Episiotomy during vaginal delivery was first recommended in 1920 as a way to protect the pelvic floor from lacerations and protect the fetal head from trauma. It was rapidly adopted as a standard practice and has been widely used since then. However, over the last several decades, there has been a growing body of evidence that episiotomy does not provide these purported benefits and may contribute to more severe perineal lacerations and future pelvic floor dysfunction. In this review, we examine the evidence that led to changing episiotomy practices and the debate that has surrounded episiotomy. By doing so, we can not only evaluate this specific obstetric procedure, but also gain insights into the challenge of changing medical practice as new data emerge.
The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of mediolateral episiotomy for all deliveries in nulliparous women. DeLee argued, in very stark language, that allowing ‘natural’ childbirth so frequently resulted in damage to the woman and her child, that intervention was obligatory: “In fact, only a small minority of women escape damage, while 4% of babies are killed and an indeterminable number [are] injured … If you believe a woman after delivery should be as healthy [and] anatomically perfect as before … then you have to agree [that] labor is pathogenic”. His rationales for episiotomy included shortening of the second stage, thereby reducing maternal exhaustion and blood loss, preservation of the pelvic floor, prevention of uterine prolapse and reducing the rates of short- and long-term damage to infants. These arguments proved to be very compelling to many obstetricians, and the practices soon became widespread.
There has been a steady decline in overall rates of episiotomy in the USA over the last four decades, and growing consensus in the literature that midline episiotomy was more harmful than beneficial, culminating in the Cochrane reviews and the JAMA article. However, new recommendations for restrictive use of episiotomy have not been universally accepted. A number of studies have shown that increasingly, the most important predictor of whether or not a woman has an episiotomy at delivery is who attends her delivery.
All of these studies concluded that additional education of obstetric providers, perhaps targeting nonacademic physicians, or those in practice longer, might decrease episiotomy use and decrease the complications associated with high episiotomy rates.
With current evidence as our guide, the exhortation of Eason almost 20 years ago about attending a vaginal delivery still rings true: “don’t just do something, sit there!”.[
J. Kyle Mathews, MD
Plano OBGyn Associates
Plano Urogynecology Associates