Episiotomy: Has Its Time Passed?

Given that there are over four million births in the United States each year, one might argue that episiotomy could potentially be the most commonly performed surgical procedure in the United States. In previous decades, episiotomy was touted as a method to protect the female perineum from the trauma of childbirth. In many institutions, residents in Obstetrics and Gynecology were taught that this procedure should in fact be routine. There were however, very little data to support the efficacy of routine episiotomy. Midwives, for decades, have argued that episiotomy is more often than not unnecessary and can frequently be avoided by having a more minimalist approach to vaginal delivery as well as employing certain methods of perineal massage to allow for relaxation of the perineum and therefore minimize the risk of damage. A number of small clinical trials from Europe and Latin America have also suggested that routine episiotomy may in fact be unnecessary. Recent data from an investigator at the University of Nebraska Medical Center suggests that in fact routine episiotomy might be better avoided than performed. John T. Repke, MD, Professor and Chairman of the Department of Obstetrics and Gynecology and a member of its Maternal Fetal Medicine Division, working with colleagues from Harvard Medical School-Brigham and Women’s Hospital, published a report essentially suggesting that midline episiotomy is not effective in protecting the perineum during childbirth and may in fact impair continence. These data were published in the January 8, 2000 issue of the British Medical Journal. While this report might have otherwise been just a "blip on the radar screen" considerably more attention was given to it when a summary of this study’s results appeared on the front page of the March 30, 2000 issue of The Wall Street Journal (I guess that shows you what doctors and patients are really reading). Dr. Repke and his co-investigators studied over 600 women who had had vaginal births both with and without episiotomy and followed up their recovery progress for six months. Prior to this study, what had been known about episiotomy was that much anal incontinence was thought to arise from injury to the anal sphincter during childbirth. Also, operative vaginal delivery seemed to place women at greater risk for injury to the sphincter muscle. The results of the current study suggest that in fact episiotomy is a risk factor for post partum anal incontinence and that women are generally better off without episiotomy. Even those women with spontaneous perineal lacerations seem to recover more quickly and with better return of function than women who have had episiotomy.

These data are important for several reasons. First and foremost it supports the notion that a once considered routine procedure should now be reconsidered and used only when clinically necessary. Secondarily, it points out the need for additional emphasis on evidence-based research and applying it to clinical practice. One of the missions of the Olson Center for Women’s Health is to support evidence-based research. Such support is essential if we are to make progress in providing health care to the women of Omaha. Dr. Repke and his colleagues have two additional manuscripts in preparation further supporting the notion that "routine" episiotomy should be anything but routine.

Signorello LB, Harlow BL, Chekos AK, Repke JT: Midline Episiotomy and Anal Incontinence: Retrospective Cohort Study. BMJ 2000; 320:86-90.

Date last updated:  January 6, 2003