Episiotomy for vaginal birth
Limiting the use of episiotomy to strict indications has a number of benefits: less posterior perineal trauma, less need for suturing and fewer complications. Episiotomy does not lead to reduction in most pain measures and severe vaginal or perineal trauma, although it may increase the risk of anterior perineal trauma.
RHL Commentary by Liljestrand J
1. EVIDENCE SUMMARY
Restrictive use of episiotomy in uncomplicated vaginal births, as compared with routine episiotomy, is associated with reduced risk of posterior perineal trauma and need for suturing perineal trauma. There is no difference in risk of severe vaginal or perineal trauma, pain, dyspareunia or urinary incontinence. There is, however, a somewhat increased risk of anterior perineal trauma. The review does not resolve the question of what type of episiotomy should be preferred, midline or mediolateral.
All appropriately controlled trials that could be identified have been included.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Routine episiotomy, or liberal use of episiotomy, is unfortunately very common, both in under-resourced settings and in some developed countries. The latter may be contributing to the persistence of this practice also in under-resourced settings despite overwhelming evidence against its routine use.
With the HIV/AIDS epidemic still growing rapidly in many countries, and with the most stricken countries having more than one-third of women giving birth HIV infected, both protection of the health workers and the risk of vertical transmission from episiotomy must be considered. During suturing of episiotomies the risk of a finger-prick injury is high, especially if a small needle is used. Current data indicate that the role of mother-to-child HIV transmission at birth may have been underestimated. Thus, any invasive intervention may increase the risk of vertical transmission.
There are therefore strong reasons to counteract the overuse of episiotomy in developing and developing countries alike.
2.2. Feasibility of the intervention
Some countries, both developed and developing, have successfully reduced their episiotomy frequencies.
The moderate increase of anterior trauma shown by this review should not be a deterring factor. Anterior perineal trauma is usually slight, and as indirectly showed by this Cochrane Review, the increase in anterior trauma was not associated with increase in severe trauma, nor did it lead to a greater need for suturing.
2.3. Applicability of the results of the Cochrane Review
The results of the review apply equally to developed and developing countries. One area where not enough is known, however is the routine use of episiotomy in women who have undergone any of the types of female genital mutilation (FGM). In its most advanced forms, FGM severely restricts the vaginal outlet, and both practice by traditional birth attendants and health care staff in such cases includes routine episiotomy. Not enough is known about the optimal application of episiotomy in women with FGM, both as regards indication and technique.
2.4. Implementation of the intervention
Limiting the use of episiotomy to strict indications has been done in some countries through adherence to standard protocols, training/retraining, and supervision and quality improvement processes. Considering the strength of the evidence and the common occurrence of the procedure, decreasing episiotomy rates can be seen as a litmus test for the application of evidence-based reproductive health care.
Further exploration of the relative merits of midline versus mediolateral episiotomy is needed. In this case results from controlled studies in developed countries could be applicable also in resource-poor settings.
Studies on obstetric consequences of FGM should evaluate the value of episiotomy in this group of women.
Source of support: World Health Organization, Geneva, Switzerland.
This document should be cited as: Liljestrand J. Episiotomy for vaginal birth: RHL commentary (last revised: 20 October 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.