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Full Title: The Use of Episiotomy in Obstetrical Care: A Systematic Review
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Context: In the United States, use of episiotomy varies from less than 10 percent to more than 75 percent of vaginal births. Overall, 30 to 35 percent of vaginal births include episiotomy. Routine episiotomy may not yield maternal benefits traditionally ascribed to it.
Objectives: The researchers addressed five key questions (KQs):
- Does the practice of liberal or routine episiotomy, versus selective use of episiotomy, influence maternal postpartum outcomes?
- Does episiotomy incision type (midline or mediolateral), influence maternal postpartum outcomes? Does the repair of the perineal defect (suture type and repair approach) influence maternal postpartum outcomes?
- Does episiotomy have a long-term influence on urinary incontinence, fecal incontinence, or pelvic floor defects?
- Does episiotomy or incision type, or both, influence future sexual function?
Data Sources: The researchers searched MEDLINE®, the Cochrane Library, and CINAHL®. They also did hand searches and consulted with experts.
Review Methods: The researchers excluded studies that were not about outcomes of vaginal birth, were published in languages other than English, were not pertinent to the key questions, included < 40 subjects, or did not represent original research. KQs 1-3 were limited to randomized, controlled trials. KQs 4 and 5 included nonrandomized, prospective cohorts.
Results: The researchers based their findings on 45 articles meeting their criteria. Fair-to-good evidence suggests that immediate maternal outcomes from routine episiotomy are no better than those from restrictive use, and subject some proportion of women to a surgical incision who would have had lesser injury. When the procedure is indicated, evidence is insufficient to provide clear guidance on the choice of midline or mediolateral episiotomy. Weak trial evidence, consistent with observational data, however, ascribes less harm to mediolateral episiotomy.
For perineal injury requiring suturing, fair-to-good evidence suggests leaving superficial vaginal and perineal skin unsutured. If used for skin approximation, a continuous, subcuticular repair is superior to an interrupted, transcutaneous method. Evidence is consistent and clear supporting absorbable sutures and that polyglycolic acid sutures are associated with less morbidity than gut and chromic gut sutures. Support for the use of novel materials, such as tissue adhesive, is currently insufficient.
Evidence regarding long-term sequelae is fair to poor; assessment of pelvic floor dysfunction was not conducted in the age groups of greatest relevance. Limited data show that episiotomy does not prevent fecal and urinary incontinence, pelvic floor relaxation, or impaired sexual function after childbirth.
Conclusions: This systematic review finds no health benefits from episiotomy, and that the immediate outcomes for routine episiotomy (liberal-use policies) are likely no better than those for episiotomy performed under more restrictive-use policies. Indeed, routine use is harmful to the degree that it creates a surgical incision of greater extent than many women might otherwise have experienced.
The Use of Episiotomy in Obstetrical Care: A Systematic Review
Evidence-based Practice Center: Research Triangle Institute/University of North Carolina at Chapel Hill (RTI/UNC-CH)
Topic Nominator: American College of Obstetricians and Gynecologists (ACOG)
Current as of May 2005