Episiotomy: Is it necessary?

What is an episiotomy?

An episiotomy is the surgical procedure that enlarges the opening of the vagina through the cutting of the perineum, the skin and the muscles between the vulva and the anus.

How did this procedure become widely used in childbirth?

The exact origins of episiotomy are not known but first accounts in European medical texts date back to the mid-18th century. It became widely used in the early 20th century due to a doctor named Joseph DeLee, who was keen to establish obstetrics as a medical specialty and who believed episiotomy should be used to prevent “brain damage, epilepsy and cerebral palsy that might result from the ‘battering’ of the fetal head against the rigid perineum” (ARHQ, 2005, p1). Due to this promotion of episiotomy as a preventative measure, it became a routine procedure by the 1930’s.

By the 1980s, 64% of births in the USA included the intervention of episiotomy. Current research, namely the Cochrane review (2009) on ‘Episiotomy for vaginal birth’, suggests that routine episiotomy is not best practice and that rates around the world vary from a low of 9.7% in Sweden to 100% of vaginal births in Taiwan. The current rates of episiotomy also vary widely from unit to unit in Ireland. For example, recent research shows an incidence rate of 18.5% in Dublin North East compared to 27.4% in Dublin Mid Leinster. At the same time, the rates vary significantly across time. For example, from 2005 to 2009 episiotomy rates increased in Dublin North East significantly from 14.75% to 22.4%, with no parallel increase in vaginal delivery rates over the same four years. The episiotomy rates in individual hospitals in Ireland vary from 5.7% of first time mothers in Our Lady of Lourdes Midwife-Led Unit (MLU) to 43.5% of first time mothers in the National Maternity Hospital (NMH).

These variations in rates seen worldwide clearly indicate that episiotomy is heavily driven by professional norms, different experiences in training and individual provider preference and not by physiological necessity. The US Agency for Healthcare Research and Quality (AHRQ, 2005) concluded in its report on The Use of Episiotomy in Obstetrical Care that “when practice variation is prominent, accrual of evidence of benefits and risks should take on a key role in informing care. In this context, episiotomy has the hallmarks of a procedure that warrants repeated synthesis of the evidence of proposed benefits and potential risks” (p.3)

Why is this procedure used in modern childbirth?

One of the topics that comes up most often in antenatal education is whether or not an episiotomy is necessary and how this intervention can be avoided. Many women are frightened of both tearing and of undergoing an episiotomy during childbirth and there is often a misconception that either one of these is inevitable. This is not true. The perineum is designed to open and to stretch  in order to accommodate the birth of a baby. However, it is not unusual for a woman’s perineum to tear or to be slightly ‘grazed’ in childbirth. Tearing is graded according to severity:

1st degree: Involves the skin around the vaginal opening and usually heals within a week or two.

2nd degree: Involves the vaginal tissue and perineal muscles, may require stitches and heals within a few weeks.

3rd degree: Involves the vaginal tissue, perineal muscles and the muscle that surrounds the anus. This tear will require stitches and will  require repair in an operating theatre under good lighting conditions and good anaesthesia. It wIll take up to a few months to heal. Third degree tears are divided into sub categories indicating whether the internal or external sphincter is involved (3A 3B 3C)

• 3a: partial tear of the external anal sphincter involving less than 50% thickness
• 3b: greater than 50% tear of the external anal sphincter
• 3c: internal sphincter is torn

4th degree: Involves the perineal muscles and anal sphincter as well as the tissue lining the rectum. Requires repair in an operating theatre. Will take up to a few months to heal.

For more information see this useful patient guide developed by the RCOG

There is approximately a 50% chance of giving birth and incurring no tears or slight grazing, while there is a 1 in 4 chance that even though your perineum is intact an episiotomy may be performed. According to a recently published Cochrane review of midwifery-led care versus consultant led care, the rates of episiotomy are 16% lower if you give birth in a midwife-led unit.  While 1st and 2nd degree tears occur in approximately half of all births (most healing quickly and requiring no stitches), 3rd and 4th degree tears that require surgical intervention account for around 6% of overall perineal trauma in childbirth. These statistics are not made available on an annual basis in Ireland as this data is not published or shared in the public domain; however, the above statistics from New South Wales, Australia in 2011 give a fairly accurate account of overall rates of perineal tears (by degrees) and of episiotomy. Looking at the table in the link here shows that the overall episiotomy rate for first time mothers, regardless of whether the perineum is intact or not, is 1 in 3 births.

What contributes to the increased rates of episiotomy in Ireland?

The rates of episiotomy in Ireland may be attributed to the reasons outlined above (professional norms, training differences and provider preference). They can not be attributed to physiological reasons alone as the vast majority of women will not have any difficulties with their perineum stretching to accommodate the birth of their baby. The outcome is more likely to be an intact perineum or minor grazing or tearing as opposed to a need for suturing.

If we look at professional norms and training differences, this may be influenced by the expectation that obstetricians and midwives will not allow a woman to tear as this is not something that is taught during their training. This may also be linked to provider preference in that each individual obstetrician and midwife will have their own ideas about the practice of episiotomy vs tearing. The research shows that healing time is quicker when the perineum is allowed to tear rather than performing an episiotomy. This is because an episiotomy will always require suturing, while the vast majority of tears or grazes will not.

What are the risk factors for tears or perineal trauma?

Episiotomy became routine practice from the early part of the 20th century and it stayed that way for at least 5 decades. Since the 1980s there has been a large body of research that supports the restrictive, or limited, use of episiotomy rather than the routine. Studies comparing routine versus restrictive practice of episiotomy have found that restrictive use (only when indicated and not performed routinely) results in:

• less posterior perineal trauma
• less suturing
• fewer complications
• no difference for most pain measures
• no difference in urinary incontinence
• no difference in painful sex
• no difference in severe vaginal/perineal trauma after birth

There are two common methods of incision when an episiotomy is performed. They are:

Midline (also known as median): where the incision is made in a straight line form the bottom of the vaginal opening toward the rectum. This is the most common method of episiotomy in the US and it is associated with higher rates and the resulting complications of 3rd and 4th degree tears due to obstetric anal sphincter injuries (OASIS). It is also associated with  reduced blood loss.

Mediolateral: where the incision is made at an angle (of around 45 degrees) from the bottom of the vaginal opening (on either side) outwards. This is the most common method of episiotomy in Europe. It is difficult to repair and associated with more bleeding; however it is widely believed to protect against OASIS. The evidence for this is not entirely clear as the research suggests that this method protects against OASIS on women who underwent operative vaginal delivery but it is controversial whether it is protective in women who have spontaneous vaginal delivery.

(Images above and description of procedures taken from: Gibbon, K (2012). How to perform and episiotomy. Midwives, Issue 5)

Is it better to tear or to have an episiotomy? 

Most current research supports prevention and minimising ‘perineal trauma’, whether referring to tearing or to episiotomy.

The consensus is that tears heal much faster than an episiotomy.

There is much less risk of infection and less blood loss with a tear compared to an episiotomy.

The risk with an episiotomy, versus allowing a woman to tear, is that the incision itself can tear and become larger, and extend to the rectum.

Vaginal deliveries with episiotomy have statistically higher rates of 3rd or 4th degree perineal tears than those without episiotomy, even in critical conditions such as shoulder dystocia or occiput-posterior labors (ie, labours where the baby is said to be ‘stuck’ or ‘back to back’). (Steiner et al., 2012)

Is an episiotomy necessary? 

The following points highlight the research that has been done to support the very restrictive use of episiotomy.

• An episiotomy does NOT provide the benefits, such as protection of the pelvic floor from lacerations or protection of the fetal head from trauma, that were described by Joseph DeLee in 1920 (Lappen and Gossett, 2010) and that initiated the widespread and long term practice of routine episiotomy.
• Rigid perineum and previous scarring are not justifiable reasons for performing an episiotomy (Enkin et al, 2000).
• The practice or use of episiotomy is more to do with the provider type, the hospital type and even the time of day of where you are giving birth. Episiotomies are performed more during the day than at night, which may be due to obstetric pressure to expedite delivery during the day, rather than the need for a surgical intervention. (Lappen and Gossett, 2010)
• Physicians’ beliefs are likely associated with rates of episiotomy. For example in a study by Klein et al. (1995), those who regarded episiotomy ‘very favourably’ performed more interventions to expedite delivery. These doctors also had great difficulty adhering to limited use of episiotomy when faced with women who were randomised to be part of the ‘restrictive‘ episiotomy group, as part of the study.
• Absolute indications for episiotomy have not been established. The increased risks of 3rd or 4th degree tears or damage to the anal sphincter with an episiotomy mean that its use should be highly restrictive to avoid the risks associated with this surgical procedure.

What methods may help to prevent perineal trauma (due to tearing and/or episiotomy)?

Rates of episiotomy are reduced when Health Care Providers (HCPs) use a “hands off” technique during labour and birth. For example, no hand(s) on the perineum and limited manual assistance for the birth of the shoulders. (Aasheim et al., 2011)

In addition to the “hands off” technique, the use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma (tears and/or episiotomy). (Aasheim et al., 2011)

While research supporting perineal massage (once or twice a week) for prevention of tears and/or episiotomy has mixed results, it appears to have the most impact on first-time mothers who give birth vaginally as it reduces the likelihood of episiotomy (by 16%) and reduces prolonged perineal pain (Beckman and Stock, 2013). While the research shows no statistical difference in outcomes for women who have had a previous vaginal birth, perineal massage is a harmless and appropriate method of relaxing the skin and muscles of the perineum from around 34 to 36 weeks gestation.

Evidence on birthing positions to prevent tears and/or episiotomy is inconclusive; however, a woman should be supported in choosing whatever birthing position is comfortable for her during labour and birth, including sitting or being upright. The feeling of being in control can help boost confidence while birthing and this seems to be equally as protective as the birthing position that a woman chooses. (De Jonge et al., 2010)

Episiotomies may be reduced in women using spontaneous pushing compared with coached pushing (sometimes referred to as valsalva or ‘purple pushing’). In fact, recent research concluded that spontaneous pushing should be accepted as best clinical practice and that women should be “supported in following the feelings of their bodies and to use their own bearing down efforts and urges to push” (Prins et al., 2011)

Talk to your HCP, your midwife and your consultant about episiotomy and state your preference to birth with an intact perineum. If you prefer to tear rather than to have an episiotomy, you can talk this over with your health care provider. It is better to know your provider’s preference and to discuss your preferences before you head to the hospital to give birth rather than trying to discuss your options during labour and birth.

References

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf RCOG guidelines on repair of perineal tears

Aasheim, V., Nilsen, A.B.V., Lukasse, M. and Reinar, L.M. (2011). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2011, Issue 12.

Beckmann, M.M. and Stock, O.M. (2013). Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4.

Carroli, G and Mignini, L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2#sthash.aeVUhyLZ.dpuf

De Jonge, A., Van Diem, T., Scheepers, H., Buitendijk, S.E. and Lagro-Janssen, A.L.M. (2010). Risk of perineal damage is not a reason to discourage a sitting birthing position: A secondary analysis. International Journal of Clinical Practice, 65(5); pp 611-618.

Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyr J. (2000) A guide to effective care in pregnancy and childbirth (3rd ed.). Oxford University Press: Oxford.

Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. (1995). Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for the women in their care. CMAJ 153(6), pp. 769–779.

Lappen, JR and Gossett, D. Changes in episiotomy practice: Evidence-based medicine in action. Expert Review of Obstetrics and Gynecology. May 2010, 5(3), pp. 301-309

NSW Perinatal Data Collection (SAPHaRI) (2011). Birth complications: Perineal tears by year. Centre for Epidemiology and Evidence, NSW Ministry of Health. URL: http://www.healthstats.nsw.gov.au/Indicator/mab_pnspvbth_cat

Steiner, N., Weintraub, A.Y., Wiznitzer, A., Sergienko, R. and Sheiner, E. (2012). Episiotomy: The final cut? Archives of Gynecology and Obstetrics Vol 286(6); pp 1369-1373.

Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson T, Lohr KN, Gartlehner G, Thorp J. (2005). The Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report/ Technology Assessment No. 112. (Prepared by the RTI-UNC Evidence-based Practice Center, under Contract No. 290-02-0016.) AHRQ Publication No. 05-E009-2. Rockville, MD: Agency for Healthcare Research and Quality. May 2005