Obstetric Myths Versus Research Realities - Episiotomy

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Obstetric Myths Versus Research Realities

Chapter 14: Episiotomy

 

Myth: A nice clean cut is better than a jagged tear.

 

Reality: " Like any surgical procedure, episiotomy carries a number of

risks: excessive blood loss, haematoma formation, and infection. . . .

There is no evidence . . . that routine episiotomy reduces the risk of

severe perineal trauma, improves perineal healing, prevents fetal trauma

or reduces the risk of urinary stress incontinence. " Sleep, Roberts, and

Chalmers 1989

 

IntroductionSummary of Significant Points Organization of Abstracts

ReferencesAbstracts 1-18Abstracts 19-28

 

Routine or prophylactic episiotomy (as opposed to episiotomy for

specific indication such as fetal distress) is the quintessential

example of an obstetrical procedure that persists despite a total lack

of evidence for it and a considerable body of evidence against it. All

the authoritative pronouncements in favor of episiotomy descend from a

75-year-old article (DeLee 1920) that produced not a shred of evidence

in its support. Most recently, Williams Obstetrics (Cunningham,

MacDonald, and Gant 1989) states, " The reasons for [episiotomy's]

popularity among obstetricians are clear. It substitutes a straight,

neat surgical incision for the ragged laceration that otherwise

frequently results. It is easier to repair and heals better than a

tear. " Human Labor and Birth (Oxorn-Foote 1986) adds that it averts

" brain damage " by " lessen[ing] the pounding of the head on the

perineum. " An earlier edition of William's Obstetrics (Pritchard,

MacDonald, and Gant 1985) claims that it reduces the incidence of

cystocele (a herniation of the posterior bladder through the anterior

rectal wall), rectocele (a herniation of the anterior rectal wall

through the posterior vaginal wall), and stress incontinence

(involuntary loss of urine in response to laughing, sneezing, etc.,

although the 1989 edition admits this benefit is unproved). It then

lists " important questions for the obstetrician concerning episiotomy, "

none of which is whether to do one at all. In a branch of medicine rife

with paradoxes, contradictions, inconsistencies, and illogic, episiotomy

crowns them all. The major argument for episiotomy is that it " protects

the perineum from injury, " a protection accomplished by slicing through

perineal skin, connective tissue, and muscle. Obstetricians presume

spontaneous tears do worse damage, but now that researchers have gotten

around to looking, every study has found that deep tears are almost

exclusively extensions of episiotomies. This makes sense, because as

anyone who has tried to tear cloth knows, intact material is extremely

resistant until you snip it. Then it rips easily.

 

By preventing overstretching of the pelvic floor muscles, episiotomies

are also supposed to prevent pelvic floor relaxation. Pelvic floor

relaxation causes sexual disatisfaction after childbirth (the concern

was the male partner, of course, hence, the once-popular " husband's

knot, " an extra tightening during suturing that made many women's sex

lives a permanent misery), urinary incontinence, and uterine prolapse.

But older women currently having repair surgery for incontinence and

prolapse all had generous episiotomies. In any case, episiotomy is not

done until the head is almost ready to be born. By then, the pelvic

floor muscles are already fully distended. Nor has anyone ever explained

how cutting a muscle and stitching it back together preserves its

strength.

 

Perhaps the most absurd rationale of all is brain damage from the fetal

head's " pounding on the perineum. " A woman's perineum is soft, elastic

tissue, not concrete. No one has ever shown that an episiotomy protects

fetal neurologic well-being, not even in the tiniest, most vulnerable

preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and

Cooke 1986; The 1990, both abstracted below).

 

Meanwhile, as the authors of this chapter's " Reality " quotation point

out, episiotomy, like any other surgical procedure, carries the risk of

blood loss, poor wound healing, and infection. Infections are painful.

Sutures must be removed to drain the wound, and later the perineum must

be restitched. In their literature survey Thacker and Banta (1983,

abstracted below) found wound infections and abscess rates ranging from

0.5% to 3%.

 

Moreover, there are two extremely rare gangrenous infections called

necrotizing fasciitis and clostridial myonecrosis reported in the

literature. These infections kill many of the women who contract them

and maim the survivors. William's Obstetrics (Cunningham, MacDonald, and

Gant 1989) says of them in boldface type, " Mortality is virtually

universal without surgical treatment, and it approaches 50% even if

aggressive excision is performed. " While these infections are rare, they

make a substantial contribution to maternal mortality. Between 1969 and

1976 they caused 27% (3/11) of the maternal deaths in Kern County,

California (Ewing, Smale, and Eliot 1979). A fourth woman survived,

spending 23 days in the hospital. Shy and Eschenbach (1979) report on

four cases in King County, Washington, between 1969 and 1977. Three

women died, representing 20% of the maternal mortality rate during those

years. The fourth woman survived, losing most of her vulva to surgical

excision and debridement. Nine additional cases are also reported, of

which seven women died and two had extensive surgeries and prolonged

hospitalizations (Soper 1986; Sutton et al. 1985; Ewing, Smale and

Elliott 1979; Golde and Ledger 1977). Since all fatalities were in

healthy women who had uncomplicated labors, their episiotomies literally

killed them!

 

Obviously an infection could start in a repaired tear, but substantial

numbers of women who do not have episiotomies have intact perineums.

There also appears to be an association between the extent of the wound

and these deadly infections. Nine of the 17 cases, or more than half,

involved third- or fourth-degree injuries (tears or deliberate cuts into

or through the anal sphincter). It bears repeating that women with no

episiotomy hardly ever suffer deep tears.

Despite two decades of evidence to the contrary, most doctors and some

midwives still cling to the liberal use of episiotomy. The Canadian

multicenter randomized controlled trial (Klein et al. 1992, abstracted

below) could not get doctors to abandon it. Episiotomy rates were

reduced by only one-third in the so-called restricted arm of the study.

More than half of primiparas in the restricted group (57%) still had

episiotomies, as did nearly one-third of multiparas (31%). " The

intensity with which physicians adhere to the belief that episiotomy

benefits women is well illustrated by the behavior of many of the

participating physicians in this trial. Many were unwilling or unable to

reduce their episiotomy rate according to protocol. "

If episiotomy lacks scientific rationale, what drives its use? As Robbie

Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits

underlying cultural beliefs about women and childbirth. It reinforces

beliefs about the inherent defectiveness and untrustworthiness of the

female body and the dangers this poses to women and babies. So DeLee

(1920), imbued with these beliefs, writes:

 

Labor has been called, and still is believed by many, to be a normal

function. . . . [Y]et it is a decidedly pathologic process. . . . If a

woman falls on a pitchfork, and drives the handle through her perineum,

we call that pathologic--abnormal, but if a large baby is driven through

the pelvic floor, we say that is natural, and therefore normal. If a

baby were to have its head caught in a door very lightly, but enough to

cause cerebral hemorrhage, we would say that it is decidedly pathologic,

but when a baby's head is crushed against a tight pelvic floor, and a

hemorrhage in the brain kills it, we call this normal.

 

Having invented the problem, he proffers a solution: as soon as the head

passes through the dilated cervix, anesthetize the woman with ether, cut

a large mediolateral episiotomy, pull the baby out with forceps, and

manually remove the placenta, then give the woman scopolamine and

morphine for the lengthy repair work and to " prolong narcosis for many

hours postpartum and to abolish the memory of labor. " Repair involves

pulling down the cervix with forceps to examine it and stitch any tears

and laboriously reconstructing the vagina to restore " virginal

conditions. " While few modern obstetricians are willing to go as far as

DeLee, these beliefs about women still pervade obstetrics, and they fuel

episotomy.

Episiotomy serves another purpose. Davis-Floyd observes that surgery

holds the highest value in the hierarchy of Western medicine, and

obstetrics is a surgical specialty. Episiotomy transforms normal

childbirth--even natural childbirth in a birthing suite--into a surgical

procedure.

Davis-Floyd also points out that episiotomy, the destruction and

reconstruction of women's genitals, allows men to control the

" powerfully sexual, creative, and male-threatening aspects of women. "

This is what lurks behind DeLee's emphasis on surgically restoring

" virginal conditions. " It also partially explains why most trials of

episiotomy have been done in European countries where normal birth is

conducted by female midwives, not in the U.S. or Canada, where birth is

conducted (until recently) by male doctors: women are not subconsciously

threatened by birth. Klein et al. attribute the greater success of a

British " restricted " versus " liberal " use of episiotomy trial in

achieving fewer episiotomies and more intact perineums to " the increased

comfort of British midwives in attending births with the intention of

preserving an intact perineum. "

In short, routine episiotomy has a ritual function but serves no medical

purpose. If any reader believes otherwise, I challenge him or her to

find a credible study done in the past 15 years that supports those

beliefs.

 

Note: There are two types of episiotomies: midline or median (straight

down toward the rectum) and mediolateral (down and off to one side) U.S.

and Canadian doctors usually do midline episiotomies while European

doctors and midwives prefer mediolateral ones. According to Williams

Obstetrics,(Cunningham, MacDonald, and Gant 1989) midline episiotomies

are less painful, heal better, are less likely to cause dyspareunia

(coital pain), and cause less blood loss, but they are more likely to

extend into the rectum. Mediolateral episiotomies are the opposite.

Because of these differences, I will note which type was performed after

the abstract citation.

Because of these differences, I have excluded studies of mediolateral

episiotomy where data were available on median episiotomies. For many

areas of interest, however, they were unavailable. (For those living in

countries where mediolateral episiotomy is the norm, conclusions about

the benefits and risks of episiotomy were similar regardless of type.)

This is because until very recently, U.S. and Canadian doctors were so

convinced of episiotomy's value that they did not feel it necessary to

test their theory. This was less true of European midwives, and by

extension, the doctors with whom they work.

 

 

 

Top

Summary of Significant Points

Episiotomies do not prevent tears into or through the anal sphincter or

vaginal tears. In fact, deep tears almost never occur in the absence of

an episiotomy. (Abstracts 1-12, 16, 19-20, 23-28)

Even when properly repaired, tears of the anal sphincter may cause

chronic problems with coital pain and gas or fecal incontinence later in

life. In addition, anal injury predisposes to rectovaginal fistulas.

(Abstracts 11, 15, 21-22)

If a woman does not have an episiotomy, she is likely to have a small

tear, but with rare exceptions the tear will be, at worst, no worse than

an episiotomy. (Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)

Episiotomies do not prevent relaxation of the pelvic floor musculature.

Therefore, they do not prevent urinary incontinence or improve sexual

satisfaction. (Abstracts 1-4, 7, 12-16)

Episiotomies are not easier to repair than tears. (Abstracts 1, 3, 9)

Episiotomies do not heal better than tears. (Abstracts 1, 5-6, 12-15,

21)

Episiotomies are not less painful than tears. They may cause prolonged

problems with pain, especially pain during intercourse. (Abstracts 1, 2,

7, 12, 14-15, 19-20)

Episiotomies do not prevent birth injuries or fetal brain damage.

(Abstracts 1, 3, 5-7, 12, 14, 17-18, 27)

Episiotomies increase blood loss. (Abstracts 1, 12, 19)

As with any other surgical procedure, episiotomies may lead to

infection, including fatal infections. (Abstracts 1, 12, 19, 22)

Epidurals increase the need for episiotomy. They also increase the

probability of instrumental delivery. Instrumental delivery increases

both the odds of episiotomy and deep tears. (Abstracts 5, 11-12, 21,

25-26)

The lithotomy position increases the need for episiotomy, probably

because the perineum is tightly stretched. (Abstracts 10, 25, 27)

The birth attendant's philosophy, technique, skill, and experience are

the major determinants of perineal outcome. (Abstracts 2, 5-7, 9-10,

25-27)

Some techniques for reducing perineal trauma that have been evaluated

and found effective are: prenatal perineal massage, slow delivery of the

head, supporting the perineum, keeping the head flexed, delivering the

shoulders one at a time, and doing instrumental deliveries without

episiotomy. (Others, such as perineal massage during labor or hot

compresses have yet to be studied.) (Abstracts 23-24, 28)

Independent of specifically contracting the pelvic floor muscles

(Kegels), a regular exercise program strengthens the pelvic floor.

(Abstract 13)

References

Cunningham FG, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 18th

ed. Norwalk, CT: Appleton and Lange, 1989.

Davis-Floyd RE. Birth as an American rite of passage. Berkeley:

University of California Press, 1992.

DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol

1920;1:34-44.

Ewing TL, Smale LE, and Elliott FA. Maternal deaths associated with

postpartum vulvar edema. Am J Obstet Gynecol 1979;134:173-179.

Golde S and Ledger WJ. Necrotizing fasciitis in postpartum patients: a

report of four cases. Obstet Gynecol 1977;50(6):670-673.

Oxorn-Foote H. Human labor and birth. 5th ed. Norwalk, CT:

Appleton-Century-Crofts, 1986.

Pritchard JA, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 17th

Edition. Norwalk: Appleton, Century, Crofts, 1985.

Shy KK and Eschenbach DA. Fatal perineal cellulitis from an episiotomy

site. Obstet Gynecol 1979;54(3):292-298.

Sleep J, Roberts J, and Chalmers I. The second stage of labour. In A

guide to effective care in pregnancy and childbirth. Enkin M, Keirse

MJNC, and Chalmers I, eds. Oxford: Oxford University Press, 1989.

Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet

Gynecol 1986;68(3 Suppl):26S-28S.

Sutton GP et al. Group B streptococcal necrotizing fasciitis arising

from an episiotomy. Obstet Gynecol 1985;66(5):733-736.

See web page for Organization of Abstracts

http://www.efn.org/~djz/birth/obmyth/epis.html