Obstet Gynecol. 2006;107:957-962
Clinical ContextEpisiotomy has been used routinely for
approximately 80 years, but the best technique of
Episiotomy and its
clinical benefits remain largely unknown. The current Practice Bulletin
from ACOG summarizes some of the known and perceived differences
between median and
mediolateral episiotomies. The median episiotomy is
the more popular technique used in the United States, reflecting its
relative ease in execution and repair compared with the mediolateral
technique. However, median episiotomy is more likely than mediolateral
episiotomy to promote a third-degree or fourth-degree extension of the
laceration. Meanwhile, mediolateral episiotomy may be preferred to
median episiotomy because it creates more
perineal space for delivery.
There are little data to indicate that one type of episiotomy is
superior to the other in terms of the risk for genital
prolapse or
recovery after delivery.
The current Practice Bulletin highlights other clinical
outcomes of episiotomy.
Study HighlightsAlthough the use of episiotomy appears to have fallen slightly
between 1992 and 2003, it is still performed in approximately 33% of
vaginal deliveries.In either median or mediolateral episiotomy, a 2-layered closure
can improve postpartum pain and healing complications vs a 3-layer
closure. A minimally reactive polyglycolic acid derivative suture is
recommended to reduce wound inflammation.Common complications of episiotomy include bleeding and infection.
For superficial wound breakdown, the authors recommend conservative
treatment with perineal care. However, wound complications involving
the anal sphincter or rectum may require surgical closure.There are no evidence-based indications for episiotomy, which has
traditionally been used in cases of complicated second stage of labor,
such as shoulder dystocia or nonreassuring fetal heart rate pattern, or
cases judged to present a high risk for spontaneous laceration. The use
of episiotomy appears mostly based on anecdotal evidence.Limited vs more liberal use of episiotomy appears to be associated
with a reduced risk for perineal lacerations. Also, median episiotomy
was the most significant risk factor for third- or fourth-degree
lacerations in one study.Episiotomy has not been definitively demonstrated to reduce the
risk for urinary or anal incontinence, genital prolapse, or pelvic
floor damage.Women with either an episiotomy or a similar
degree of perineal
laceration generally complain of similar levels of postpartum pain, and
return to sexual activity occurs at approximately the same pace.There is little evidence that episiotomy improves any fetal
outcomes, including its use in common situations, such as shoulder
dystocia. Research has not consistently demonstrated that episiotomy
reduces the duration of the second stage of labor.Overall, the authors found good and consistent scientific evidence
that the restricted use of episiotomy is preferable to routine use of
episiotomy and that median episiotomy is associated with higher rates
of anal sphincter and rectum injury vs mediolateral episiotomy. They
found limited or inconsistent evidence that mediolateral episiotomy may
be preferred to median episiotomy in some situations and that routine
episiotomy does not protect against pelvic floor damage leading to
incontinence.
Pearls for PracticeMedian episiotomy may be easier to perform and repair than
mediolateral episiotomy, but it is associated with an increased risk of
third- and fourth-degree extension. Both types of episiotomy appear
similar in outcomes of postpartum recovery and genital prolapse.There is no evidence-based indication for the routine use of episiotomy.
More abstracts about the Practice Guidelines Issued for Use of Episiotomy C