The move away from episiotomies may need reconsideration: study
The trend away from episiotomies during vaginal childbirth may be hurting many women, a study led by University of B.C. researcher Giulia Muraca shows.
Episiotomies are incisions in the perineum made to enlarge the opening to aid childbirth, cuts that are then quickly stitched up.
They are also used to help prevent severe soft tissue tears of the area during vaginal deliveries.
Severe tears — called obstetric anal sphincter injury — can cause problems including infections, sexual problems and incontinence.
Routine episiotomies began to fall out of favour a few decades ago when they were deemed unnecessary, traumatic medical interventions. Their discontinuation came about as a “triumph of the feminist movement against the medical establishment” and because of evidence-based science, Muraca said.
But Muraca said the new study she co-wrote, published today in the Canadian Medical Association Journal, suggests the pendulum has swung too far away from episiotomies. The evidence shows there are scenarios in which some women still derive a benefit from them. A “reconsideration” of episiotomies is necessary, she said.
Muraca and her research colleagues at Sweden’s Karolinska Institute looked at hospital data for 2.57 million vaginal deliveries from April 2004 to March 2018.
Spontaneous deliveries — those without the use of forceps or vacuum devices — were compared to deliveries in which those devices were used.
Episiotomies are mostly used in forceps and vacuum-assisted deliveries and in women who are induced, who are older, or have large infants, have had epidurals, prolonged labour or fetal distress.
The study showed that episiotomies were used in 65 per cent of forceps deliveries, 38 per cent of deliveries using vacuum devices, and 68 per cent of deliveries when both were used.
The researchers found that episiotomies were associated with higher rates of anal sphincter injuries among women who had spontaneous vaginal deliveries, at 4.8 per cent compared to 2.4 per cent who didn’t have an episiotomy. However, for women who were giving birth for the first time and required forceps, and for those having a vaginal birth after an earlier caesarean section, episiotomies were associated with lower rates of severe tears.
Among women delivering babies for the first time, with forceps-assisted deliveries, 18.7 per cent of women who had an episiotomy had a perineal injury compared to 28.4 per cent who didn’t have an episiotomy. In vacuum-assisted deliveries among women delivering for the first time, 12.7 per cent of women who had an episiotomy had such injuries while 13.8 per cent who didn’t have an episiotomy had such injuries.
In deliveries in which both tools were used, 33.8 per cent of women delivering for the first time and who didn’t have an episiotomy had injuries compared to 24.4 per cent who had an episiotomy.
Muraca said she thinks the move away from episiotomies over the past few decades stemmed from a “clinical creep that meant it was overgeneralized to apply to all vaginal deliveries.”
“The evidence shows that episiotomies should be used in situations like deliveries when forceps and/or vacuum devices are necessary to get babies out,” she said, adding that benefits in those cases outweigh the risks.
While the surgical tools themselves can cause injuries, not using them in high-risk situations can lead to worse problems.
“More liberal use of an episiotomy may be warranted to prevent obstetric anal sphincter injuries” in women having instrument-assisted deliveries, first-time vaginal births or vaginal deliveries after previous C-sections, she said.