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Viswanathan M, Hartmann K, Palmieri R, et al. The Use of Episiotomy in Obstetrical Care: A Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 May. (Evidence Reports/Technology Assessments, No. 112.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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The Use of Episiotomy in Obstetrical Care: A Systematic Review.

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1Introduction

Background

Episiotomy, incision of the perineum at the time of vaginal childbirth, is a common surgical procedure experienced by women in the United States.1 Based on national hospital discharge data for 1999, just over 35 percent of women who gave birth vaginally had an episiotomy performed; the figure was approximately 33 percent in 2000.2, 3 National rates reflect a steady decline over the prior two decades,1 with 2001 data suggesting that approximately 30 percent of vaginal births include episiotomy.4

Actual rates are likely to be higher because administrative data sources are prone to capture fewer events than occur. A study of the validity of birth data for Washington state in 1989 found that hospital discharge data underestimated episiotomy incidence by 44 percent overall when compared with medical records; accuracy of discharge record reporting for individual facilities ranged from recording none of the episiotomies performed at worst, to 86.4 percent at best.5 In their nationally representative survey of women's childbearing experiences between 2000 and 2002, the Maternity Center Association documented that 35 percent of women who had a vaginal birth reported having an episiotomy.6

Likelihood of episiotomy is known to vary based on whether a woman is having a first vaginal birth or a subsequent birth and whether the birth is assisted by use of vacuum or forceps. Both a first birth and assisted vaginal delivery are associated with greater use of episiotomy.1, 7 Likelihood of episiotomy also varies across obstetric care settings. A study of 49,692 vaginal births in 18 hospitals in Philadelphia between 1994 and 1998 examined use of episiotomy among women giving birth for the first time to infants who weighed 2500 to 4000 grams and whose records did not note a difficult labor or assisted delivery. Forty-two percent of women in the study had an episiotomy, with a range of hospital averages from 20 percent to 73 percent.8

The precise origins of episiotomy are lost. Descriptions appear in European texts by the 1740s.9 Taliaferro first described its use in the U.S. medical literature in 1852.10 While caring for a moribund primiparous woman with eclampsia, he describes “immense distension of the vulva” and proceeding to make “an incision at the vulva, believing that preferable to permitting it [the fetal head] to force its way through [the anus] below.” He further noted: “…surely a smooth incised wound would be less injurious and heal more readily than one by rough violence.”10

These observations foreshadow early uses of episiotomy that became ingrained in hospital obstetric practice beginning in the 1920s: to hasten delivery for maternal or fetal indications; to resolve the “unyielding vulva”; and in cases thought to portend imminent severe laceration, to forestall an extensive spontaneous laceration and substitute a more readily repaired surgical incision. In this decade, Joseph DeLee, an opinion leader in the drive to establish obstetrics as a medical specialty, began to promote the concept that episiotomy should be “used routinely” for the maternal indications above as well as to prevent brain damage, epilepsy, and cerebral palsy that might result from the “battering” of the fetal head against a rigid perinuem.11, 12

Most obstetric textbooks endorsed episiotomy by the 1930s: “This is a prophylactic procedure, its purpose being: (a) to prevent extensive damage of the posterior vaginal wall and pelvic floor; (b) to save from gross injury the sphincter ani muscle and wall of the anal canal; (c) to curtail long-drawn-out overdistension of the vaginal wall, and the damage resulting therefore…,” providing the advantages of preventing extensive laceration, preserving sphincter integrity, providing a clean-cut wound and making scar tissue less likely to form, and ultimately achieving a result that is more satisfactory from “anatomical, functional, and cosmetic standpoints.”13 (Chapter 22, p. 666) Authors of texts frequently note that the procedure is especially warranted for primiparous patients, observing, “inasmuch as some degree of laceration occurs in the majority of cases episiotomy is a conservative rather than a radical procedure”14 (Vol 2, Section 10, p. 330).

In the 1940s and 1950s, routine episiotomy was little debated and increasingly used. During subsequent decades, the proposed benefits of episiotomy continued to take on broader scope. These benefits included goals of reducing postpartum perineal pain when compared to spontaneous lacerations, preventing future pelvic organ prolapse and urinary and rectal incontinence, and preserving sexual function both by reducing slackness of the vaginal introitus and by reducing the likelihood of pain with intercourse.15, 16 By the 1980s, episiotomy accompanied 64 percent of vaginal births in this country.17

Episiotomy became a routine practice of physicians long before emphasis on using outcomes research to inform practice. In seeking to establish an evidence base to support or refute the use of episiotomy, randomized clinical trials in the mid and late 1980s revealed two key findings: (1) routine mediolateral episiotomy use compared to restricted use was associated with higher risk of anal sphincter and rectal injuries, and (2) such surgery precluded a woman's possibility of giving birth with an intact or minimally damaged perineum.18 Larger trials in more varied populations of women and providers followed in the 1990s, with similar results. Investigators also sought to assess longer-term effects of perineal management at the time of birth on outcomes such as persistent pain, pelvic floor defects, urinary and rectal continence, and sexual function and satisfaction. The latter topics entered the spotlight as these outcomes became more dominant among the prevention-oriented goals proposed to be achieved by episiotomy.

Despite several decades of research, which many interpret as definitive evidence against routine use of episiotomy, little professional consensus has developed about the appropriateness of routine use. Lack of consensus is illustrated by variation in rates of use. From 1987 to 1992, Kane Low and her colleagues documented provider-level variation from 13.3 percent to 84.6 percent, with an average of 51 percent among spontaneous term births in a prospectively enrolled low-risk population.19 Episiotomy use varied widely in the midwives and physicians studied. Variation has been reported by time of day20 and by facility type, size, and location.21

Although restricted-use arms of trials have achieved episiotomy rates as low as 8 percent to 10 percent,22, 23 use remains common in many locations. Current obstetric care providers who continue to view episiotomy favorably most strongly agree with survey items that indicate they employ episiotomy to “prevent perineal trauma and to prevent pelvic floor relaxation and the consequences of pelvic floor relaxation, such as bladder prolapse and urinary incontinence.” Furthermore, providers endorse the statement that they “prefer to employ episiotomy frequently, because it is easier to repair than the laceration that results when episiotomy is not used.”24

Five points summarize the long history of episiotomy:

  • 1. routine use of episiotomy evolved from more limited indications;
  • 2. a goal of preventing future problems is eclipsing goals for labor “management”;
  • 3. provider type is associated with acceptance or avoidance of its use;
  • 4. among providers of the same type, use varies widely; and
  • 5. rates of use vary distinctively by institution and region.

The last three of these characteristics—wide practice variation—suggest to health services researchers that episiotomy use is heavily driven by local professional norms, experiences in training, and individual provider preference. Variation in biology, in this case the physiology of vaginal birth, rarely explains discrepancies in practice as large as those seen for episiotomy use. 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. A 1968 Lancet editorial aptly captures the issues: “Despite the apparent simplicity of episiotomy, argument continues about how often the operation should be undertaken, the choice of incision, and the method of repair. Moreover, little information is available about the incidence of later complications such as dyspareunia.”25

This systematic evidence review revisits randomized trials of routine versus restricted use, identifies the sole trial of midline versus median episiotomy, presents evidence for choosing among options for repair methods, and extends prior reviews to encompass longer-term outcomes. Specifically, we have systematically assessed the evidence from trials and prospective cohorts related to the influence of episiotomy on measures of pelvic floor relaxation, continence, and sexual function and satisfaction. The goal of this synthesis is to inform care providers, professional organizations, advocates, and individual women about the current state of the evidence about the routine use of episiotomy.

Key Questions and Conceptual Framework

Key Questions

The original Scope of Work for this review was developed by the American College of Obstetricians and Gynecologists (ACOG) and forwarded by the Agency for Healthcare Research and Quality (AHRQ) to the RTI International-University of North Carolina Evidence-based Practice Center (RTI-UNC EPC). The work assignment proposed four provisional questions for review. Those questions were the basis for a brief review completed by the EPC Coordinating Center (The Lewin Group). Brief reviews help prioritize the topics AHRQ assigns to the 10 “generalist” EPCs.

The RTI-UNC EPC further revised the proposed questions after discussions with internal technical staff, AHRQ staff, and our Technical Expert Advisory Group (TEAG). The final key questions (KQ s) are listed below.

KQ 1. Does the practice of liberal or routine episiotomy compared to more selective use of episiotomy influence maternal postpartum outcomes?

KQ 2. Does episiotomy incision type (i.e., midline or mediolateral) influence maternal postpartum outcomes?

KQ 3. Does the repair of the perineal defect (i.e., suture type and repair approach) influence maternal postpartum outcomes?

KQ 4. Does episiotomy have a long-term influence on urinary incontinence, fecal incontinence, or pelvic-floor defects?

KQ 5. Does episiotomy or incision type, or both, influence future sexual function?

Conceptual Framework for Analysis of the Use of Episiotomy in Obstetric Care

The conceptual framework in Figure 1 (i.e., the causal pathway developed for this systematic review) summarizes the critical issues addressed here and their links to the key questions.

Figure 1. Conceptual framework for routine use of episiotomy in obstetric care.

Figure

Figure 1. Conceptual framework for routine use of episiotomy in obstetric care.

The key questions for this review present several conceptual challenges. Although the conceptual framework (Figure 1) treats episiotomy as the exposure of interest, trial participants cannot feasibly be allocated to receive an episiotomy with 100 percent certainty under any circumstance versus no episiotomy under any circumstance. Relevant controlled clinical trials most often compare a policy of liberal or routine use to a policy of indicated use only (often with varied or unspecified indications). These studies appropriately conduct analyses that compare maternal outcomes by study group as allocated. As a result, authors report on the status of the integrity of the vagina and perineum, including whether episiotomy was performed, as an outcome. In contrast, nonrandomized prospective studies (included for KQ 4 and 5) most often report outcomes, such as pain with intercourse, stratified by actual perineal status after the birth. To address potential differences arising from these variations in exposure categorization as study group versus episiotomy status, we have analyzed outcomes such as type of perineal trauma by strata, including episiotomy versus none, spontaneous versus assisted vaginal birth, and by other potential modifiers such as parity whenever such a summary is possible.

Another issue is how to define “routine episiotomy.” Defining the term is a challenge because the category is described in studies by negatives such as “not for fetal distress” and “not for dystocia.” We captured the operational definitions provided by authors of included publications and attempted to isolate data that reflect use of episiotomy at the time of uncomplicated spontaneous vaginal births. The text of this review and the evidence tables specify how authors define the terms “indicated” and “routine” so that our readers may use this information as a filter through which to view study findings.

A third concern is how to distinguish immediate versus long-term outcomes. To ensure a broad review of the available literature, we included all studies that report relevant outcomes without regard to the specific followup interval. We abstracted the intervals at which followup data are collected. Studies were later classified into those that report on postpartum versus those that include longer-term followup. If a study provides both types of information—immediate and long-term followup—study results appear in more than one portion of the review.

Production of This Evidence Report

Organization of This Evidence Report

Chapter 2 describes our methods, including our search strategies and inclusion/exclusion criteria; we also document our approach to grading the quality of articles and rating the strength of evidence. In Chapter 3, we present the results of our literature search and synthesis of retained articles by key question. Chapter 4 further discusses the findings, presents our conclusions, and offers recommendations for future research. Our references and included studies and a listing of excluded studies follow Chapter 4. Appendixes include a detailed description of our search strings (Appendix A), abstraction and quality-rating forms (Appendix B), detailed evidence tables (Appendix C), and acknowledgments (Appendix D). Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/ tp/epistp.htm.

Technical Expert Advisory Group (TEAG)

We identified technical experts in the field of episiotomy to provide assistance throughout the project. The TEAG (see Appendix D) was expected to contribute to AHRQ's broader goals of (1) creating and maintaining science partnerships as well as public-private partnerships and (2) meeting the needs of an array of potential customers and users of its products. Thus, the TEAG was both an additional resource and a sounding board during the project. The TEAG included eight members: seven technical/clinical experts and one potential user of the final evidence report, an ACOG representative.

To ensure robust, scientifically relevant work, we called on the TEAG to provide reactions to work in progress and advice on substantive issues or possibly overlooked areas of research. TEAG members participated in conference calls and discussions through e-mail to

  • refine the analytic framework and key questions at the beginning of the project;
  • discuss the preliminary assessment of the literature, including inclusion/exclusion criteria; and
  • provide input on the information and categories included in evidence tables.

Because of their extensive knowledge of the literature, including numerous articles authored by TEAG members themselves, and their active involvement in professional societies and as practitioners in the field, we also asked TEAG members to participate in the external peer review of the draft report.

Uses of This Report

This evidence report addresses the key questions outlined in Chapter 2 through systematic review of published literature. We anticipate that the report will be of value to ACOG and other professional societies for their various efforts to inform and educate obstetricians, family physicians, nurses, midwives, childbirth educators, doulas, and women in their reproductive years. This report can bring practitioners up to date about the current state of evidence, and it provides an assessment of the quality of studies that aim to determine the outcomes of the practice of episiotomy. Researchers can obtain a concise analysis of the current state of knowledge in this field and will be poised to pursue further investigations that are needed to improve health for obstetric populations.

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