So you think you need . . . An episiotomy

Since the middle of the 18th century, when episiotomy was first introduced, the practice of artificially widening the vaginal opening by cutting into the perineum (the skin and tissue lying between the vulva and the anus) has become more and more popular. It is now one of the most common surgical procedures in the world, with an estimated 50-90 per cent of deliveries in the US alone involving its use.

The incision is usually made during the second stage of labour, following a local anaesthetic, just as the baby’s head is about to crown.

There are two types of episiotomy: one involves a midline incision that runs straight from the bottom of the vagina towards the anus; the other uses a diagonal incision that goes across the midline between the vagina and anus. The latter, the less common of the two, is often associated with more postsurgical pain and a longer healing time than a midline episiotomy.

What doctors tell you
The routine use of episiotomy has been justified by a number of reasons, but the main one is that it avoids perineal tearing. It is believed that a controlled incision will prevent severe third- and fourth-degree tears to the anal sphincter and rectum and, consequently, bowel incontinence (Am J Obstet Gynecol, 2003; 189: 1543-9).

An episiotomy is also supposed to protect against urinary incontinence and lax pelvic floor muscles, and improve or maintain sexual function. In addition, it is claimed that a sterile surgical cut will heal better and more quickly than spontaneously ruptured tissue, and involve less pain.

What doctors don’t tell you
Disagreement over the liberal performance of episiotomy has been growing in the medical field, and even the World Health Organization stands among the dissenters.

There is little scientific evidence to support the claim that episiotomy can protect the patient from severe tearing and reduce postpartum (after-birth) pain. In a landmark study carried out in 1993, Argentinian researchers assessed the claim that routine episiotomy prevented severe perineal tearing. The study involved two groups of women: in one, episiotomy was selectively performed; in the other, it was routinely done to all of them. The scientists found that the incidence of perineal trauma was low in both groups of women, but occurred slightly less frequently in the selective group. Moreover, perineal pain, healing complications and spontaneous opening of the wound (dehiscence) were less common in those who had undergone selective episiotomy (Lancet, 1993; 342: 1517-8).

In a separate report, these same researchers assessed the long-term effects of episiotomy by reviewing different studies involving the procedure (Am J Obstet Gynecol, 1996; 174: 1399-402). Their findings shot down several other claims that are often used to justify routine episitomy.

* Episiotomy does not protect the pelvic floor muscles. Women who had an episiotomy were found to have weaker pelvic floor muscles than those with spontaneous tears.

* Episiotomy does not improve future sexual function. Women who had their perineum intact or who had spontaneous tears resumed sexual intercourse earlier, had less pain on resuming sexual intercourse and were more sexually satisfied than those undergoing episiotomy.

* Episiotomy does not protect against urine incontinence. There was little difference in the severity of incontinence among women who had received selective episiotomy and those who were in the liberal-use group.

As a result, the authors concluded that there was no reliable evidence supporting the purported benefits of routine episiotomy. In fact, their findings suggested more harm in terms of a greater need for surgical repair and poorer sexual function.

Aside from the effect of an episiotomy on the mother’s postsurgical health, a couple of other considerations to take into account before going for the snip are that:

* bonding between mother and baby takes longer in women who have had an episiotomy compared with those who have not, according to one Turkish study (J Adv Nurs, 2003; 43: 384-94)

* inflicting unnecessary wounds opens yet another gateway for bacteria to infect the body. Given that the rates of hospital-acquired infections are currently on the rise (see WDDTY vol 16 no 2), it would appear wiser to avoid taking any additional risks.