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Pregnancy Guide Update-No Routine Episiotomy!

There is NO evidence to support routine episiotomy—cutting the area between the vagina and the rectum during birth.  But a current ACOG* brochure for obstetricians starts with this sentence: 

“Episiotomy is the most common operative procedure that most obstetricians will perform in their lifetime.”

Since the 1920s, studies demonstrate significant risks associated with episiotomy, including laceration of the anal sphincter, fecal and urinary incontinence, perineal pain, and greater blood loss than vaginal delivery without episiotomy.  Almost three decades ago a detailed review of the literature concluded there is no evidence for the efficacy of routine episiotomy.  The authors stated that “if [women] were fully informed as to the evidence for benefit and risk in the face of demonstrable risks, it is unlikely that women would readily consent to having routine episiotomies.”  In 1999, a Cochrane Review of randomized trials comparing routine and restrictive use of episiotomy found that restrictive use resulted in decreased risk of perineal trauma (accidental cutting of the anal sphincter), decreased need for suturing, and fewer complications related to wound healing. More restrictive use of the procedure was again recommended.  Perhaps as a result, the rate of episiotomy dropped from 61% in 1969 to 24.5% in 2004. Still, that means a million women have episiotomies every year.  A 2008 study found that women who had episiotomy during their first birth were about five times more likely to have spontaneous second-degree to severe lacerations during their second birth.  Based on these findings, the authors concluded, for every four episiotomies not performed, one second degree laceration could be prevented.   They said this finding should encourage providers to further restrict use of episiotomy.   

In light of this evidence, I find the information in ACOG’s current patient brochures surprising.  Patient information on pain management during labor says simply,

“A procedure called an episiotomy may be done by your doctor before delivery. Local anesthesia is helpful when an episiotomy needs to be done, or when any vaginal tears that happened during birth are repaired.”   

It sounds so, well, routine; there is no need to describe it to women or to discuss it with them.   Another ACOG brochure titled “You and Your Baby” says,

“… When your baby's head appears at the opening of the vagina, the tissue of the vagina becomes very thin and tightly stretched. Sometimes it is not possible for the baby's head to fit through without tearing the woman's skin and muscles. Your doctor may make a small cut in the vaginal opening while it is numbed with an anesthetic. This is called an episiotomy.”    

This statement ignores the evidence that a tear heals better and faster than a cut and that serious complications can and do occur with episiotomy. It implies, erroneously that the woman’s body is inadequate for the task of birthing, and that the procedure is beneficial to both mother and baby and risky to neither.  

Women and those who support them through pregnancy and birth need to be aware that practice often lags behind the scientific evidence. Beginnings Pregnancy Guide will continue to inform women about episiotomy and recommend discussing it with the doctor well before birth. See page 75

*American Congress of Obstetricians and Gynecologists; also American College of Obstetricians and Gynecologists References: ACOG Educational Pamphlet AB005-- You and Your Baby.  Available online at http://www.acog.org/publications/patient_education/ab005.cfm 

ACOG Education Pamphlet AP086—Pain Relief During Labor and Delivery.  Available online at http://www.acog.org/publications/patient_education/bo086.cfm Alperin M, Krohn MA & Parviainen K. (2008)

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery. Obstetrics & Gynecology 111 (60):1274-1278. Frankman EA, Wang L, Bunker CH, et al. (2009)

Episiotomy in the United States: has anything changed? American Journal of Obstetrics & Gynecology 200: 573.e1 -.e7
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