ACOG PRACTICE BULLETIN

CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIANGYNECOLOGISTS NUMBER 71, APRIL 2006

Episiotomy
This Practice Bulletin was developed by the ACOG Committee on Practice Bulletins Obstetrics with the assistance of John T. Repke, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. 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. Episiotomy is one of the most commonly performed procedures in obstetrics. In 2000, approximately 33% of women giving birth vaginally had an episiotomy (1). Historically, the purpose of this procedure was to facilitate completion of the second stage of labor to improve both 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 resulting from 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 of episiotomy, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia. The purpose of this document is to examine the risks and benefits of episiotomy and to make recommendations regarding the use of this procedure in current obstetric practice.

Background
History
Episiotomy has been described in the medical literature for more than 300 years, but it was not until the 1920s, with the publication of papers by DeLee (2) and Pomeroy (3), that more routine use of episiotomy became accepted. However, there was certainly not unanimity about the utility of this approach at that time (4). The shift to in-hospital deliveries in the 20th century was associated with decreased morbidity and an increase in the use of episiotomy and proliferation of many other obstetric practices (eg, use of forceps, use of cesarean delivery, use of anesthesia). More recently, in 1992 more than 1.6 million episiotomies were performed in the United States, with a background cesarean delivery rate of 22.3%. In 2003, 716,000 episiotomies were performed with a

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background cesarean delivery rate of 27.5%, suggesting that use of this procedure in obstetrics is decreasing (5, 6).

Techniques of Episiotomy
In general, two types of episiotomy have been described: the median (or midline or medial) episiotomy and the mediolateral episiotomy. In the United States, the more commonly used technique is the median episiotomy. It gained popularity because it is easy to perform and to repair. Postpartum pain is reported to be reduced with this technique, as is postpartum dyspareunia (4). Median episiotomy, however, is associated with a greater risk of extension to include the anal sphincter (third-degree extension) or rectum (fourth-degree extension) (710). Mediolateral episiotomy, an incision at least 45 degrees from the midline, is more commonly performed outside the United States and is favored by some because it maximizes perineal space for delivery while reducing the likelihood of third- or fourth-degree extension (8, 11). Reported disadvantages of the mediolateral procedure include difficulty of repair, greater blood loss, and, possibly, more early postpartum discomfort (4).

such infections are localized and may resolve with perineal wound care. In rare cases, an abscess may form, which will result in either the need for disruption of the repair to allow for evacuation of the abscess or spontaneous breakdown of the repair. In extreme cases, infections such as necrotizing fasciitis can cause maternal death if not effectively evaluated and treated. In cases of less severe infection with wound breakdown, several approaches can be used. For superficial breakdowns not involving the rectum or anal sphincter, expectant management with perineal care may allow for spontaneous healing to occur over a period of several weeks. For more extensive breakdowns, or when the logistics of many follow-up visits may be prohibitive, primary closure of the defect may be attempted. Data suggest that early closure of episiotomy dehiscence in properly selected cases may be appropriate (20). In rare cases, inadequately repaired episiotomies may lead to rectovaginal fistula formation (21). Repair of such defects can be challenging, depending on size and location, and should be repaired by someone familiar with fistula repair techniques.

Technique of Repair
The median episiotomy tends to be a simpler incision to repair, even if it requires repair of the rectal mucosa and anal sphincter. For either technique, a two-layered closure has been shown to decrease postpartum pain and healing complications compared with a three-layer closure (1214). Compared with interrupted, transcutaneous suturing, one study reported less postpartum pain at 3 months with continuous subcutaneous suturing (15). Although a second study reported no difference (16), both studies found a lower need for suture removal with the continuous method (15, 16). Various suture materials have been used for episiotomy repair, with limited data to suggest the superiority of one type of material over another. A minimally reactive, absorbable polyglycolic acid suture may be preferable to chromic catgut because there may be less perineal pain and dyspareunia (13, 16, 17). The drawback of using less reactive materials is a slower resorption profile that rarely may result in the need for suture removal (18, 19). For this reason, many clinicians now use monofilament absorbable sutures or more rapidly absorbable polyglactin derivatives.

Clinical Considerations and Recommendations

What are the indications for episiotomy?
The indications for episiotomy are varied and based largely on clinical opinion. It has been suggested that episiotomy is indicated in cases where expediting delivery in the second stage of labor is warranted or where the likelihood of spontaneous laceration seems high. Such clinical circumstances would include a nonreassuring fetal heart rate pattern, operative vaginal delivery, shoulder dystocia, and cases where the perineal body is thought to be unusually short. The data supporting these claims are largely descriptive or anecdotal. Several trials suggest the lack of evidence supporting use of episiotomy in these circumstances. Two recent trials also failed to show that episiotomy improved neonatal outcome, provided better protection of the perineum, or facilitated operative vaginal delivery (22, 23). Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure (24).

Complications
Bleeding from the episiotomy site is one of the most frequent complications. Such bleeding often is easily controlled with conservative measures and compression, but substantial hematoma formation may occur. Infection also may complicate episiotomy healing. In most cases,

How does episiotomy affect the rate and severity of perineal lacerations?

A systematic review of seven trials comparing routine episiotomy with restrictive use of the procedure found

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that an intact perineum was more common in the restricted group, but anterior labial lacerations also were more common. There were no differences in rectal injuries (24). Another systematic review suggests that routine mediolateral episiotomy compared with restricted use does not protect against anal sphincter trauma, and median episiotomy caused more anal sphincter tears (25). Nonetheless, anterior lacerations are not associated with an increased need for suturing, suggesting that these tears are less severe than posterior tears. Thus, restrictive use of episiotomy appears to reduce the likelihood of perineal lacerations.

Can episiotomy prevent pelvic muscle relaxation leading to incontinence?

There is consensus that the risk of incontinence increases with increasing degrees of pelvic trauma. One study of extended episiotomies demonstrated that the occurrence of a fourth-degree extension was more highly associated with anal incontinence (26). The single greatest risk factor for third- or fourth-degree lacerations seems to be the performance of a median episiotomy, suggesting that avoiding episiotomy itself may be the best way to minimize the risk of subsequent extensive damage to the perineum (27). In four cohort studies, investigators asked women about anal incontinence episodes; one study also included physical examinations (25, 2830). Episiotomy was not found to be associated with reduced risk of incontinence of stool or flatus (24). Similarly, in another study of perineal muscle function, women who had an episiotomy had less recovery of postpartum perineal muscle function than did women who did not undergo episiotomy, leading the investigators to conclude that use of episiotomy for preservation of perineal muscle function is not warranted (31). A prospective study of 519 primiparous women compared those who had a mediolateral episiotomy with those who had an intact perineum or first- or second-degree lacerations (28). No differences in urinary or anal incontinence or genital prolapse were reported. A systematic review of routine versus restrictive episiotomy found no evidence to support episiotomy in preventing pelvic floor damage (24).

Whether episiotomy contributes to immediate postpartum pain is debated. One study suggests that duration of the second stage of labor correlated most closely with acute postpartum pain (32), whereas other studies suggest that immediate postpartum pain is well correlated with degree of perineal trauma and, therefore, with episiotomy use (27, 33, 34). The most studied measure of postpartum sexual function is the time from delivery until resumption of sexual intercourse. Most data suggest that 90% of women in the postpartum period have resumed intercourse within 34 months of delivery (34). In at least two studies, episiotomy was not identified as an independent risk factor for dyspareunia or delayed return to sexual activity when compared with equally severe perineal trauma in women who did not have an episiotomy (34, 35). Prospective cohort studies did not find differences in dyspareunia or resumption of intercourse at 3 months (24). Another aspect of postpartum discomfort relates to method of episiotomy closure or repair of a spontaneous laceration. A number of trials have reported on different techniques of perineal closure aimed at reducing postpartum pain and facilitating expeditious healing (12, 13, 36). Newer approaches using more rapidly absorbing synthetic sutures, either braided or monofilament, have been reported. Larger trials are needed before a conclusion can be reached about their efficacy (13, 15, 37, 38).

What are the fetal benefits of episiotomy?

How does episiotomy affect postpartum pain and sexual functioning?

Proposed fetal benefits of episiotomy include cranial protection, especially for premature infants, reduced perinatal asphyxia, less fetal distress, better Apgar scores, less fetal acidosis, and reduced complications from shoulder dystocia. Despite these claims, few data are available to support any of them. Even the presumption that episiotomy shortens the second stage of labor has not been conclusively shown. Although increasing perineal space would seem intuitively beneficial with respect to the prevention and management of shoulder dystocia, few data other than anecdotes support this notion. A systematic review of the literature (13) found only one study that addressed this issue and concluded that the use of episiotomy had no influence on the risk of shoulder dystocia (39). However, if shoulder dystocia occurs, episiotomy may be useful to facilitate its management. No data support or refute the benefits of episiotomy with operative vaginal delivery.

Postpartum recovery is an area of obstetrics that lacks systematic study and analysis. Recovery depends on many factors, and a number of investigators have attempted to determine what factors, if any, lead to more expeditious recovery and return of normal function.

Which type of episiotomy (median or mediolateral) is favored?

Median episiotomies are associated with a greater risk of extension into the rectum and compromise of the exter-

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nal anal sphincter muscle (7). Mediolateral episiotomies have been linked to greater postpartum pain, more blood loss, more difficulty in effecting proper repair, and more dyspareunia (4), especially when compared with spontaneous tears (28, 40). Also, because of the potential for greater expansion of the pelvic floor with mediolateral episiotomy, it has been suggested that use of this procedure may provide more protection against the development of incontinence (41). Multiple studies using an endpoint of avoiding anal sphincter or rectal injury have demonstrated that mediolateral episiotomy is superior to median episiotomy (9, 42, 43). However, there may be other drawbacks to the use of mediolateral episiotomy, including increased perineal trauma not involving the sphincter (44). There does not appear to be evidence to support a protective effect of mediolateral episiotomy with respect to subsequent development of genital prolapse (28). In addition, although the data are insufficient to determine the superiority of either approach, data do suggest that both median and mediolateral episiotomies have similar outcomes, including pain from the incision and time to resumption of intercourse (7). The timing of episiotomy has long been the subject of debate (2, 3). There are no data to show that early episiotomy results in decreased pelvic floor trauma. It has been demonstrated that episiotomy, whether median or mediolateral, is associated with increased maternal blood loss at the time of delivery (45).

Summary of Recommendations and Conclusions

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.

Proposed Performance Measure

For patients with episiotomy, the percentage for whom the indication for episiotomy is included in the delivery notes

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Should episiotomy be routine or restricted in clinical practice?

The best available data do not support liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications, such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries. According to a recent systematic evidence review (24), although episiotomy is performed in approximately 3035% of vaginal births in the United States, prophylactic use of episiotomy does not appear to result in maternal or fetal benefit. Another systematic review comparing routine episiotomy with restrictive use reported that the group routinely using episiotomy had an overall incidence of 72.7%, versus 27.6% in the restricted-use group (46). 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, leading the reviewers to conclude that restrictive-use protocols are preferable to routine use of this procedure.

References
1. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM. Births: final data for 2000. Natl Vital Stat Rep 2002;50(5):1101. (Level II-3) 2. DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:3444. (Level III) 3. Pomeroy RH. Shall we cut and reconstruct the perineum for every primipara? Am J Obstet Dis Women Child 1918;78:21120. (Level III) 4. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretive review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983;38:32238. (Level III) 5. DeFrances CJ, Hall MJ, Podgornik MN. 2003 National Hospital Discharge Survey. Advance data; No. 359. Hyattsville (MD): National Center for Health Statistics; 2005. Available at: http://www.cdc.gov/nchs/data/ad/ad 359.pdf. Retrieved December 29, 2005. (Level II-3) 6. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2003. Natl Vital Stat Rep 2005;54(2):1116. (Level II-3)

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7. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980;87:40812. (Level II-1) 8. Bodner-Adler B, Bodner K, Kaider A, Wagenbichler P, Leodolter S, Husslein P, et al. Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med 2001;46:7526. (Level II-3) 9. Riskin-Mashiah S, OBrian Smith E, Wilkins IA. Risk factors for severe perineal tear: can we do better? Am J Perinatol 2002;19:22534. (Level II-2) 10. Helwig JT, Thorp JM Jr, Bowes WA Jr. Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries? Obstet Gynecol 1993;82:2769. (Level II-2) 11. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:76570. (Level II-2) 12. Oboro VO, Tabowei TO, Loto OM, Bosah JO. A multicentre evaluation of the two-layered repair of postpartum perineal trauma. J Obstet Gynaecol 2003;23:58. (Level I) 13. Grant A, Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S. The Ipswich childbirth study: one year followup of alternative methods used in perineal repair. BJOG 2001;108:3440. (Level II-2) 14. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich Childbirth Study: I. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynaecol 1998;105: 43540. (Level I) 15. Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359: 221723. (Level I) 16. Mahomed K, Grant A, Ashurst H, James D. The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol 1989;96: 127280. (Level I) 17. Mackrodt C, Gordon B, Fern E, Ayers S, Truesdale A, Grant A. The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. Br J Obstet Gynaecol 1998; 105:4415. (Level I) 18. Grant A. The choice of suture materials and techniques for repair of perineal trauma: an overview of the evidence from controlled trials. Br J Obstet Gynaecol 1989; 96:12819. (Level III) 19. Ketcham KR, Pastorek JG 2nd, Letellier RL. Episiotomy repair: chromic versus polyglycolic acid suture. South Med J 1994;87:5147. (Level III) 20. Hankins GD, Hauth JC, Gilstrap LC 3rd, Hammond TL, Yeomans ER, Snyder RR. Early repair of episiotomy dehiscence. Obstet Gynecol 1990;75:4851. (Level III) 21. Barranger E, Haddad B, Paniel BJ. Fistula in ano as a rare complication of mediolateral episiotomy: report of three cases. Am J Obstet Gynecol 2000;182:7334. (Level III)

22. Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with prolonged second stage of labor. Obstet Gynecol 2003;102:528. (Level II-3) 23. Bodner-Adler B, Bodner K, Kimberger O, Wagenbichler P, Mayerhofer K. Management of the perineum during forceps delivery. Association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery. J Reprod Med 2003;48:23942. (Level II-3) 24. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005;293:21418. (Level III) 25. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000;95:46471. (Meta-Analysis) 26. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189:154350. (Level II-3) 27. Robinson JN, Norwitz ER, Cohen AP, McElrath TF, Lieberman ES. Epidural analgesia and third- and fourthdegree lacerations in nulliparas. Obstet Gynecol 1999; 94:25962. (Level II-3) 28. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E, Guaschino S. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 2004;103:66973. (Level II-2) 29. MacArthur C, Bick DE, Keighley MR. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997;104: 4650. 30. Walsh CJ, Mooney EF, Upton GJ, Motson RW. Incidence of third-degree perineal tears in labour and outcome after primary repair. Br J Surg 1996;83:21821. (Level II-2) 31. Fleming N, Newton ER, Roberts J. Changes in postpartum perineal muscle function in women with and without episiotomies. J Midwifery Womens Health 2003;48:539. (Level II-2) 32. Thranov I, Kringelbach AM, Melchior E, Olsen O, Damsgaard MT. Postpartum symptoms. Episiotomy or tear at vaginal delivery. Acta Obstet Gynecol Scand 1990; 69:115. (Level II-3) 33. Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol 2004;191: 1199204. (Level II-2) 34. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184:8817; discussion 88890. (Level II-2) 35. Abraham S, Child A, Ferry J, Vizzard J, Mira M. Recovery after childbirth: a preliminary prospective study. Med J Aust 1990;152:912. (Level II-2) 36. Isager-Sally L, Legarth J, Jacobsen B, Bostofte E. Episiotomy repairimmediate and long-term sequelae. A prospective randomized study of three different methods of repair. Br J Obstet Gynaecol 1986;93:4205. (Level I)

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37. Upton A, Roberts CL, Ryan M, Faulkner M, Reynolds M, Raynes-Greenow C. A randomised trial, conducted by midwives, of perineal repairs comparing a polyglycolic suture material and chromic catgut. Midwifery 2002;18: 2239. (Level I) 38. Bowen ML, Selinger M. Episiotomy closure comparing enbucrilate tissue adhesive with conventional sutures. Int J Gynaecol Obstet 2002;78:2015. (Level II-1) 39. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol 1993;168:17327; discussion 17379. (Level II-3) 40. Rockner G, Wahlberg V, Olund A. Episiotomy and perineal trauma during childbirth. J Adv Nurs 1989;14:2648. (Level II-2) 41. Poen AC, Felt-Bersma RJ, Dekker GA, Deville W, Cuesta MA, Meuwissen SG. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997;104:5636. (Level II-2) 42. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: a retrospective cohort study. BMJ 2000;320:8690. (Level II-2) 43. De Leeuw JW, Vierhout ME, Struijk PC, Hop WC, Wallenburg HC. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 2001;80:8304. (Level II-2) 44. Anthony S, Buitendijk SE, Zondervan KT, van Rijssel EJ, Verkerk PH. Episiotomies and the occurrence of severe perineal lacerations. Br J Obstet Gynaecol 1994;101: 10647. (Level II-3) 45. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:6976. (Level II-2) 46. Carroli G, Belizan J. Episiotomy for vaginal birth. The Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081. (Meta-Analysis)

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 ACOG were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetriciangynecologists were used. Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force: 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 casecontrol 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. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level ARecommendations are based on good and consistent scientific evidence. Level BRecommendations are based on limited or inconsistent scientific evidence. Level CRecommendations are based primarily on consensus and expert opinion. I

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