Episiotomy in Modern Obstetrics OR Episiotomy: It's Time to Stop Cutting!
Main Article Content
Abstract
Episiotomy consists of incising the perineum to widen the birth canal. It was historically introduced into medical practice in the 18th century. The purpose of the episiotomy would be to reduce the probability of severe perineal lacerations, while the association with the forceps would minimize the risk of fetal trauma and hypoxia, which was accepted for a long time as an indisputable truth. The use of episiotomy spread enormously after the recommendations of famous obstetricians and began to be used on a larger scale in several countries since the 20th century, although there was no reliable scientific evidence of its effectiveness and safety. In the last decades well-conducted clinical studies on the subject were published and the routine use of episiotomy was questioned. Despite of methodological limitations, the first studies contributed to reduce its practice, including the important participation of women's movements and active childbirth campaigns arguing about the episiotomy use. Current evidence shows that routine episiotomy is not supported in clinical practice and a recent World Health Organization (WHO) guideline strongly recommends against it. However, a lack of knowledge remains as the role of episiotomy in obstetric emergencies and, considering the present evidence, what would be the real benefits for performing an episiotomy. This review aims to show the current state of the art running through the historical background of episiotomy and techniques, analyzing its use worldwide in obstetric practice and discussing the published studies concerning the necessity, the effectiveness, and the consequences of the procedure. Ultimately, regarding the accumulated evidence shown, the authors express their conclusions about the use of episiotomy in obstetric modern practice and the possible strategies to reduce its rates.
Keywords:
Episiotomy, Episiotomy technique, Pregnancy, Labor
Article Details
How to Cite
AMORIM, Melania Maria; KATZ, Leila; DA CUNHA, Anna Catharina Carneiro.
Episiotomy in Modern Obstetrics OR Episiotomy: It's Time to Stop Cutting!.
Medical Research Archives, [S.l.], v. 11, n. 7.1, july 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4068>. Date accessed: 22 dec. 2024.
doi: https://doi.org/10.18103/mra.v11i7.1.4068.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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25. Gu S, Pei J, Zhou C, Zhao X, Wan S, Zhang J, Adanlawo A, Luo Z, Wu G, Hua X. Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies. BMC Pregnancy Childbirth. 2022; 22: 475. doi: 10.1186/s12884-022-04790-0
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31. Mahgoub S, Piant H, Gaudineau A, Lefebvre F, Langer B, Koch A. Risk factors for obstetric anal sphincter injuries (OASIS) and the role of episiotomy: A retrospective series of 496 cases. J Gynecol Obstet Hum Reprod. 2019;48(8):657-662. doi:10.1016/j.jogoh.2019.07.004
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38. Carmo Leal Md, Pereira AP, Domingues RM, et al. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica. 2014;30 Suppl 1:S1-S16. doi:10.1590/0102-311x00151513
39. de Menezes FR, da Silva TPR, Felisbino-Mendes MS, et al. Influence of the COVID-19 pandemic on labor and childbirth care practices in Brazil: a cross-sectional study. BMC Pregnancy and Childbirth. 2023 Feb;23(1):91. doi: 10.1186/s12884-023-05358-2.
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2. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2(2):CD000081. Published 2017 Feb 8. doi:10.1002/14651858.CD000081.pub3
3. Thorp JM Jr, Bowes WA Jr. Episiotomy: can its routine use be defended? Am J Obstet Gynecol. 1989;160(5 Pt 1):1027-1030. doi:10.1016/0002-9378(89)90152-x
4. Myers-Helfgott MG, Helfgott AW. Routine use of episiotomy in modern obstetrics. Should it be performed? Obstet Gynecol Clin North Am. 1999; 26: 305-25.
5. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018;132(3):e87-e102. doi:10.1097/AOG.0000000000002841
6. World Health Organization. (2018). WHO recommendations: intrapartum care for a positive childbirth experience. World Health Organization. Accessed March 28, 2023. https://apps.who.int/iris/handle/10665/260178.
7. Ould, Sir Fielding. A Treatise of Midwifery: In Three Parts. O. Nelson and C. Connor, 1742.
8. Nugent F. The primiparous perineum after forceps delivery. Am J Obstet Gynecol. 1935; 30: 249-56. doi:10.1016/S0002-9378(35)90169-7.
9. Pomeroy RH. Shall we cut and reconstruct the perineum for every primipara? Am J Obstet Dis Women Child. 1918; 78: 211-9.
10. DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol. 1920; 254: 66-83. doi:10.1016/S0002-9378(20)90067-4
11. Caldeyro-Barcia R. The Influence of Maternal Position on Time of Spontaneous Rupture of the Membranes, Progress of Labor, and Fetal Head Compression. Birth-issues in Perinatal Care. 1979; 6: 7-15. doi:10.1111/J.1523-536X.1979.TB01297.X
12. Harris RE. An evaluation of the median episiotomy. Am J Obstet Gynecol. 1970;106(5):660-665. doi:10.1016/0002-9378(70)90385-6
13. Cohen WR. Influence of the duration of second stage labor on perinatal outcome and puerperal morbidity. Obstet Gynecol. 1977;49(3):266-269.
14. Brendsel C, Peterson G, Miehl C. The role of episiotomy in pelvic symptomatology. In: Kitzenger S, ed. Episiotomy: Physical and Emotional Aspects. London: National Childbirth Trust; 1981.
15. Crawford JS. Episiotomy. Br Med J (Clin Res Ed). 1982;284(6315):594-595. doi:10.1136/bmj.284.6315.594
16. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv. 1983;38(6):322-338.
17. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J (Clin Res Ed). 1984;289(6445):587-590. doi:10.1136/bmj.289.6445.587
18. Routine vs selective episiotomy: a randomized controlled trial. Argentine Episiotomy Trial Collaborative Group. Lancet. 1993;342(8886-8887):1517-1518.
19. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2(2):CD000081. Published 2017 Feb 8. doi:10.1002/14651858.CD000081.pub3
20. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141-2148. doi:10.1001/jama.293.17.2141
21. Thorp JM Jr, Bowes WA Jr, Brame RG, Cefalo R. Selected use of midline episiotomy: effect on perineal trauma. Obstet Gynecol. 1987;70(2):260-262.
22. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol. 1990;75(5):765-770.
23. Klein MC, Gauthier RJ, Jorgensen SH, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? [published correction appears in Online J Curr Clin Trials 1992 Sep 12;Doc No 20:[54 words; 1]. Online J Curr Clin Trials. 1992;Doc No 10: doi:10.1097/00006254-199404000-00008
24. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol. 1994;171(3):591-598. doi:10.1016/0002-9378(94)90070-1
25. Gu S, Pei J, Zhou C, Zhao X, Wan S, Zhang J, Adanlawo A, Luo Z, Wu G, Hua X. Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies. BMC Pregnancy Childbirth. 2022; 22: 475. doi: 10.1186/s12884-022-04790-0
26. Marcellier G, Dupont A, Bourgeois-Moine A, Le Tohic A, De Carne-Carnavalet C, Poujade O, Girard G, Benbara A, Mandelbrot L, Abramowitz L. Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study. Journal of Clinical Medicine. 2023; 12(4):1531. https://doi.org/10.3390/jcm12041531
27. Faden YA, Fatani AM, Fallatah BM, et al. Examining the Association Between Episiotomy and Severe Perineal Tears in a Tertiary Care Center Implementing a Restrictive Episiotomy Policy. Cureus. 2022;14(11):e31606. Published 2022 Nov 17. doi:10.7759/cureus.31606
28. Min L, Xudong D, Qiubo L, et al. Two-year follow-up and comparison of pelvic floor muscle electromyography after first vaginal delivery with and without episiotomy and its correlation with urinary incontinence: A prospective cohort study. Acta Obstet Gynecol Scand. 2023;102(2):200-208. doi:10.1111/aogs.14487
29. Benti Terefe A, Gemeda Gudeta T, Teferi Mengistu G, Abebe Sori S. Determinants of Pelvic Floor Disorders among Women Visiting the Gynecology Outpatient Department in Wolkite University Specialized Center, Wolkite, Ethiopia. Obstet Gynecol Int. 2022;2022:6949700. Published 2022 Aug 13. doi:10.1155/2022/6949700
30. Sangkomkamhang U, Kongwattanakul K, Kietpeerakool C, et al. Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial. BJOG. 2020;127(3):397-403. doi:10.1111/1471-0528.15982
31. Mahgoub S, Piant H, Gaudineau A, Lefebvre F, Langer B, Koch A. Risk factors for obstetric anal sphincter injuries (OASIS) and the role of episiotomy: A retrospective series of 496 cases. J Gynecol Obstet Hum Reprod. 2019;48(8):657-662. doi:10.1016/j.jogoh.2019.07.004
32. Anderson CJ, Kilpatrick C. Supporting patients' birth plans: theories, strategies & implications for nurses. Nurs Womens Health. 2012;16(3):210-218. doi:10.1111/j.1751-486X.2012.01732.x
33. Logue TC, Wen T, Arditi B, et al. Trends in and Factors Associated with Episiotomy in the Setting of Nonoperative Vaginal Delivery, 2000-2018. Obstet Gynecol. 2022;139(1):110-112. doi:10.1097/AOG.0000000000004631
34. Blondel B, Alexander S, Bjarnadóttir RI, et al. Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand. 2016;95(7):746-754. doi:10.1111/aogs.12894
35. Teixeira C, Lorthe E, Barros H. Time trends in episiotomy and severe perineal tears in Portugal: a nationwide register-based study. BMC Pregnancy Childbirth. 2022;22(1):976. Published 2022 Dec 28. doi:10.1186/s12884-022-05314-6
36. Goldberg J, Purfield P, Roberts N, Lupinacci P, Fagan M, Hyslop T. The Philadelphia Episiotomy Intervention Study. J Reprod Med. 2006;51(8):603-609.
37. Diniz SG, Chacham AS. "The cut above" and "the cut below": the abuse of caesareans and episiotomy in São Paulo, Brazil. Reprod Health Matters. 2004;12(23):100-110. doi:10.1016/s0968-8080(04)23112-3
38. Carmo Leal Md, Pereira AP, Domingues RM, et al. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica. 2014;30 Suppl 1:S1-S16. doi:10.1590/0102-311x00151513
39. de Menezes FR, da Silva TPR, Felisbino-Mendes MS, et al. Influence of the COVID-19 pandemic on labor and childbirth care practices in Brazil: a cross-sectional study. BMC Pregnancy and Childbirth. 2023 Feb;23(1):91. doi: 10.1186/s12884-023-05358-2.
40. Medina ET, Mouta RJO, Carmo CND, Filha MMT, Leal MDC, Gama SGND. Boas práticas, intervenções e resultados: um estudo comparativo entre uma casa de parto e hospitais do Sistema Único de Saúde da Região Sudeste, Brasil [Good practices, interventions, and results: a comparative study between a birthing center and hospitals of the Brazilian Unified National Health System in the Southeastern Region, Brazil] [published correction appears in Cad Saude Publica. 2023 May 26;39(5):eER160822]. Cad Saude Publica. 2023;39(4):e00160822. Published 2023 Apr 17. doi:10.1590/0102-311XPT160822
41. Wagner M. Episiotomy: a form of genital mutilation. Lancet. 1999;353(9168):1977-1978. doi:10.1016/S0140-6736(05)77197-X
42. Davis-Floyd R. Birth as an American Rite of Passage. University of California Press; 1993:382. Acessed March 28, 2023. https://doi.org/10.1525/california/9780520229327.001.0001
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