A Systematic Review
Summary
Evidence Report/Technology Assessment: Number 112
Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
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Introduction / Key Questions / Methods / Results / Discussion / Limitations / Future Research / Conclusion / Availability of Full Report / References
Authors: Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson T,
Lohr KN, Gartlehner G, Thorp J Jr.
Introduction
Episiotomy, incision of the perineum at the
time of vaginal childbirth, is a common surgical
procedure experienced by women in the United
States.1 Based on national hospital discharge data
for 1999, just over 35 percent of women who
gave birth vaginally had an episiotomy
performed; the figure was approximately 33
percent in 2000.2,3
Despite several decades of research, which
many interpret as definitive evidence against
routine (or "liberal") use of episiotomy, little
professional consensus has developed about the
appropriateness of routine use. Lack of consensus
is illustrated by variation in rates of use, ranging
from 13.3 percent to 84.6 percent in one study
with a prospectively enrolled low-risk population,
with an average of 51 percent among spontaneous
term births.4 Variation has been reported by type
of clinician,4 time of day,5 and facility type, size,
and location.6 Wide practice variations suggest
that episiotomy use is heavily driven by local
professional norms, experiences in training, and
individual provider preference rather than
variation in the physiology of vaginal birth.
The
goal of this synthesis is to inform care providers,
professional organizations, advocates, and
individual women about the current state of the
evidence on routine use of episiotomy.
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Key Questions
The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) addressed the following
Key Questions (KQs):
- KQ 1. Does the practice of liberal or routine episiotomy, compared to more selective use of episiotomy, influence maternal postpartum outcomes?
- KQ 2. Does episiotomy incision type (i.e., midline or mediolateral) influence the risk of maternal morbidity?
- KQ 3. Does the repair of the perineal defect (i.e., suture type and repair approach) influence the risk of maternal morbidity?
- KQ 4. Does episiotomy have a long-term impact on urinary incontinence, fecal incontinence, or pelvic floor defects?
- KQ 5. Does episiotomy or incision type, or both, influence future sexual function?
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Methods
Inclusion and Exclusion Criteria
We excluded studies that:
- Did not report on women of reproductive age.
- Were published in languages other than English.
- Did not report information pertinent to the key clinical questions.
- Had fewer than 40 subjects.
- Were not original studies.
Criteria for study
design were based on sufficiency and quality of
evidence. KQs 1 and 3 have been more
commonly examined in randomized controlled
trials (RCTs); thus, we elected to limit searches to
RCTs. KQs 2, 4, and 5 have been studied less
extensively in trials; therefore, we included both
RCTs and prospective cohort studies.
Literature Search and Retrieval
Process
We used standard electronic databases:
MEDLINE®, Cochrane Collaboration resources,
and the Cumulative Index to Nursing and Allied
Health Literature (CINAHL®). We reviewed reference lists of relevant articles and consulted with the
Technical Expert Advisory Group (TEAG) to obtain additional
relevant articles. We conducted a dual review for abstracts and a
single review for full articles to decide inclusion according to
preset criteria.
Development of Evidence Tables and Data
Abstraction Process
Abstractors trained themselves on entering data into evidence
tables by abstracting several articles and then reconvening as a
group to discuss the utility of the table design. After several
iterations and TEAG review, the final table design had all
needed, appropriate categories for systematically recording
information on the articles.
All team members did initial entry of information onto data
abstraction forms. Another team member reviewed articles and
edited all initial table entries for accuracy, completeness, and
consistency. The two abstractors reconciled all disagreements
concerning information in the abstraction tables. We then
entered data from the abstraction forms into evidence tables
and again checked for consistency and accuracy.
Quality and Strength of Evidence Evaluation
Rating the Quality of Individual Articles
Two article abstractors independently rated each article on
each of the categories on our quality assessment form. A third
reviewer reviewed the scores and flagged studies with differences
in scoring on individual components. We reconciled these
differences by consensus.
Grading the Strength of Available Evidence
Our scheme follows the criteria utilized by Berkman, et al.7
That system included three domains:
- Quality of the research.
- Quantity of studies (including number of studies and adequacy of the sample size).
- Consistency of findings.
Grades were
assigned by consensus of the four senior staff members.
External Peer Review
As is customary for all evidence reports and systematic
reviews done for AHRQ, the RTI-UNC EPC requested review
of this report from a wide array of outside experts in the field
and from relevant professional societies and public
organizations. We compiled comments from 18 respondents
and addressed each one individually, revising the text as
appropriate.
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Results
Literature Search Yield
The literature search yielded 986 articles. Of these, we
excluded 659 articles after reviewing the abstracts. Of the
remaining 327 articles, we included 45 in our evidence report.
Of these, 7 address KQ 1, 1 addresses KQ 2, 20 address KQ 3,
15 address KQ 4, and 10 address KQ 5.
Key Question 1: Episiotomy and Maternal
Postpartum Outcomes
Seven primary publications of RCTs addressed liberal versus
restrictive use of episiotomy.8-14 Each trial compared two study
arms or groups:
- An intention to restrict routine use of episiotomy.
- A liberal-use policy that endorsed routine use.
Use of episiotomy in the restrictive groups ranged from
lows of 7.6 percent9 and 10.2 percent8 to highs of 44 percent11
and 53 percent.13 We emphasize that these trials compared
policies of episiotomy use, not episiotomy to no episiotomy; six
of the seven studies used mediolateral episiotomy.
This literature has high internal consistency with respect to
the postpartum effects of differing strategies for episiotomy use.
Compared to women in liberal-use groups, women in the
restrictive-use groups had less severe posterior perineal trauma,
less need for suturing, higher probability of having an intact
perineum, no greater or lesser risk of wound healing
complications, and higher likelihood of resuming intercourse
earlier.
Key Question 2: Episiotomy Incision Type and
Maternal Morbidity
Only one RCT compared outcomes of midline episiotomy
to those of mediolateral episiotomy.15 An additional focused
literature search did not reveal any prospective cohort studies
on this issue. Women in the midline group began sexual
intercourse significantly earlier and had a significantly better
cosmetic appearance of the scar than women in the
mediolateral group. The groups did not differ significantly on
pain or satisfaction from sexual intercourse. Women receiving
midline episiotomy also had a significantly greater probability
of anal sphincter injuries than women in the mediolateral
episiotomy group. This study did not assess fecal incontinence
as a long-term health outcome. Because of considerable
methodologic flaws, any conclusions must be drawn cautiously.
Key Question 3: Repair of Perineal Defect and
Maternal Morbidity
We included 17 RCTs (in 21 articles) examining various
methods and materials for repairing perineal defects; virtually
all episiotomies in these trials were mediolateral.16,17-35
Four trials investigated techniques of repair.17,27,29,32,35 Two
compared a two-layer approach (leaving the perineal skin
unsutured) with a three-layer approach (suturing the perineal
skin); two others compared a continuous (subcutaneous)
technique with an interrupted (transcutaneous) technique.
Fourteen trials investigated materials for repair;16,17,19,20-23,25-28,30-34 eight compared polyglycolic-acid sutures with chromic-catgut
sutures, both absorbable; two compared absorbable sutures (one
polyglycolic acid and one chromic catgut) with an enbucrilate
tissue adhesive (Histoacryl®); two compared standard
absorbable suture material with its rapidly absorbed counterpart; and one compared untreated chromic catgut with
a glycerol-treated "softgut" chromic catgut. In addition, two
trials compared nonabsorbable and absorbable sutures: one
compared silk sutures with polyglycolic-acid sutures and one
compared silk sutures with both polyglycolic-acid and chromic-catgut
sutures.
Finally, two trials combined comparison of both techniques
and materials in their design.18,24
Most of these trials randomly allocated participants to one of
two groups. However, three trials incorporated a factorial
design of randomization. Using a 2x2 design, both the so-called
Ipswich Childbirth Study29,30,32 and the Kettle, et al. trial36
randomized to methods of repair and type of sutures. The
Mahomed, et al. perineal suture study used a 2x3x2 design and
randomized to suture type for deep tissue repair (two groups),
suture type for the perineal skin (three groups), and method of
repair (two groups).27
Methods
Two-layer vs. three-layer repair. The trials provided
consistent evidence that favored the two-layer approach;
differences between the two approaches were not always
statistically significant.29,32,35
Despite some limitations, collectively these trials suggest that
less overall perineal morbidity is associated with the two-layer
repair approach than with the traditional three-layer approach.
The reduction in pain, need for analgesia, wound healing
problems, and sexual morbidity as well as a decrease in the time
and cost required for initial suturing of the perineal skin,
removal, and possible resuturing, may make the two-layer
approach more beneficial than the three-layer approach.
Continuous vs. interrupted sutures. Two good-quality
trials produced inconsistent evidence that the continuous
method of repair has less perineal morbidity and more patient
satisfaction associated with it than the interrupted method.17,27
In both trials, the authors describe greater familiarity with the
interrupted method of repair. One clinical group even suggests
that their inconsistencies with other trials might be attributable
to lack of practice with the method and subsequent
unpopularity with the operators that performed the repair.27
Whether such differences in outcome arise for clinicians and
women outside the United Kingdom, where methods of repair
and training of those performing the repair could be different
than in other countries, remains to be seen.
Materials
Absorbable vs. tissue adhesive. These two trials were small
(n < 65 in both trials) and of poor quality because of poor
randomization,16,33 but they defined and measured perineal pain
well and achieved good followup. They contribute possible
evidence that repair with tissue adhesive may decrease perineal
pain in the immediate postpartum.
Absorbable sutures: standard vs. rapidly absorbed.
Mixed results from a good trial36 and lack of significant
differences between groups in a poor trial31 yielded insufficient
evidence, pointing to a difference in perineal pain between
standard and rapidly absorbed sutures. Stronger evidence
indicated that women who had rapidly absorbed sutures
required less removal of the material, presumably because it was
absorbed into the skin quickly in the postpartum period.
Although the two trials evaluated sexual functioning at different
times, rapidly absorbed sutures may decrease the amount and
severity of dyspareunia in the puerperium.
Untreated catgut vs. treated catgut. Only one trial
addressed treated and untreated chromic catgut.25 It produced
no evidence that treated catgut is superior to untreated catgut
with regard to perineal morbidity; in fact, treated catgut may be
associated with higher morbidity (more perineal pain in the
immediate postpartum period; painful sexual intercourse in the
longer term).
Nonabsorbable vs. absorbable suture. Because of the
study design of the fair-quality trial23 and lack of control for
possible confounding by method of repair, we cannot draw
conclusions about the role of silk sutures in perineal morbidity
from this trial. The authors concluded that the subcuticular
method lent itself to short-term advantages but did not present
supporting data. Thus, although this trial may contribute to a
body of evidence about combinations of materials and
methods, it does not contribute to the overall understanding of
the role of suture materials in perineal morbidity, separate from
methods of repair.
The Mahomed, et al. trial27 found no
differences between the two groups in the short-term
postpartum period, but did find differences at 3 months,
indicating a possible delayed effect of the suture material.
Polyglycolic acid vs. chromic catgut. In 2004, the
Cochrane Library published a systematic review and metaanalysis
of information on polyglycolic-acid versus catgut suture
material for repair of perineal trauma.37 The authors reported
that polyglycolic-acid sutures were associated with less pain in
the short-term postpartum period (odds ratio [OR] = 0.62;
95% confidence interval [CI], 0.54-0.71) and with less need
for analgesia (OR = 0.63; 95% CI, 0.52-0.77), but groups did
not differ in long-term pain outcomes or reports of
dyspareunia.
Our systematic review includes six of the eight trials that
appeared in the Cochrane review and two additional trials.
Overall, the evidence is from a combination of poor, fair, and
good trials; it is consistent with the previous Cochrane review.
Polyglycolic-acid sutures are associated with less perineal pain,
less need for analgesia use, and fewer healing problems in the
short term. Long-term outcomes do not differ substantially
between polyglycolic-acid sutures and chromic catgut. One
trial not in the Cochrane review reported more perineal pain
and dyspareunia in the polyglycolic-acid group at 6 months,34 an outcome the authors attributed to the slower absorption rate
of polyglycolic-acid sutures; however, these results were neither
statistically significant nor precise. Overall, the body of
evidence about polyglycolic-acid versus chromic-catgut sutures
suggests that polyglycolic-acid sutures offer many short-term
advantages.
Combined Methods and Materials
Two trials compared
entire approaches, combining both materials and methods in a
single randomization design.18,24 The poor trial18 found no
differences between the groups; the fair-quality trial24 found
that women repaired with polyglycolic-acid sutures using a
continuous, subcuticular approach suffered less perineal
morbidity. This result is consistent with other trials that
investigated subcuticular suturing and polyglycolic-acid sutures
separately, perhaps reinforcing the notion that this method and
suture type are superior to other options available to obstetric
clinicians.
Key Question 4: Episiotomy and Urinary
Incontinence, Fecal Incontinence, and Pelvic
Floor Defects
Sixteen publications prospectively collected data about some
aspect of continence or pelvic floor muscle function with good
documentation of perineal status and episiotomy use at the
time of the index birth. Outcomes of interest included
physiologic measures of muscle strength, clinical urodynamic
testing, or self-report by interview or questionnaire.
The 16 publications include four reports from two RCTs of
liberal versus restrictive use of episiotomy and 11 prospective
studies of representative cohorts of women delivering at
particular facilities or with a particular practice group
(including two publications from a cohort of women who
participated in an RCT of perineal massage versus none in the
third trimester). One study of a cohort of all women in a
region who had third-degree lacerations at the time of the index
birth followed them to assess risk of fecal incontinence at 3
months.
All studies reflect the dominant practice patterns in the
countries in which the studies were conducted. No study
directly compared the influence of mediolateral versus midline
(also called median) episiotomy on pelvic floor function or
continence. For this reason, long-term differences in
continence and pelvic floor muscle outcomes that would be
anticipated secondary to differences in episiotomy type are
unknown.
Randomized Controlled Trials
Both RCTs (Sleep and colleagues in the United Kingdom8
and Klein and colleagues in Canada11) required providers to
alter their use of episiotomy. These trials randomized women
to "liberal use" or "restricted use" of episiotomy; the latter
category intended to restrict use to circumstances such as fetal
distress or maternal exhaustion with an "unyielding perineum."
Both trials enrolled singleton, vertex presentation pregnancies at
term and randomized in the delivery suite close to the time of
birth.
Neither trial showed meaningful differences in varied
measures of urinary incontinence such as subjective sensation of
perineal bulging, perineometry readings, involuntary loss of
urine, use of a pad, loss of urine with coughing, sneezing,
laughing, and loss with urgent need to void. Neither trial
collected data about continence of flatus or stool, descriptive
data from physical examination, or urodynamic studies. Both
research teams concluded that they did not observe any benefits
associated with episiotomy. Klein and colleagues, using
perineometry measures, also concluded that episiotomy fails to
prevent pelvic floor relaxation.11
Prospective Studies
The most global assessment of continence and pelvic floor
function concluded that episiotomy is associated with lower
pelvic floor muscle strength than spontaneous tears.38 The
clinical significance of this finding is unclear because all self-reported
symptoms of urinary and anal incontinence and
degree of prolapse on physical examination were equivalent
across groups. Overall, episiotomy apparently did not protect
against incontinence, prolapse, or decrements in pelvic floor
muscle function by 3 months postpartum.
Studies focused on self-reported urinary continence.
Excluding the clinical trial populations and the Sartore, et al.
study above, five studies (in four study populations) evaluated
self-reports of urinary continence.39-43 Overall, episiotomy and
spontaneous-tear groups had the same frequency of
incontinence symptoms; no evidence emerged that episiotomy
prevents pelvic floor damage.
Studies focused on self-reported incontinence of stool or
flatus. Three cohort studies asked women about rectal
incontinence symptoms; one also conducted physical
examinations.44-46 These authors focused on the high prevalence
of anorectal dysfunction at 3 months with episiotomy as a key
risk factor. None of these research teams found episiotomy to
be statistically associated with reduced risk.
Studies focused on physiologic measures of pelvic floor
function. Overall, none of these research teams concluded that
episiotomy had advantages,29,47,48 and one identified a decrease
in functional muscle strength. As intermediate measures, these
findings concur with the self-report and clinical examination
findings of other studies: essentially, episiotomy confers no
benefits with respect to preserving continence or pelvic floor
muscle function.
Key Question 5: Episiotomy and Future
Sexual Function
Nine studies (in 10 publications) prospectively collected
outcome data about sexual function among women who did or did not have a routine episiotomy. One study compared
incision type and assessed sexual function;15 three RCTs
examined restrictive versus liberal use of episiotomy;8,11,49 one
trial studied mediolateral versus median episiotomy;15 and five
were prospective cohort studies.38,42,50-52 One study (the only
study conducted in the United States), described by the authors
as "retrospective," included a single followup time point (6
months) with prospective data collection about sexual
function.53 Two publications reflect a primary analysis from an
RCT with 3 months of followup8 and a secondary analysis after
3 years49 in the same UK study population. In two
publications with analyses of the same study population, a
Canadian research team reported analyses of 3-month followup
data: one on randomization to liberal or restrictive episiotomy
groups, and the other on perineal trauma at the time of delivery
by exposure group.11,52
Apart from the one study directly comparing mediolateral to
median episiotomy, all studies reflect the dominant practice
patterns of the countries in which they were conducted. Thus,
the literature reflects two distinct types of procedures, the
effects of which need to be addressed separately.
Randomized Controlled Trials
Two publications from RCTs of restrictive compared to
liberal use of episiotomy reported intention-to-treat analyses of
long-term effects on the sexual outcomes of populations of
women. In one study,8 by 1 month after delivery, 37 percent of
the restrictive group and 27 percent in the liberal group had
resumed sexual intercourse (P < 0.01). The proportion of
women with resumption of intercourse by 3 months, current
dyspareunia at 3 months, or any dyspareunia within the 3
months of followup did not differ significantly by group. By
the third year of followup, the likelihood of "ever suffering
painful intercourse" remained comparable across groups.49
Klein and colleagues found less episiotomy use in the
restrictive group with higher rates of spontaneous lacerations.11
Women in the restrictive group resumed intercourse an average
of 1 week earlier that those in the liberal group; however, all
other measures of sexual function were equivalent by 3
months.11 This team conducted a separate analysis of the
relationship between degree of perineal trauma and sexual
function using 3-month interview data. They regrouped
participants by perineal status that had been systematically
documented at the time of the index birth, creating a
prospective cohort. Women with episiotomy had the slowest
return to intercourse. Pain with the first intercourse followed a
similar pattern.
Prospective Cohorts
These cohort studies did not find large or statistically
significant differences in sexual function. Only one study
identified lasting differences in dyspareunia at 3 months.
Current dyspareunia at 3 months can be estimated from three
of the cohort studies using 818 women with episiotomy and
938 women without episiotomy.38,50,51 A meta-estimate from
the combined cohorts suggests that women with episiotomy are
54 percent more likely to have pain with intercourse 3 months
after delivery, with an absolute increase in risk of dyspareunia of
5 percent among women who had episiotomy. The two studies
that assessed any dyspareunia during the 3 months after
childbirth revealed no difference in the overall probability of
having had painful intercourse.
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Discussion
Findings by Key Question
Key Question 1: Episiotomy and Maternal Postpartum
Outcomes
Trials of fair to poor quality provide consistent findings that
clearly support limited use of episiotomy. Routine episiotomy
achieves no short-term goals that it has been hypothesized to
achieve. Indeed, routine use is harmful to the degree that it
creates a surgical incision of greater extent than many women
might have experienced had episiotomy not been performed.
Key Question 2: Episiotomy Incision Type and Maternal
Morbidity
A single study found that women with midline episiotomy
had a significantly greater rate of anal sphincter injuries than
women with mediolateral episiotomy.15 Treatment groups did
not report differences in pain or satisfaction with intercourse at
3 months. Because of considerable methodological flaws in this
trial (poor internal validity), any conclusions must be drawn
cautiously. However, because differences in sphincter injury
rates are clinically important, we consider the finding of
increased risk of severe injury with midline episiotomy
compared to mediolateral episiotomy to be relevant
observational evidence.
Key Question 3: Repair of Perineal Defect and Maternal
Morbidity
Limited but consistent evidence favored two-layer repair over
three-layer repair; limited and inconsistent evidence favored
continuous over interrupted sutures. Evidence was insufficient
to comment on comparisons between standard and rapidly
absorbed sutures, tissue adhesive and absorbable sutures, or
nonabsorbable and absorbable sutures. We found no evidence
that treated catgut is superior to untreated catgut with regard to
perineal morbidity; the former may in fact be associated with
higher morbidity. The evidence suggests short-term advantages
for perineal repeat associated with the use of polyglycolic-acid
sutures compared to chromic-catgut sutures.
Three major classes of suture material (nonabsorbable,
absorbable, and tissue adhesive) and two subtypes of sutures
(treated versus untreated and standard versus rapidly absorbed)
were studied, all in the presence of different approaches to the
method of suturing; thus, individual effects of the materials
themselves cannot be examined. Likewise, methods of repair were examined in the context of different materials both among
and within studies for different stages of repair. We are unable
to assess the true effects of a certain method of repair because
we cannot tell whether outcomes are confounded or modified
by suture material.
Key Question 4: Episiotomy and Urinary Incontinence,
Fecal Incontinence, and Pelvic Floor Defects
These prospective studies did not identify improvements in
continence for urine or stool or in pelvic floor muscle function
among women who had had episiotomy compared to those
who had not. This finding includes comparison to women
who had spontaneous lacerations of similar severity.
Several
authors reported decrements in pelvic floor function among
women who had had episiotomy. Only a single study, using
multivariable models, found that episiotomy was an
independent predictor of urinary continence.41 In the majority
of other studies using multivariate models, adjusting for factors
such as parity, neonatal weight, and length of second-stage
labor, episiotomy was not an independent risk factor for
incontinence. Taken in total, this literature, predominantly of
fair to poor quality, does not support use of episiotomy for the
purpose of preventing pelvic floor defects, urinary
incontinence, or incontinence of stool or flatus.
These studies are limited because they do not follow women
long enough to detect disease occurrence. At present, the
assumption that intermediate variables, such as pelvic muscle
strength measured by perineometry, urodynamic test results, or
early reports of symptoms, can predict later disease has not
been validated. Prospective evaluation only during the months
after birth when the pelvic floor is still in a recovery and
stabilization period may be misleading. Conclusions about
whether episiotomy prevents or increases risk for incontinence
and prolapse later in adult life cannot be reached from currently
available randomized and cohort studies.
Key Question 5. Episiotomy and Future Sexual Function
The studies addressing this question need to be considered in
two groups: mediolateral episiotomy and median episiotomy.
From the clinical trials of episiotomy strategy—liberal versus
restrictive—one trial addressed each type of incision and one
directly compared the two incision types. None found
substantive differences in sexual function. The preponderance
of the studies, however, supported a conclusion that degree of
perineal trauma is associated with probability of pain with
intercourse, in a dose-response fashion such that greater
perineal injury is associated with greater probability of pain.
Measures that are more complex than those typically used in
this literature are needed to understand properly the
relationships between perineal trauma and future sexual
function. Specific factors such as prior sexual function and
current libido, in addition to factors such as duration of
second-stage labor, size of infant, and lactation status, need to
be incorporated into multivariable models to derive more
informative and less biased estimates of the long-term effects of
episiotomy or to determine that they do not exist.
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Limitations
Deficiencies in the Literature
The available studies that met our inclusion criteria for this
systematic review contained numerous (and commonly
encountered) deficiencies. These included:
- Variations in episiotomy rate.
- Violations of protocol.
- Inconsistent reporting of the definitions of measures.
- Inadequate reporting of statistics.
- Infrequent a priori designation of primary and secondary outcomes.
- Infrequent masking of the assessor.
- Infrequent use of multivariate modeling.
- Infrequent use of validated outcome measures.
In all, much of this literature could be regarded as
fair in quality, with some studies of good quality and a few of
poor quality.
Limitations to Our Review Procedures
Our review process also had some limitations. Because of
time and resource constraints, we did not conduct dual,
independent, blinded review of articles for inclusion or
abstraction of information into evidence tables. Instead, one
reviewer performed the initial review, and a second reviewer
examined that input and recommended changes. Differences
were reconciled between the two reviewers. We used dual
review for grading the quality of individual articles, allowing us
to evaluate rigorously systematic bias in these assessments.
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Future Research
Currently, the evidence suggests that the putative benefits of
episiotomy do not outweigh its harms. Instead, outcomes from
episiotomy are worse because some proportion of women who
would have had lesser injury instead had a surgical incision.
If episiotomy were restricted to indicated uses, an important
question remains for women and their care providers: Which,
if any, of the prevailing indications for episiotomy are
supported by an adequate research base?
A two-stage research
agenda could address this need. First, a systematic review may
clarify current knowledge about outcomes of episiotomy for the
leading presumed indications. Second, primary data collection
may be needed to fill in research gaps identified by such a
review and to improve understanding of whether these are
indeed indications for episiotomy.
Work relating to this latter part of such a research agenda is
under way on several topics. This work includes a recent
publication of a retrospective cohort study that suggests that
episiotomy conferred no benefit in averting neonatal injury at
the time of births that had been complicated by shoulder
dystocia.54 Additional evidence will be required to investigate
fully what circumstances should be considered indications for
episiotomy.
Furthermore, if the professional community accepts that
routine episiotomy is not an effective means to reduce perineal
injury, then that attitude should enable them to redouble
efforts to understand fully various other approaches to
attending the second stage of labor that can promote maternal
and infant safety, minimize perineal trauma, and maximize
maternal comfort. These steps might include giving attention
to maternal position, avoiding fundal pressure, reducing
coached pushing, providing perineal support, and employing
"hands poised" versus "hands on" techniques to support the
perineum. The role for lubrication and types of lubrication for
use during crowning of the infant head are other important
research topics that warrant more rigorous investigation.
To understand pelvic floor defects and childbirth experiences
properly, including history of episiotomy, studies need to be
designed to identify populations of women who have a known
episiotomy history. In this way, researchers can evaluate
continence and pelvic organ prolapse status in the age groups
between 40 and 70 years.
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Conclusion
Our systematic review finds no health benefits from
episiotomy. We found fair to good evidence suggesting that the
immediate outcomes for routine (liberal-use policies)
episiotomy are no better than those for indicated use of
episiotomy under more restrictive-use policies. Indeed, routine
use is harmful to the degree that it creates a surgical incision of
greater extent than many women might have experienced had
episiotomy not been performed. Weak trial evidence,
consistent with observational data, suggests that the harms of
midline episiotomy are greater than the harms of mediolateral
episiotomy.
For episiotomy repair, fair to good evidence, albeit across
different comparisons of methods and materials, suggests that
leaving the perineal skin unsutured may confer some benefit; if
suturing is indicated, then a continuous, subcuticular method is
better than an interrupted, transcutaneous method. Regarding
suture material, the evidence is consistent and clear that
absorbable sutures are preferred and that polyglycolic-acid
sutures have significantly less perineal morbidity associated with
them. Newer materials, such as tissue adhesive, may offer
further benefits, but the data are at present wholly inadequate
to inform care practices.
The level of evidence for long-term sequelae, specifically fecal
and urinary incontinence, pelvic floor function, and future
sexual function, is fair to poor. Nonetheless, it is consistent in
demonstrating the lack of benefit of the procedure in a
comparatively early timeframe. For women in later adult life,
when morbidity is most likely to occur in the form of severe
and persistent incontinence or pelvic organ prolapse, the
expected results of routine episiotomy are unknown.
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Availability of Full Report
The full evidence report from which this summary was taken
was prepared for the Agency for Healthcare Research and
Quality (AHRQ) by the RTI-UNC Evidence-based Practice
Center, under Contract No. 290-02-0016. Requesters should ask
for Evidence Report/Technology Assessment No. 112, The Use of Episiotomy in Obstetrical
Care: A Systematic Review (AHRQ Publication No. 05-E009-2).
The Evidence Report can also be downloaded as a PDF file (3.5 MB). PDF Help.
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