• American College of Obstetricians and Gynecologists (ACOG). Episiotomy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006 Apr. 6 p. (ACOG practice bulletin; no. 71). [46 references]

This is the current release of the guideline.

Second stage labor associated with:

• Nonreassuring fetal heart rate
• Operative vaginal delivery
• Shoulder dystocia
• Unusually short perineal body

Assessment of Therapeutic Effectiveness
Management
Prevention

Family Practice
Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To examine the risks and benefits of episiotomy
• To make recommendations regarding the use of this procedure in current obstetric practice

Pregnant women

1. Median (midline or medial) episiotomy
2. Mediolateral episiotomy

• Rate and severity of perineal laceration
• Rate of anal or urinary incontinence
• Rate of perineal muscle function recovery
• Rate of genital prolapse
• Postpartum recovery (duration of pain and time to intercourse)
• Duration of second stage labor
• Rate of shoulder dystocia
• Neonatal outcome

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and May 2005. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field

The following recommendation and conclusion are based on good and consistent scientific evidence (Level A):

• Restricted use of episiotomy is preferable to routine use of episiotomy.
• Median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than is mediolateral episiotomy.

The following recommendation and conclusion are based on limited or inconsistent scientific evidence (Level B):

• Mediolateral episiotomy may be preferable to median episiotomy in selected cases.
• Routine episiotomy does not prevent pelvic floor damage leading to incontinence.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate use of episiotomy in current obstetric practice

• Mediolateral episiotomy is associated with difficulty of repair, greater blood loss, and, possibly, more early postpartum discomfort.
• Median episiotomy is associated with a greater risk for extension to include the anal sphincter or rectum.
• Reported complications of episiotomy include bleeding, infection, abscess formation, and dehiscence.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness
Safety

• American College of Obstetricians and Gynecologists (ACOG). Episiotomy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006 Apr. 6 p. (ACOG practice bulletin; no. 71). [46 references]

Not applicable: The guideline was not adapted from another source.

2006 Apr

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Not stated

Not stated

This is the current release of the guideline.

Proposed performance measures are included in the original guideline document.

None available

This NGC summary was completed by ECRI Institute on August 3, 2007. The information was verified by the guideline developer on September 10, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.