Episiotomies: Not So Routine Any More

The ACOG has stated that the routine use of the episiotomy does not protect against pelvic relaxation or fetal intracranial bleeds, and points out that the procedure actually increases rates of perineal infection, blood loss, pain during healing, and injury to the anal sphincter. Body image and sexual function may also be negatively impacted.

Dr. Kurt Martinuzzi, MD, an OB-GYN with the Department of Obstetrics/Gynecology at Elmhurst Hospital Center in Queens, New York, says, "We now realize that episiotomies are frequently not necessary and indeed have little benefit to the mother or her baby. Patients who have episiotomies often end up with extensions to third- and fourth-degree lacerations, as well as increased blood loss. Whether you have an episiotomy or laceration, or deliver over an intact perineum, you're going to be sore during the postpartum period."

Midwives have long questioned the need for routine episiotomies, says Janette O'Sullivan, CNM, a nurse-midwife in New York City. "Birth is a normal process, not an illness, and, in most cases, thinning and stretching of the perineum can be facilitated by perineal support, lubrication, and possibly perineal massage."

According to Dr. Martinuzzi and O'Sullivan, episiotomies may be needed when:

• There is fetal distress, such as meconium or a slowed heart rate
• There is a shoulder dystocia (stuck shoulder), which can't be resolved with initial maneuvers
• There is a difficult forceps delivery
• The infant's head has been crowning for a long time without progress
• The perineum is not stretching and giving enough.

"The decision whether or not to do an episiotomy depends both on the doctor's training and personal philosophy, and the clinical picture at the time when birth is imminent," Dr. Martinuzzi adds.

The overall decline in episiotomy rates reflects both the impact of a growing body of knowledge, which strongly advises against using the episiotomy as a routine procedure during the birthing process, as well as improved patient education which has led to the laboring woman's increased participation in the decision-making process. Once again, women are reclaiming their bodies and clamoring to have a say in what happens to them during the exhilarating, exhausting process of giving birth.