Episiotomy and Repair

Episiotomy is a surgical incision of the perineum performed by the accoucheur to widen the vaginal opening to facilitate the delivery of an infant (see the following images). It is one of the most commonly performed procedures on women worldwide. Initially described in 1742, episiotomy was introduced into the United States in the mid-19th century. ^[1] In 1920, at a meeting of the American Gynecological Society in Chicago, Dr Joseph DeLee first publicly advocated the routine adoption of mediolateral episiotomy for all deliveries in nulliparous women. ^[2]

Anatomy of the female perineum, with potential sites for episiotomy incision indicated. Image courtesy of Wikimedia Commons (Blausen.com staff in Blausen gallery 2014. Wikiuniversity Journal of Medicine. Available at: https://commons.wikimedia.org/wiki/File:Blausen_0355_Episiotomy.png).

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Crowning of an infant's head, with potential sites for episiotomy incision indicated. Image courtesy of Wikimedia Commons (Blausen.com staff in Blausen gallery 2014. Wikiuniversity Journal of Medicine. Available at: https://commons.wikimedia.org/wiki/File:Blausen_0294_Delivery_Crowning.png).

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Episiotomy was first recommended as a way of facilitating completion of the second stage of labor and reducing the maternal and neonatal trauma and morbidity associated with delivery. The purported short-term benefits for the parturient included its ease of repair compared to a spontaneous perineal laceration, decreased postpartum pain, and reduction in severe or third- or fourth-degree lacerations.

Additional long-term benefits were believed to accrue from shortening the time for which the perineum was stretched during birth, including prevention of pelvic floor relaxation, pelvic organ prolapse, sexual dysfunction, and urinary and fecal incontinence. The purported benefits to the neonate included prevention of asphyxia, cranial trauma, and cerebral hemorrhage, as well as reduction of the risk of shoulder dystocia.

Despite a lack of supporting data, episiotomy was widely adopted into obstetric practice after 1920 and came to be considered standard of care by many American obstetric care providers. By 1979, episiotomy was performed in approximately 63% of all deliveries in the United States, with higher rates among nulliparas. ^[3] In Great Britain in the same era, episiotomy rates ranged from 14-96% among nulliparas and from 16-71% among multiparas. ^[4]

In the 1970s and 1980s, however, obstetric providers began to question the routine use of episiotomy. A growing body of evidence began to emerge that demonstrated the potential consequences of episiotomy, including increased risk of extension to severe perineal lacerations, dyspareunia, and future pelvic floor dysfunction.

As a result, the use of episiotomy has decreased from its 20th-century peak. For example, the number of episiotomies performed annually in the United States fell from over 1.6 million in 1992 to 716,000 in 2003 as a more restricted use of the procedure was adopted. ^{[5, 6]}

The ability to provide evidence-based recommendations regarding the indications for and technique of episiotomy is limited by the scarcity of high-quality data. Accordingly, indications for the procedure are based largely on clinical opinion and anecdote. The best data on episiotomy focus on routine versus restricted use of the procedure.

A Cochrane review of the existing literature on episiotomy found that most studies were of such poor quality that they could not be included. ^[7] Their review concluded that episiotomy did not decrease rates of urinary incontinence, pain, or sexual dysfunction, and that it increased the rates of perineal laceration, suture placement and perineal repair, and wound complications.

In addition, the authors concluded that episiotomy conferred no benefits on the neonate. ^[7] They also found that of the 3 studies comparing midline (median) episiotomy with mediolateral episiotomy, none were of high enough quality to be included in their review; thus, they were unable to draw any conclusions about the superiority or inferiority of a given episiotomy type.

Another systematic review was published in the Journal of the American Medical Association (JAMA) in 2005. ^[8] This review included more studies than the Cochrane review had, but it came to identical conclusions.

In regard to short-term outcomes, the JAMA review concluded that episiotomy resulted in more pain, more need for pain medication, and more severe lacerations than no episiotomy. ^[8] In regard to long-term outcomes, it found that the evidence was of poor quality, that episiotomy yielded no significant improvement in urinary or fecal incontinence, prolapse, or sexual function, and that it was associated with greater dyspareunia.

The JAMA authors concluded that “[i]n the absence of benefit and with a potential for harm, a procedure should be abandoned…. Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had a lesser injury instead had a surgical incision.” ^[8]

Since the publication of the JAMA and Cochrane meta-analyses, various professional bodies, including the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), and the National Institute for Health and Clinical Excellence (NICE), have published consensus guidelines addressing episiotomy in current clinical practice.

An ACOG Practice Bulletin published in 2006 and reaffirmed in 2016 concluded that median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than mediolateral episiotomy and recommending restricted use of episiotomy in clinical practice (level A recommendation). ^{[9, 10]}  ACOG further concluded that routine episiotomy does not prevent pelvic floor damage leading to incontinence and that mediolateral episiotomy may be preferable to midline episiotomy when clinically indicated (level B recommendation).

The ACOG Practice Bulletin further advised that data show no immediate or long-term maternal benefit of routine episiotomy in perineal laceration severity, pelvic floor dysfunction, or pelvic organ prolapse compared with restrictive use of episiotomy. The Practice Bulletin also again noted that episiotomy has been associated with increased risk of postpartum anal incontinence. ^[10]  The ACOG recommendations also noted that although most lacerations during vaginal delivery are first-and second-degree lacerations, more severe third-and fourth-degree lacerations that result in obstetric anal sphincter injuries (OASIS) may occur in up to 11% of women giving birth vaginally. ^[10]

In 2007, NICE and RCOG published similar guidelines recommending against routine episiotomy and advocating mediolateral episiotomy in clinically indicated cases. ^[11] The NICE and RCOG guidelines also outline the recommended technique for performing a mediolateral episiotomy.

In 2015, RCOG updated their guidelines on the Management of Third- and Fourth-Degree Perineal Tears adding the following ^{[12, 13]} :

• Evidence for the protective effect of episiotomy is conflicting
• Mediolateral episiotomy should be considered in instrumental deliveries

Major society recommendations recognize a restricted role for episiotomy to assist with difficult deliveries (eg, shoulder dystocia, ^[14] although dissents from this recommendation have been expressed ^[15] ), to facilitate delivery in the context of nonreassuring fetal status, or possibly to avoid a serious maternal laceration. ^[9]

Few contraindications to episiotomy exist. Episiotomy cannot be performed without consent of the patient. ^[16] Relative contraindications to the procedure include inflammatory bowel disease and severe perineal malformations. Episiotomy should not be performed unless vaginal delivery is considered to be possible.

Additionally, episiotomy should not be performed with operative vaginal delivery (forceps or vacuum) unless deemed necessary by the delivering provider; both procedures are associated with a significantly increased risk of severe perineal laceration. ^[17]