March 31, 2000 (Eugene, Ore.) -- Episiotomies, small cuts made into the vagina, should not be a routine part of delivery, according to a commentary published in the April issue of the journal Obstetrics and Gynecology.
Episiotomies have been widely used in the U.S. since at least the 1920s. Doctors believed that an episiotomy helped avoid damage to the woman's vagina and tissues, which support the pelvis. It's also believed that an episiotomy is easier to repair than a tear in the vagina, which can occur if an episiotomy is not done. In addition, some thought that it resulted in shortened delivery times and that a shortened second stage of labor was better for the baby. The second stage of labor begins with complete dilation of the cervix, or opening of the uterus, and ends with the delivery of the baby.
This is not always the case, say researchers who reviewed classic teachings and some of the recent evidence on delivering without an episiotomy. "We found that the various interventions available to prevent ? trauma are safe for the baby and don't lead to damage for the mother," says lead author Erica Eason, MD, of the department of obstetrics and gynecology at the University of Ottawa. "They include doing perineal massage, slowing the delivery, controlling the head delivery, and avoiding episiotomy and forceps delivery." Perineal massage is done on the perineum, the area below the vagina.
"This is an excellent article," says Suzanne Trupin, MD. "I'm surprised it took so long for something like this to come out. ? Many of us who are in active practice have long given up routine episiotomies." Trupin is clinical professor of obstetrics and gynecology at the University of Illinois College of Medicine and was not involved in the study.
Michael Klein, MD, says, "It is an accurate description of the debate, which should no longer be a debate." Klein, who was also not involved in the study, is professor of family practice and pediatrics at the University of British Columbia School of Medicine and head of family practice at Children's and Women's Health Center of British Columbia.
Official guidelines agree. The 1997 Guidelines for Perinatal Care by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists says, "Episiotomy may be used to aid in the management of delivery in some situations. The routine use of episiotomy is not necessary and leads to a delay in the patient's resumption of sexual activity."
Overuse of episiotomies is an issue worldwide, Eason tells WebMD. "North America has been the leader in doing episiotomies, but the rest of the world has followed our lead. The practice has been taken up worldwide, expect perhaps in certain European countries. The authors speculate on the reasons so many episiotomies are still done. "Research data and practice guidelines are not sufficient to induce change," they write.
"There are two key reasons why episiotomy is still done so often," Eason says. "It's difficult to interpret fetal heart rates during the second stage of labor, so doctors feel safer getting the baby out quickly. Also, using techniques such as slowing the delivery to allow an intact perineum are more time-consuming, so a doctor who doesn't do routine episiotomies does spend more time in the delivery room."
Consumers need to understand that in some circumstances an episiotomy is really needed, Trupin says. "It should definitely be used if there is any sign that the baby is in trouble during the second stage of labor, or if the second stage is going on too long. There is some debate about the appropriate length for the second stage. We used to talk about limiting that stage to two hours, but now it is clear that three to four hours is perfectly safe in many cases."
Klein encourages women to discuss attitudes towards episiotomy early in their pregnancies, while they are still selecting their caregiver. "Asking the physician about the circumstances where he/she would chose to do an episiotomy can be a vehicle for opening a whole discussion of their attitude toward birth. It will illuminate the physician's views on other potential interventions such as forceps delivery or cesarean delivery."
Trupin agrees that pregnant women should discuss these issues with their doctors, but believes the conversation is more appropriate later in pregnancy. "When first selecting a doctor you want to ask about their C-section and epidural rates, what hospitals they use, who covers for them when they are not available. Those are the big global issues. The discussion about episiotomy might be excellent sometime in the late second or third trimester, when you start to focus on the details of a planned birth," she says.
- Experts agree that episiotomies should not be performed as a routine part of delivery and that they are still overused in this country.
- Other interventions to prevent trauma include employing perineal massage, slowing the delivery, controlling the head delivery, and avoiding the use of forceps.
- In some cases, episiotomy is still necessary, such as if the baby is in trouble during the second stage of labor or if the second stage of labor lasts too long.