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Should Use of Episiotomy
Be Restricted?
Marianna Alperin, MD, MS; Kristiina Parviainen, MD
E
pisiotomy is one of the surgical proce-
dures a woman is most likely to undergo
during her lifetime.1 Since the 1980s, how-
ever, a growing body of literature discour-
aging routine episiotomy has resulted in a
reduction of episiotomy use.2,3 Despite this
trend, routine use of episiotomy among some
practitioners and institutions remains alarm-
ingly high.4 Why is this?
Many clinicians assert that meticulous repair
of surgical episiotomy yields improved wound
healing compared with unpredictable sponta-
neous laceration. This theory, however, has
never been substantiated by empiric evidence.5
Episiotomy has been associated with increased
blood loss at delivery, perineal scar breakdown,
infection, pelvic pain, and dyspareunia.3 The
protective effect of prophylactic episiotomy
against severe (third- and fourth-degree) obstet-
ric lacerations has also been disproved by stud-
ies highlighting increased incidence of severe
lacerations with episiotomy.6,7 The resulting
damage to internal and external anal sphincters
can lead to devastating long-term sequelae,
including fecal incontinence and rectovaginal
fistulae.8 In addition, other studies have demon-
strated that episiotomy increases perineal pain
and dyspareunia when compared with sponta-
neous lacerations.9 Despite compelling evidence
of limited (if any) benefit and potential harm,
episiotomy use is still common.
We recently reported the impact of episiot-
omy beyond an index delivery, quantifying the
effect of episiotomy on the risk of obstetric lac-
eration in a subsequent vaginal delivery while
controlling for other risk factors.4 Episiotomy
Marianna Alperin, MD, MS, is Attending Urogynecolo-
gist, Female Pelvic Medicine and Reconstructive Surgery,
Department of Obstetrics and Gynecology, Kaiser Perman-
ente, West Los Angeles, CA. Kristiina Parviainen, MD, is
Assistant Professor, Department of Obstetrics, Gynecology,
and Reproductive Sciences, Division of Maternal-Fetal
Medicine, The University of Pittsburgh School of Medicine,
Pittsburgh, PA.
VIEWPOINT
A Professional Opinion Article
was previously suggested to FOCUSPOINT
be associated with increased
risk of obstetric lacerations in Does meticulous
subsequent deliveries based repair of episiotomy
on epidemiologic data; how-
ever, authors of that study were yield improved
unable to account for other wound healing com-
risk factors known to increase pared with spontan-
the risk of obstetric lacer-
ations.10 Our study, consis-
eous laceration? This
tent with previously published theory has never
literature, again refuted the been substantiated
premise that episiotomy is pro-
tective against severe (third-
by empiric
and fourth-degree) lacerations: evidence.
the incidence of severe lacera-
tion in the first delivery was
20.4% with episiotomy and 6.8% without.
Additionally, repeat episiotomy in the second
delivery again more than doubled the inci-
dence of severe laceration (1.5% in women
without episiotomy, compared to 3.6% in
women with episiotomy).
Moreover, our findings support the asser-
tion that healed tissue after trauma is weaker
than uninjured tissue. After controlling for
other known risk factors, our results indicate
more than a 4-fold risk of perineal laceration
in the second delivery attributable to episiot-
omy at first delivery. Thus, we demonstrated
yet another detrimental aspect of episiotomy
in that consequences of this procedure are not
limited to the index delivery, but are perpetu-
ated in subsequent vaginal deliveries.
Although spontaneous second-degree lacera-
tion and episiotomy would appear to confer
similar relative risk for obstetric laceration in a
subsequent delivery, the incidence of spontane-
ous second-degree laceration at first delivery was
only 19% in our cohort, compared with a 59.7%
rate of episiotomy. Thus, high rates of episiotomy
at first delivery were responsible for increased
risk of obstetric laceration in the second delivery
in 40% of women in our series.
The Female Patient | VOL 34 FEBRUARY 2009 27
 VIEWPOINT
Should Use of Episiotomy Be Restricted?
FOCUSPOINT There are situations in which
episiotomy is warranted. Episi-
Not only is there otomy has a critical role in diffi-
no proven benefit to cult instrumented deliveries,
shoulder dystocia, and circum-
this procedure, but stances in which a non-reassur-
episiotomy may also ing fetal status must expedite
result in weakened delivery. In addition to deliver-
tissue and render ing healthy babies, however, the
labor attendant bears responsi-
the patient more sus- bility for minimizing perineum
ceptible to injury trauma, which includes judi-
in subsequent cious use of episiotomy. Previ-
ous studies established that a
deliveries. primary determinant for episi-
otomy use in obstetric practice
is the health care professional,
not patient characteristics.11,12 Concurrently, the
rate of episiotomy in our cohort was significantly
higher among private practitioner patients than
those cared for by the resident service (67.6% vs
19.7%). This would suggest that provider bias
not obstetric factorsmay be the most powerful
predictor of episiotomy use.
Our study raises new concerns regarding episi-
otomy. Not only is there no proven benefit to this
procedure, but episiotomy may also result in
weakened tissue and render the patient more
susceptible to injury in subsequent deliveries.
We encourage health care professionals to weigh
all the available evidence and to further restrict
the use of episiotomy.
28 The Female Patient | VOL 34 FEBRUARY 2009
Neither author reports any actual or potential
conflicts of interest in relation to this article.
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