1. Episiotomy: When will we cut it out?
Alice Teich, PGY1
Dept of Family and Social Medicine
April 27, 2010
11/22/2018

2. Case
3/26/10
HPI: 16yo by LMP (7/5/09) EDD 4/8/10 c/w 11w sono p/w CTX q5min since 3pm today. LOF en route to hospital (~30min ago.) No VB, +FM
PNI: Intake BP 102/50 ( /50-90). Weight gain 31lbs (intake >189)
Adolescent pregnancy: saw SW, and nutritionist. Attended all prenatal appointments. Has WIC and Medicaid filled out.
PNL: wnl/unremarkable
Sonos: 9/20/09 dating
11/14/09 anatomy 19wks. No anat. Anomalies. Fetus 50%tile
2/17/10 no anat. Fetus 55%tile w adequate interval growth. AFI 14.
PObHx: 2008 TOP 1st trim. D&C. uncomplicated
PGynHx: no cysts/fibroids/STIs/abnl pap.
12/reg/5.
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3. Case continued..
PMH: asthma -no intubations or hospitalizations. Albuterol PRN
PSH: D&C only
Meds: PNV
Allergies: NKDA
SH: lives w mom. No tob/EtOH/drugs at all. In high school. FOB involved.
FH: non-contributory.
PE: BP: 112/60 HR 74 Tmax: 36.6
FHT: 140/mod/+accels, -decels (EFM)
Toco: CTX q2-3 min (monitored externally)
SVE: 9/10/ Vsono EFW: 3100g (Leopolds)
A/P: 16yo in active labor
Admit to L&D -- anticipate NSVD
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4. Case continued..
Pt c/o pain and need to “make bm”. Found to be FD and ready to push.
SVE: 10/100/+1
Toco: CTX q2-3min
Pt is in significant pain while pushing and requesting pain medication: infant’s head has been crowning for approx 2 minutes/too late for epidural or IV analgesia.
Pt is screaming, thrashing around, and FHT begins to decel to 70s, 80s, then comes back up to 120s, then decels again. Pt repositioned to lateral decub on both sides, but unable to stay in these positions, given discomfort.
Episiotomy is cut midline, attempt made to deliver head for approx 30 seconds, then additional space cut, creating 2nd degree episiotomy. Infant is quickly delivered without instrumentation.
Delivery of vigorous female infant w apgars of 9/9. Cord clamped, cut, and gases sent. 3 cord placenta delivered spontaneously and intact. Fundus firmed with fundal massage and pitocin administration. Lidocaine administered locally and 2nd degree episiotomy repaired with 2-0 and 3-0 vicryl w/o further complication. No 3rd degree extension into rectal sphincter. Hemostasis achieved. EBL ~500cc.
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5. Episiotomy
Definition: a surgical incision of the perineum usually performed at point when perineum is stretched and distended, just prior to crowning of the fetal head.
Median/Midline: vertical incision from fourchette straight back towards anus
Easier to repair
Mediolateral episiotomy: incision ~ perpendicular to midline, with angle becoming smaller (~45º) beyond fetal presenting part
Less extension to rectum
J incision: hybrid
There are three major types: median, mediolateral, and J incisions
Median epis: standard in US/Canada
Mediolateral: Europe: Royal College of Obstetricians and Gynaecologists recommend mediolateral rather than median episiotomy, when episiotomy is clinically indicated [32].
American College of Obstetricians and Gynecologists also state mediolateral episiotomy may be preferable to median episiotomy in selected cases [12].
The anatomical structures involved in the incision include the vaginal epithelium, perineal body, and the junction of the perineal body with the bulbocavernosus muscle in the perineum.
Directed away from anal sphincter/preventing rectum from extension injury
No data on the J
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6. Episiotomy
The purpose is to increase the diameter of the soft tissue pelvic outlet, thereby preventing perineal lacerations, facilitating delivery, and reducing the time for expulsion of the infant.
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7. Episiotomy: One of the most common operations performed on women
Prevalence is decreasing
Changing trends in obstetrical practice over time have influenced the decision to perform an episiotomy and resulted in a decreasing prevalence of the procedure (60.9 percent of vaginal deliveries in 1979 versus 24.5 percent in 2004) [2]. The prevalence of episiotomy is highest in Latin America and lower in Europe [3], with reported rates varying widely from 1 percent (Sweden) to 80 percent (Argentina) [4,5].
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8. Indication for Episiotomy?
The only indication for episiotomy that cannot be categorically dismissed is for fetal concerns (non-reassuring tracing, etc) that arise urgently during advanced labor.
Other historical indications for episiotomy are not evidence-based and are proven to do more harm than good.
Nulliparity
Imminent tear
Shoulder dystocia
Need for vacuum or forceps delivery
ACOG Practice Bulletin
Episiotomy is one of the most commonly performed procedures in obstetrics. In 2000, approximately 33% of women giving birth vaginally had an episiotomy (1). Historically, the purpose of this procedure was to facilitate completion of the second stage of labor to improve both maternal and neonatal outcomes. 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. 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. 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.
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9. Not an Indication for Episiotomy
Nulliparity
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10. Not an Indication for Episiotomy
Tearing is imminent
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11. Not an Indication for Episiotomy
Severe Shoulder dystocia
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12. Not an Indication for Episiotomy
Using vacuum or forceps for delivery
his may aid in the delivery of a macrosomic or breech infant, and may shorten the time to expulsion if fetal compromise is suspected. If a shoulder dystocia is anticipated, it may be prudent to perform an intentional episiotomy to create more room for the obstetric maneuvers required to relieve the dystocia.
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13. Episiotomy Other enduring myths about episiotomy
It prevents pelvic floor weakness
It is easier to repair than a tear
It heals better than a tear
It minimizes intraventricular hemorrhage in preterm infants
Although episiotomy has been advocated to minimize the risk of intraventricular hemorrhage in preterm births, there is no evidence that this intervention is effective on a routine basis [18]. Delivery of the premature infant.AUBottoms SSOClin Obstet Gynecol 1995 Dec;38(4):780-9.
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14. Evidence against routine use of episiotomy:
Increases the following:
Wound extension, dehiscence, infection, and healing time
Blood loss
Postpartum pain
Likelihood of leaking stool and gas (bowel incontinence)
Dyspareunia
+/- urine incontinence
Extension of the episiotomy to create a third or fourth degree laceration or deep vaginal tear is one of the more common complications of episiotomy. The prevalence of third or fourth degree lacerations by type of episiotomy among primiparous women delivering vaginally has been reported to be: no episiotomy (1 percent), mediolateral episiotomy (9 percent), and median episiotomy (20 percent) [48]. †Owen, J, Hauth, JC. Episiotomy infection and dehiscence. In: Gilstrap, LC III, Faro, S (eds) Infections in Pregnancy, Alan R Liss, New York 1990.†no abstract available
What the evidence DOES show is that routine use of episiotomy increases rates and incidence of the following:
In Conclusion:
ïA systematic review of randomized trials comparing restrictive use of episiotomy to routine use found that the restricted use resulted in less posterior perineal trauma (relative risk [RR] 0.88, 95% confidence interval [CI] ), less suturing (RR 0.74, 95% CI ), and fewer healing complications (RR 0.69, 95%CI ), although there was more anterior perineal trauma (RR 1.79, 95% CI ) [3]. Both median and mediolateral episiotomies were included in the trials. There were no differences in the incidence of severe lacerations, dyspareunia, urinary incontinence, and several measures of pain.ïAnother systematic review concluded that there was no evidence that a policy of routine episiotomy resulted in significant reductions in laceration severity, pain, or pelvic organ prolapse compared to a policy of restricted use [28]. A total of 26 randomized controlled trials which assessed outcomes in the first three months postpartum and prospective studies which assessed longer-term outcomes were included in the analysis. A subsequent randomized trial that compared restrictive and routine episiotomy in nulliparas also reported no difference between groups in the rates of urinary or anal incontinence, with follow-up four years postpartum [29].ïIn addition, a decision-tree model showed that a policy of routine episiotomy was more costly than restricted performance of the procedure [30]. Only procedure related costs up to one month postpartum were considered in the analysis.Based on these data, the American College of Obstetricians and Gynecologists support the position of restricted instead of routine use of episiotomy [12]. Avoidance of routine episiotomy is recommended for both spontaneous and instrumental deliveries. (See "Operative vaginal delivery".)Training courses, audits, presence of a staff leader and episiotomy rate feedback for individual midwives and obstetricians appear to help reduce the use of routine episiotomy [31].
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15. Episiotomy: Why is it still performed?
High-intervention standards for childbirth
Practice style and values of individual providers
Practice style and values in specific birth settings
Influence of colleagues
Influence of medical education
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16. Avoiding episiotomy: As early as possible in pregnancy:
Encourage pts to learn about episiotomy as part of learning about pregnancy, labor and delivery
Encourage pt’s to create a birth plan that takes into account their values, preferences
Even if you have been the provider for a pt throughout their entire pregnancy and especially if you haven’t, ask pts about their birth plans again at the time of labor/admission.
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17. Avoiding episiotomy Kegel exercises Perineal massage Warm Compresses
Slowed, spontaneous pushing during second stage of labor
Upright birthing position
Kegels during pregnancy to help strengthen the pelvic floor muscles.
Prenatal perineal massage to stretch and relax the tissue around the vaginal opening.
Applying warm compresses during delivery.
Slowed spontaneous pushing during second stage labor may allow the tissues to stretch rather than tear.
Upright birthing position (rather than lithotomy) may decrease the perceived need for episiotomy.
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18. References http://www.childbirthconnection.org
Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005; 293:2141-8
UptoDate
ACOG PRACTICE BULLETIN. CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN/GYNECOLOGISTS NUMBER 71, APRIL 2006
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