Thursday, September 28, 2006


Episiotomy appears to be a litmus test issue among natural childbirth and homebirth advocates. I wonder, therefore, when they will catch up with the reality in obstetrics today.

This month's issue of OBG Management has an editorial, featured on the cover, that is entitled "It's time to restrict the use of episiotomy." OBG Management is not really a journal; it's more like a magazine. It does not contain original research. Instead, it is intended for practitioners, particularly older practitioners, to explain the latest research, guidelines and implications for clinical practice.

The editorial is written by Dr. Robert Barbieri, the editor-in-chief, who is also the chief of OB-GYN at Brigham & Women's Hospital and a professor at Harvard Medical School. As such, he is about as representative of high-tech obstetrics as anyone can be. Here is what he writes:
I confess. In the past, when performing a vaginal delivery, I frequently cut an episiotomy. During my residency training, I was taught that an episiotomy shortened the second stage and reduced the risk of tears to the anterior perineum and perurethral area. In addition, repair of the episiotomy offered an opportunity to perform a "posterior repair" and reconstruct the perineal body...

Currently, our practice has an episiotomy rate for vaginal deliveries of less than 5% and an operative vaginal delivery rate of less than 6%, mostly vacuum-assisted deliveries.
Under the section "Benefits were never proven":
Routine episiotomy is harmful because some women who would not have had a perineal tear had a surgical incision.

The 2006 ACOG Practice Bulletin recommends that obstetricians restrict their use of episiotomy.
Under the section "We can do better":
Will the episiotomy rate ultimately drop to less than 1% of vaginal deliveries? That is unlikely because of clinical conditions, such as a nonreassuring fetal heart rate tracing in the late second stage, sometimes necessitate an episiotomy.

...[I]t is possible to reduce the rate of episiotomy to less than 5% during vaginal delivery. For nonoperative vaginal delivery, the episiotomy rate could be less than 3%. For operative vaginal deliveries (about 5%-8% of all vaginal deliveries), the episiotomy rate could be less than 25%.

I confess. It was difficult for me to change my practice from liberal episitomy to restricted episiotomy. The residents in my program stipulated the change, and now that I have adopted a new practice pattern, it is relatively easy to maintain.

My advice to the readers of OBG Management: It is time to stop the practice of liberal episiotomy and restrict the use of this timeworn procedure.

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