April 6, 2006 -- The American College of Obstetrics and Gynecology (ACOG) has prepared practice guidelines for use of episiotomy, which are published in the April issue of Obstetrics & Gynecology. The authors note that this is one of the most commonly performed procedures in obstetrics; approximately 33% of women giving birth vaginally in 2000 had an episiotomy.

"Historically, the purpose of this procedure was to facilitate completion of the second stage of labor to improve both maternal and neonatal outcomes," write John T. Repke, MD, and colleagues from the ACOG Committee on Practice Bulletins. "Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor resulting from more rapid spontaneous delivery or from instrumented vaginal delivery."

The guidelines were designed to assist practitioners in making decisions about appropriate obstetric and gynecologic care, but they should not be construed as dictating an exclusive course of treatment or procedure. Individual patient needs, and resources and limitations of each institution or type of practice may necessitate variations in practice.

"The purpose of this document is to examine the risks and benefits of episiotomy and to make recommendations regarding the use of this procedure in current obstetric practice," the authors write. "Despite limited data, this procedure became virtually routine resulting in an underestimation of the potential adverse consequences of episiotomy, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia."

Level A recommendations and conclusions, based on good and consistent scientific evidence, are that restricted use of episiotomy is preferable to routine use and that median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than is mediolateral episiotomy.

Level B recommendations and conclusions, based on limited or inconsistent scientific evidence, are that mediolateral episiotomy may be preferable to median episiotomy in selected cases and that routine episiotomy does not prevent pelvic floor damage leading to incontinence. As a performance measure, the panel recommends the percentage of patients for whom the indication for episiotomy is included in the delivery notes.

Although the indications for episiotomy vary and are based largely on clinical opinion, the procedure may be indicated in cases where it is necessary to expedite delivery in the second stage of labor or where spontaneous laceration is likely. However, evidence is lacking to support these indications.

"Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure," the authors write. "Restrictive use of episiotomy appears to reduce the likelihood of perineal lacerations."

A systematic review of routine vs restrictive episiotomy found no evidence to support episiotomy in preventing pelvic floor damage leading to incontinence. Whether episiotomy adds to immediate postpartum pain is still unclear. In prospective cohort studies, women who did or did not have episiotomy had no differences in dyspareunia or resumption of intercourse at 3 months.

Several trials have reported on different techniques of perineal closure aimed at reducing postpartum pain and promoting rapid healing, but larger trials are needed to draw any definite conclusions.

Proposed fetal benefits of episiotomy include cranial protection, especially for premature infants; reduced perinatal asphyxia and fetal distress; higher Apgar scores, less fetal acidosis, and fewer complications from shoulder dystocia, but few data are available to support these claims. The presumed effect of episiotomy on shortening the second stage of labor has also not been demonstrated conclusively.

Median episiotomies are associated with higher risk of extension into the rectum and compromise of the external anal sphincter muscle, and mediolateral episiotomies are associated with greater postpartum pain, more blood loss, greater difficulty in repair, and more dyspareunia, especially when compared with spontaneous tears. Because of the potential for greater expansion of the pelvic floor with mediolateral episiotomy, this procedure may theoretically help lower the risk for incontinence.

"Although the data are insufficient to determine the superiority of either approach, data do suggest that both median and mediolateral episiotomies have similar outcomes, including pain from the incision and time to resumption of intercourse," the authors conclude. "The best available data do not support liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications, such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries."

Obstet Gynecol. 2006;107:957-962