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Am Fam Physician. 2000;62(8):1895-1889

Several recent publications in the medical and popular press have debated the advantages and disadvantages of episiotomy. This controversy is reviewed by Eason and Feldman, who conclude that routine episiotomy should be abandoned, and active measures taken to change clinical practices.

Episiotomy was introduced to shorten the second stage of labor, avoid pressure to the infant's head during delivery, and reduce trauma and the risk of tearing of the perineum. No evidence can be provided to support the idea that passage through soft tissues is harmful to infants in the short term or during later neurologic development. In the six published randomized controlled trials of Apgar scores following delivery with intact perineum compared with delivery with episiotomy, no difference was found. No studies of long-term effects on infants have been conducted. Other studies have questioned the adverse effect of a prolonged second stage of labor. At least two studies found no correlation between Apgar score and a prolonged second stage. In addition, in a large study of neurologic development, no correlation was found between motor deficits, IQ and other measures at seven years of age and duration of the second stage of labor.

Episiotomy has also been advocated to reduce damage to the pelvic floor during childbirth. Several studies demonstrate that delivery with an intact perineum is associated with retained pelvic floor strength, urinary and fecal continence, and sexual satisfaction. When restricted and liberal episiotomy protocols were studied, rates of dyspareunia were not significantly different between patients in the two groups. Overall, maternal pelvic floor damage appears to be proportional to perineal trauma, but episiotomy does not appear to prevent perineal trauma.

The authors conclude that episiotomy has become routinely used in the belief that the intervention is beneficial but that there is no evidence for such benefit. They believe that the exaggerated fear of uncontrolled “shredding” lacerations and an interventionist culture in modern obstetrics have perpetuated the widespread and pervasive use of episiotomy. As a result, experience with techniques to retain an intact perineum has been lost. They strongly advocate returning such techniques to routine practice and teaching programs. In addition, they call for research to scientifically evaluate this and other areas of “routine” delivery.

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