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Am Fam Physician. 2006;74(11):1970-1976

ACOG Recommends That Physicians Restrict Episiotomy

Although episiotomy is performed in approximately one third of vaginal births in the United States, prophylactic use of the procedure does not result in maternal or fetal benefit and should be restricted, according to a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG). The recommendations were published in the April 2006 issue of Obstetrics & Gynecology.

Historically, the purpose of episiotomy was to facilitate completion of the second stage of labor to improve maternal and neonatal outcomes. Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor caused by a more rapid spontaneous delivery or from instrumented vaginal delivery. Despite limited data, this procedure became virtually routine, resulting in an underestimation of the potential adverse consequences, such as extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia.

The best available evidence does not support liberal or routine use of episiotomy. However, there still is a place for episiotomy for maternal or fetal indications (e.g., avoiding severe maternal lacerations, facilitating or expediting difficult deliveries). A systematic review comparing routine episiotomy with restrictive use reported that 72.7 percent of women in the routine-use group underwent episiotomy compared with 27.6 percent in the restricted-use group. The restricted-use group had significantly lower risks of posterior perineal trauma, suturing, and healing complications but a significant increase in anterior perineal trauma. No statistically significant differences were reported for severe vaginal or perineal trauma, dyspareunia, or urinary incontinence.

In general, two types of episiotomy have been described: the median (or midline or medial) episiotomy and the mediolateral episiotomy. The median episiotomy tends to be a simpler incision to repair and is the more commonly used procedure in the United States. However, median episiotomy is associated with a greater risk of extension to the anal sphincter (third-degree extension) or rectum (fourth-degree extension). Mediolateral episiotomy, an incision at least 45 degrees from the midline, maximizes perineal space for delivery while reducing the likelihood of third- or fourth-degree extension. Reported disadvantages of the mediolateral procedure include difficulty of repair, greater blood loss, and, possibly, more discomfort during the early postpartum period. Although the data are insufficient to determine the superiority of either approach, the procedures seem to have similar outcomes, including pain from the incision and time to resumption of intercourse.

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