect clinical
circumstances, important site-to-site variations and
interspecialty differences point to potential areas where
physician behaviors influence the performance of episiotomy.
Mansfield CJ, Hueston WJ, Rudy M "Neonatal
circumcision: associated factors and length of hospital
stay" Journal of Family Practice 1995 Oct;41(4):370-376. BACKGROUND.
Controversy exists regarding the efficacy of routine neonatal
circumcision of male infants. Little is known about parental or
provider characteristics or the use of medical resources
associated with this procedure. METHODS. Records of 3703 male
infants born during 1990 and 1991 at four US sites were analyzed
to discern associations between circumcision and the above
factors. Analyses were limited to healthy infants. RESULTS.
Eighty-five percent of the infants in the study population were
circumcised. White and African-American male infants were much
more likely to be circumcised than those of other races (odds
ratios [ORs], 7.3 and 7.1, respectively, P < .001). Compared
with self-pay patients, those covered by private insurance were
2.5 times more likely to be circumcised (P < .001). Logistic
regression showed that rates for obstetricians and family
physicians were not significantly different. Increased odds of
circumcision were found if the mother received an episiotomy (OR
= 1.9, P < .001) or cesarean section (OR = 2.1, P < .001).
Circumcised infants stayed in the hospital an average of one
fourth of a day longer than did those who were not circumcised
(mean difference, 0.26 days; 95% confidence interval, 0.16 to
0.36). CONCLUSIONS. Mother's insurance status and race as well as
surgical interventions during delivery are related to
circumcision. Associations with episiotomy and cesarean section
suggest physician and/or parental preference for interventional
approaches to health care. Generalizing the difference in
hospital length of stay to the United States suggests an annual
cost between $234 million and $527 million beyond charges for the
Argentine Episiotomy Trial Collaborative Group. 1993.
"Routine vs selective episiotomy: a randomised controlled
trial." Lancet 342:1517-8.
Episiotomy is a widely-done intervention in childbirth,
regardless of poor scientific evidence of its benefits. This
randomised controlled trial compares selective with routine use
of a mediolateral episiotomy for women having first and second
deliveries in 8 public maternity units in Argentina. 2606 women
participated; 1555 were nulliparous (778 in the selective group
and 777 in the routine group) and 1051 primiparous (520 in the
selective group and 531 in the routine group). The two
interventions compared were selective (limited to specified
maternal or fetal indications), and routine episiotomy (following
the hospital's previous policy). Episiotomy was done in 30.1% of
deliveries in the selective, and 82.6% in the routine group. The
main outcome measure was severe perineal trauma. Severe perineal
trauma was uncommon in both groups but was slightly less frequent
in the selective group (1.2% vs 1.5%). Anterior perineal trauma
was more common in the selective group but posterior perineal
surgical repair, perineal pain, healing complications, and
dehiscence were all less frequent in the selective group. Routine
episiotomy should be abandoned and episiotomy rates above 30%
cannot be justified.
Borgatta, L., S. L. Piening and W. R. Cohen. 1989.
"Association of episiotomy and delivery position with deep
perineal laceration during spontaneous delivery in nulliparous
women." American Journal of Obstetr Gynecol 160:294-7.
Spontaneous deliveries of 241 nulliparous women found that
deep perineal tears occurred in 1% of the women delivered without
either episiotomies or stirrups, and in 28% with both
episiotomies and stirrups. Women with either episiotomies or
stirrups had intermediate amounts of tears.
Combs, C. A., P. A. Robertson and R. K. Laros. 1990.
"Risk factors for third-degree and fourth-degree perineal
lacerations in forceps and vacuum deliveries." American
Journal of Obstet Gynecol 163:100-4.
Among 2832 consecutive forceps and vaccum extraction
deliveries, 30% suffered thrid- or fourth-degree lacerations (to
the anus). In regression, the predictors of severe laceration
were: midline episiotomy, nulliparity, forceps delivery (vs.
vacuum extraction), local anaesthesia, and Asian race. Birth
weight and gestational age were not predictors.
Doherty, P. J. and I. Cohen. 1993. "Spontaneous
vaginal deliveries and perineal trauma in Lucea, Jamaica."
Journal of the Louisiana State Medical Society 145:531-3.
In 1991, there were 995 uncomplicated vaginal deliveries at
Noel Holmes Hospital (NHH) in Lucea, Jamaica. Seven hundred and
forty-two women were discharged with intact perineums. Only 3
episiotomies were performed. These data raise a concern that
episiotomy may be overused in the United States.
Farabow, W. S. et al. 1993. "A twenty-year
retrospective analysis of the efficacy of epidural
analgesia-anesthesia when administered and/or managed by
obstetricians." American Journal of Obstetrics &
Postdate pregnancy, use of oxytocin, low forceps delivery,
episiotomy, and type of anesthesia were unrelated to shoulder
dystocia in newborns. This study clearly indicates that most of
the traditional risk factors for shoulder dystocia have no
predictive value, shoulder dystocia itself is an unpredictable
event, and infants at risk for permanent injury are virtually
impossible to predict. In addition, no delivery method in
shoulder dystocia was superior to another with respect to injury.
Thus no protocol should serve to substitute for clinical
Golay, J., S. Vedam and L. Sorger. 1993. "The
squatting position for the second stage of labor: effects on
labor and on maternal and fetal well-being." Birth 20:73-8.
A cohort study was designed to assess the effects of maternal
squatting position for the second stage of labor on the evolution
and progress of labor, and on maternal and fetal well-being.
Outcomes from 200 squatting births, randomly selected from a
sample of 1000, were compared with 100 semirecumbent births,
randomly selected from a sample of 300. Data collection was by
chart review. The two groups were similar with respect to most
antepartal, intrapartal, and socioeconomic variables likely to
affect labor outcomes. The mean length of the second stage of
labor was 23 minutes shorter in squatting primiparas and 13
minutes shorter in squatting multiparas than in semirecumbent
women. Squatting women required significantly less labor
stimulation by oxytocin during second stage (P = 0.0016), and
they showed a trend toward fewer mechanically assisted
deliveries. Significantly fewer and less severe perineal
lacerations occurred, and fewer episiotomies were performed in
the squatting group (P = 0.0001). No statistically
significant differences were found between groups for third-stage
complications and infant complications.
Green, J. R. and S. L. Soohoo. 1989. "Factors
associated with rectal injury in spontaneous deliveries."
Obstet Gynecol 73:732-8.
In a study of 2706 spontaneous cephalic deliveries, midline
episiotomies increased the risk of rectal injury (laceration of
the rectal sphincter) by 9 times, nulliparity by 3 times,
physician-assisted delivery vs. midwife by 2.5 times.
Helwig, J. T., J. M. Thorp and W. A. Bowes. 1993.
"Does midline episiotomy increase the risk of third- and
fourth-degree lacerations in operative vaginal deliveries?"
Obstetrics & Gynecology 82:276-9.
OBJECTIVE: To explore the association between midline
episiotomy and the risk of third- and fourth-degree lacerations
during operative vaginal delivery with either vacuum extractor or
forceps. METHODS: This retrospective cohort study analyzed all
operative vaginal deliveries at a university hospital in 1989 and
1990. Univariate analysis of the relationships between perineal
lacerations and obstetric variables was performed. Stratified
analysis using the relevant variables was used to calculate
relative risk (RR) estimates. RESULTS: Episiotomy, birth weight,
and whether the index birth was the first vaginal birth were
associated with third- and fourth-degree perineal lacerations.
Stratified analysis demonstrated an RR of 2.4 with a 95%
confidence interval of 1.7-3.5 for rectal injury with episiotomy,
adjusting for parity and birth weight. CONCLUSION: Midline
episiotomy is associated with an increased risk of third- and
fourth-degree perineal lacerations in operative vaginal
Henriksen TB. Bek KM. Hedegaard M. Secher NJ. 1994.
"[Episiotomy and perineal lesions in spontaneous vaginal
delivery]. [Danish]." Ugeskrift for Laeger 156:3176-9.
The purpose of the study was to evaluate the influence of
mediolateral episiotomy on the perineal state after spontaneous,
singleton vaginal deliveries with the foetus in the occiput
anterior position. The design was that of a population based,
observational study. Two approaches were used in the analyses:
Initially, we considered the parturients as quasi-randomised to
one of three equally sized groups of midwives with different
attitudes towards episiotomy. Secondly, we studied the effect of
episiotomy on the state of the anal sphincter, controlling for
birth weight, parity, and duration of second stage of labour. The
subjects were 2188 pregnant women delivering consecutively, and
the main outcome measures were perineal lacerations and tearing
of the anal sphincter. Women allocated to the group of midwives
with the lowest rate of episiotomy were more likely to have an
intact perineum after delivery (OR = 1.8 (1.4-2.2)), had a slight
tendency towards more perineal lacerations (OR = 1.3 (1.0-1.5)),
but no increased risk of tearing of the anal sphincter, compared
with the women allocated to the two groups of midwives with
higher frequencies of episiotomy. The second approach showed that
episiotomy was related to an increased risk of tearing of the
anal sphincter (OR = 2.3 (1.2-4.6)). However, this relation was
not found among the group of parturients delivered by the
midwives with the lowest rate of episiotomy (22%). Our results
encourage a conservative approach to the use of mediolateral
episiotomy, and in the light of previous findings, it seems
reasonable to suggest that episiotomy should ideally be used in
about one in five spontaneous vaginal deliveries.
Henriksen, T. B. et al. 1992. "Episiotomy and perineal
lesions in spontaneous vaginal deliveries." Br Journal of
Obstetr Gynaecol 99:950-4.
British midwives were classified as high, moderate or low
users of episiotomies (EP). A total of 2188 of the women they had
delivered were retrosepctively studied. Women with the low EP
midwives were the most likely to have an intact perineum after
delivery, with a slightly higher risk of a laceration, but no
increased risk of a tear to the anus. Among the moderate and high
EP midwives however, episiotomies were found to increase the
risk of a tear to the anus. "Our findings encourage a
conservative approach to the use of mediolateral
Hueston, W. J. and M. Rudy. 1993. "A comparison of
labor and delivery management between nurse midwives and family
physicians." Journal of Fam Pract 37:449-54.
BACKGROUND. Practice associations between family physicians
and nurse midwives have been suggested as a means to increase the
availability of obstetric care in rural areas. No evidence
exists, however, that family physicians and midwives have
comparable practice styles or achieve similar outcomes in
obstetric patients. METHODS. The study examines patients cared
for by a co-practice of nurse midwives and family physicians at a
rural hospital. Data were collected through a retrospective chart
audit for all patients whose prenatal care, labor, or delivery
was managed by members of the practice in 1990 and 1991. RESULTS.
Few differences were noted between nurse midwives and family
physicians in the management of labor or delivery. The only
consistent finding was that family physicians were more likely
than midwives to use an episiotomy for delivery (40% vs 30% in
primiparous women, P = .02; and 20% vs 10% in multiparous women,
P = .007). Despite seemingly similar management styles,
primiparous women managed by family physicians were more likely
to undergo cesarean section (14% vs 8%, P = .05) resulting from
the diagnosis of dystocia. When practice specialty was included
in a logistic regression model with parity and the number of
preexisting risk factors, the effect of specialty on cesarean
sections remained significant with a relative risk of 2.79 for
cesarean section if patients had their labor managed by a family
physician (P .001). CONCLUSIONS. Family physicians and nurse
midwives managed patients in labor similarly, but nurse
midwives were more likely to achieve a vaginal delivery in
primiparous women and do so without an episiotomy. Although
the differences found would not interfere with a collaborative
practice, subtle differences in patient management do exist.
Further exploration of these differences may be helpful in
understanding the impact of these differences on mixed-specialty
Klein MC. Gauthier RJ. Robbins JM. Kaczorowski J. Jorgensen
SH. Franco ED. Johnson B. Waghorn K. Gelfand MM. Guralnick MS. et
al. 1994. "Relationship of episiotomy to perineal trauma and
morbidity, sexual dysfunction, and pelvic floor relaxation."
American Journal of Obstetrics & Gynecology 171:591-8.
OBJECTIVE: Our purpose was to compare consequences for women
of receiving versus not receiving median episiotomy early and 3
months post partum on the outcomes perineal pain, urinary and
pelvic floor functioning by electromyography, and sexual
functioning and to analyze the relationship between episiotomy
and third- and fourth-degree tears. STUDY DESIGN: A secondary
cohort analysis was performed of participants within a randomized
clinical trial, analyzed by type of perineal trauma and pain,
pelvic floor, and sexual consequences of such trauma, while
controlling for trial arm. The study was conducted in three
university or community hospitals; 356 primiparous and 341
multiparous women were studied. RESULTS: Early and
3-month-postpartum perineal pain was least for women who gave
birth with an intact perineum. Spontaneous perineal tears were
less painful than episiotomy. Sexual functioning was best for
women with an intact perineum or perineal tears. Postpartum
urinary and pelvic floor symptoms were similar in all perineal
groups. At 3 months post partum those delivered with an intact
perineum had the strongest pelvic floor musculature, those with
episiotomy the weakest. Among primiparous women third- and
fourth-degree tears were associated with median episiotomy
(46/47). After forceps births were removed and 21 other variables
potentially associated within such tears were controlled for,
episiotomy was strongly associated with third- and fourth-degree
tears (odds ratio +22.08, 95% confidence interval 2.84 to
171.53). Physicians using episiotomy at high rates also used
other procedures, including cesarean section, more frequently. CONCLUSION:
Perineal and pelvic floor morbidity was greatest among women
receiving median episiotomy versus those remaining intact or
sustaining spontaneous perineal tears. Median episiotomy was
causally related to third- and fourth-degree tears. Those using
episiotomy at the highest rates were more likely use other
interventions as well. Episiotomy use should be restricted to
specified fetal-maternal indications.
Larsson, P. G. et al. 1991. "Advantage or disadvantage
of episiotomy compared with spontaneous perineal
laceration." Gynecol Obster Invest 31:213-6.
In a prospective investigation of 2144 deliveries comparing women
with episiotomies and those with spontaneous lacerations, women
with episiotomies were found to have a sig higher infection rate
and longer healing times. Morbidity was higher for the episiotomy
group immediately and at the 3-month follow-up.
McGuinneess, M., K. Norr and K. Nacion. 1991.
"Comparison between different perineal outcomes on tissue
healing." Journal of Nurse Midwifery 36:192-8.
Perineal healing was compared between 181 women with
episiotomies and 186 women without at one to two weeks after
delivery. All subjects were medically indigent low-risk women at
a tertiary care hospital. Maternal age, race, parity, and birth
weight were not correlated to perineal healing. Length of the
second stage of labor was correlated. Of the EP group, 8%
experienced delayed perineal healing, while only 2% had delayed
healing in the no-episiotomy group.
Piper DM. McDonald P. 1994. "Management of anticipated
and actual shoulder dystocia. Interpreting the literature."
Journal of Nurse-Midwifery 39:91S-105S.
Shoulder dystocia is a rare but serious obstetric
complication that can result in significant neonatal and maternal
morbidity and in costly litigation. Conflict exists in the
literature regarding definition, incidence, predictability and
preventability, relationship to neonatal injury, and appropriate
management models. Anticipatory clinical interventions for
potential shoulder dystocia have included ultrasound assessment
of macrosomia; elective induction of labor; elective caesarean
section; altered place of birth; and generous
episiotomy/episioproctotomy. The authors note that these
interventions often conflict with client desires and
nurse-midwifery philosophy of birth, generate significant risks
and costs in themselves, and do not address the poor
predictability of shoulder dystocia. In recent literature, the
safety and efficacy of maternal position change maneuvers (such
as McRoberts maneuver, hands-knees position, and squatting) have
been presented as methods to resolve most cases of shoulder
dystocia. Despite the success of these more benign, external
maneuvers, the episiotomy mandate remains in nearly all obstetric
and midwifery texts and handbooks (1-8) and journal references
(9-19). A literature review of related professional
disciplines was undertaken to study these conflicts and to
identify support for applying a philosophy of minimal,
appropriate intervention to the complex issue of shoulder
dystocia. [References: 75].
Rockner, G. and A. Olund , A Jonasson. 1991. "The
effect of mediolateral epsiotomy at delivery on pelvic floor
muscle strength evaluated with vaginal cones." Acta Obstet
Gynecol Scand 70:51-4.
In a prospective study, pelvic floor muscle was studied pre-
and post-partum in 71 primiparous women with uncomplicated
pregnancies delivered vaginally. Pelvic floor muscle was
significantly weakened in the group with episiotomies, while the
muscle strength was the same in those who had spontaneous
lacerations and those with intact perineums.
Ruderman, J. et al. 1993. "Are physicians changing the
way they practise obstetrics?" Canadian Medical Association
OBJECTIVE: To examine trends in obstetric interventions in
women at low risk over approximately 3 years. It was postulated
that there would be a general reduction in most intervention
rates. DESIGN: Retrospective review of hospital records. SETTING:
Three downtown hospitals of the University of Toronto, in which
academic and nonacademic family physicians and obstetricians
practised. PATIENTS: A total of 2365 women in phase 1 (April 1985
to March 1986) and 1277 in phase 2 (May to September 1988) met
the inclusion criteria for grade A (pregnancy at no predictable
risk) of the Ontario Antenatal Record at the time of admission to
hospital. OUTCOME MEASURES: Rates of artificial rupture of the
membranes, induction, augmentation, epidural anesthesia,
continuous electronic fetal monitoring (EFM), instrumental
delivery, episiotomy and cesarean section. RESULTS: The family
physicians and the obstetricians had significant decreases (p
0.01) over time in the rates of episiotomy, especially
mediolateral, and low forceps delivery. The rate of epidural
anesthesia decreased significantly in the obstetrician group. The
rates of artificial rupture of the membranes, induction and
continuous EFM increased in the two physician groups; the
increased rate of EFM was significant in the obstetrician group
(p 0.01). There was no significant change in the rates of
augmentation, midforceps delivery, vacuum extraction or cesarean
section. All of the trends were found to hold when the
intervention rates were analysed according to the women's parity.
CONCLUSIONS: Some of the findings reflect recommendations and
trends reported in the literature, whereas others are not
supported by clear medical evidence. The unpredictable nature of
the trends suggests that further study is warranted of the
reasons for obstetric trends and for the changes in physicians'
Shiono, P., M. A. Klebanoff and J. C. Carey. 1990.
"Midline episiotomies: more harm than good?" Obstet
Episiotomy and severe perineal lacerations were studied in
24,114 women. Overall 8% of primiparous women and 1.5% of
multiparous women had sever lacerations. Women with midline
episiotomies were 50 times more likely and women with
mediolateral episiotomies were more than eight times more likely
to suffer a sever laceration than women without episiotomies.
Severe lacerations, and episiotomies, were also correlated with
forceps delivery, larger babies, breech and transverse
presentations, and smaller women. After adjusting for these
risk factors, midline episiotomy was still still associated with
4 (nulliparas) to 12 (multiparas) times as many severe
lacerations, and mediolateral episiotomy was still associated
with a 2.5 times greater risk of severe laceration.
Smith, M. A., M. T. Ruffin and L. A. Green. 1993. "The
rational management of labor." American Family Physician
Some practices and procedures that are common during the
management of childbirth lack proof of efficacy, and some have
adverse effects. The practice of withholding food and liquids and
using intravenous fluids during labor may pose risks such as
fluid overload, and maternal and fetal hyperglycemia. Enemas
should be reserved for women with painful constipation. Evidence
does not support the value of shaving the perineal area.
Nonpharmacologic measures to control pain during labor are safe
and moderately effective. Pharmacologic methods of analgesia and
anesthesia provide good pain relief but pose significant risks.
Continuous electronic fetal monitoring should be considered a
diagnostic procedure, not a screening procedure. Amniotomy may
shorten labor but can result in abnormally high uterine forces,
infection, umbilical cord prolapse and fetal laceration. Position
changes and alternative birth positions promote greater comfort
and efficiency during labor. Finally, episiotomy has not been
shown to reduce severe lacerations or prevent pelvic relaxation,
and use of this procedure should be limited.
Stones, R. W. et al. 1993. "Risk factors for major
obstetric haemorrhage." European Journal of Obstetrics,
Gynecology, & Reproductive Biology 48:15-8.
Induced labour, caesarean delivery and episiotomy significantly
increased the risk of potentially life threatening haemorrhage.
Sultan AH. Kamm MA. Hudson CN. Bartram CI. 1994.
"Third degree obstetric anal sphincter tears: risk factors
and outcome of primary repair." BMJ 308:887-91.
OBJECTIVES--To determine (i) risk factors in the development
of third degree obstetric tears and (ii) the success of primary
sphincter repair. DESIGN--(i) Retrospective analysis of obstetric
variables in 50 women who had sustained a third degree tear,
compared with the remaining 8553 vaginal deliveries during the
same period. (ii) Women who had sustained a third degree tear and
had primary sphincter repair and control subjects were
interviewed and investigated with anal endosonography, anal
manometry, and pudendal nerve terminal motor latency
measurements. SETTING--Antenatal clinic in teaching hospital in
inner London. SUBJECTS--(i) All women (n = 8603) who delivered
vaginally over a 31 month period. (ii) 34 women who sustained a
third degree tear and 88 matched controls. MAIN OUTCOME
MEASURES--Obstetric risk factors, defecatory symptoms,
sonographic sphincter defects, and pudendal nerve damage.
RESULTS--(i) Factors significantly associated with development of
a third degree tear were: forceps delivery (50% v 7% in controls;
P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001),
birth weight > 4 kg (P = 0.00002), and occipito-posterior
position at delivery (P = 0.003). No third degree tear occurred
during 351 vacuum extractions. Eleven of 25 (44%) women who
were delivered without instruments and had a third degree tear
did so despite a posterolateral episiotomy. (ii) Anal
incontinence or faecal urgency was present in 16 women with tears
and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter
defects were identified in 29 with tears and 29 controls (85% v
33%; P = 0.00001). Every symptomatic patient had persistent
combined internal and external sphincter defects, and these were
associated with significantly lower anal pressures. Pudendal
nerve terminal motor latency measurements were not significantly
different. CONCLUSIONS--Vacuum extraction is associated with
fewer third degree tears than forceps delivery. An episiotomy
does not always prevent a third degree tear. Primary repair is
inadequate in most women who sustain third degree tears, most
having residual sphincter defects and about half experiencing
anal incontinence, which is caused by persistent mechanical
sphincter disruption rather than pudendal nerve damage. Attention
should be directed towards preventive obstetric practice and
surgical techniques of repair.
Thorp, J. M. and W. A. Bowes. 1989. "Episiotomy: can
its routine use be defended?" American Journal of Obstet
A careful review finds little evidence to support the claim that
episiotomy reduces perineal trauma or pelvic floor weakening, and
in fact the evidence shows that it increases the risks of severe
Walker, M. P., D. Farine, S. H. Rolbin and J. W. Ritchie.
1991. "Epidural anaesthesia, episiotomy, and obstetric
laceration." Obstetr Gynecol 77:668-71.
Uncomplicated vertex deliveries with spontaneous onset and
normal course (N= 9493) were retrospectively studied. Epidural
anaesthesia was not associated with increased risk of birth canal
trauma, but episiotomy was associated with an increased risk
of perineal trauma, and with a four-fold increased risk of major
Wilcox, L. S. et al. 1989. "Episiotomy and its role in
the incidence of perineal lacerations in a maternity center and
tertiary hospital obstetric service." American Journal of
Obstet Gynecol 160: 732-8.
A retrospective study of the records of 1262 women who
delivered at a maternity center staffed by midwives and a
teaching hospital staffed with physicians found that, controlling
for several factors, women at the teaching hospital were twice
as likely to have episiotomies. In turn, episiotomies were
associated with a four-fold increase in the incidence of severe
This page: http://www.changesurfer.com/Hlth/episiotomy.html
British National Health Service, Health
Evidence Bulletin on "Episotomy/
based on Enkin et al. above. Conclusion:
"routine use (of episiotomy) in spontaneous delivery
should be strongly discouraged."
Chairs, Midwives and Medicine
by Amanda Carson Banks