Content uploaded by Katherine Eubanks Hartmann
Author content
All content in this area was uploaded by Katherine Eubanks Hartmann on Mar 12, 2014
Content may be subject to copyright.
CLINICIAN’S CORNER
CLINICAL REVIEW
Outcomes of Ro utine Episiotomy
A Systematic Review
Katherine Hartmann, MD, PhD
Meera Viswanathan, PhD
Rachel Palmieri, BS
Gerald Gartlehner, MD, MPH
John Thorp, Jr, MD
Kathleen N. Lohr, PhD
E
PISIOTOMY IS AMONG THE MOST
common surgical procedures
experienced by women in the
United States.
1
Thirty percent to
35% of vaginal births include episi-
otomy.
2,3
Episiotomy became routine
practice well before emphasis on us-
ing outcomes research to inform prac-
tice. In seeking to establish an evi-
dence base to support or refute the use
of episiotomy, randomized clinical trials
in the mid and late 1980s found that
routine episiotomy compared with re-
strictive use was associated with higher
risk of anal sphincter and rectal inju-
ries and precluded a woman from giv-
ing birth with an intact or minimally
damaged perineum.
4-7
Larger trials in
more varied populations followed in the
1990s, with similar results. Investiga-
tors also began to assess longer-term
outcomes such as persistent pain, pel-
vic floor defects, urinary and rectal con-
tinence, and sexual function and sat-
isfaction.
Despite decades of research, which
many interpret as definitive evidence
against routine use of episiotomy, little
professional consensus has developed
about the appropriateness of routine
use. Lack of consensus is illustrated by
variation in use. At 18 Philadelphia hos-
pitals studied in the mid 1990s, 42% of
women overall had an episiotomy,
while hospital averages ranged from
20% to 73%.
8
From 1987 to 1992, Low
and colleagues
9
documented clinician-
level variation from 13.3% to 84.6%,
with an average of 51% among spon-
taneous term births in a prospectively
enrolled population of uncomplicated
births. Wide variation existed among
both midwives and physicians. Varia-
tion has also been reported by time of
day
10
and by facility type, size, and lo-
cation.
11
Obstetric health care practi-
tioners who view episiotomy favor-
ably endorse survey items that state that
episiotomy should be used to “pre-
vent perineal trauma and to prevent pel-
vic floor relaxation and the conse-
See also Patient Page.
CME available online at
www.jama.com
Author Affiliations: Center for Women’s Health Re-
search (Drs Hartmann and Thorp and Ms Palmieri),
Department of Epidemiology, School of Public Health
(Dr Hartmann and Ms Palmieri), Department of Ob-
stetrics and Gynecology, School of Medicine (Drs Hart-
mann and Thorp), and Cecil G. Sheps Center for Health
Services Research (Drs Hartmann and Gartlehner), Uni-
versity of North Carolina at Chapel Hill; Research Tri-
angle Institute, Research Triangle Park, NC (Drs
Viswanathan and Lohr).
Corresponding Author: Katherine Hartmann, MD,
PhD, Center for Women’s Health Research, Univer-
sity of North Carolina, Campus Box 7521, 725 Air-
port Rd, Chapel Hill, NC 27599-7521 (khartman@med
.unc.edu).
Clinical Review Section Editor: Michael S. Lauer, MD.
We encourage authors to submit papers for consid-
eration as a “Clinical Review.” Please contact Mi-
chael S. Lauer, MD, at lauerm@ccf.org.
Context Episiotomy at the time of vaginal birth is common. Practice patterns vary widely,
as do professional opinions about maternal risks and benefits associated with routine use.
Objective To systematically review the best evidence available about maternal out-
comes of routine vs restrictive use of episiotomy.
Evidence Acquisition We searched MEDLINE, Cumulative Index to Nursing and
Allied Health Literature, and Cochrane Collaboration resources and performed a hand
search for English-language articles from 1950 to 2004. We included randomized con-
trolled trials of routine episiotomy or type of episiotomy that assessed outcomes in
the first 3 postpartum months, along with trials and prospective studies that assessed
longer-term outcomes. Twenty-six of 986 screened articles provided relevant data.
We entered data into abstraction forms and conducted a second review for accuracy.
Each article was also scored for research quality.
Evidence Synthesis Fair to good evidence from clinical trials suggests that immedi-
ate maternal outcomes of routine episiotomy, including severity of perineal laceration,
pain, and pain medication use, are not better than those with restrictive use. Evidence is
insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evi-
dence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor out-
comes have not been followed up into the age range in which women are most likely to
have sequelae. With this caveat, relevant studies are consistent in demonstrating no ben-
efit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor re-
laxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function—
pain with intercourse was more common among women with episiotomy.
Conclusions Evidence does not support maternal benefits traditionally ascribed to rou-
tine episiotomy. In fact, outcomes with episiotomy can be considered worse since some
proportion of women who would have had lesser injury instead had a surgical incision.
JAMA. 2005;293:2141-2148 www.jama.com
©2005 American Medical Association. All rights reserved. (Reprinted) JAMA, May 4, 2005—Vol 293, No. 17 2141
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
quences of pelvic floor relaxation, such
as bladder prolapse and urinary incon-
tinence.” Furthermore, they agree with
the statement that they “prefer to em-
ploy episiotomy frequently because it
is easier to repair than the laceration
that results when episiotomy is not
used.”
12
Simultaneous belief in preven-
tion of future sequelae and ease of re-
pair creates potential for misattrib-
uted motivations.
National data on use of episiotomy
show a consistent decline over the prior
2 decades.
1,2
However, persistent wide
practice variation suggests that episi-
otomy use is heavily driven by local pro-
fessional norms, experiences in train-
ing, and individual practitioner
preference rather than variation in the
needs of individual women at the time
of vaginal birth. Our goal was to refo-
cus attention on routine episiotomy by
systematically reviewing the best evi-
dence available about the maternal out-
comes of routine vs restrictive use of
episiotomy, including type of episi-
otomy. Specifically, we sought to de-
scribe maternal outcomes such as de-
gree of perineal injury and pain close
to the time of birth, as well as longer-
term outcomes such as urinary and fe-
cal incontinence, pelvic floor defects,
and sexual dysfunction.
EVIDENCE ACQUISITION
We sought studies that (1) reported out-
comes related to episiotomy and peri-
neal injury at the time of vaginal birth;
(2) were published in English; (3) had
more than 40 participants; and (4) re-
ported original research.
13
For sum-
mary of short-term maternal outcomes
of routine vs restrictive use of episi-
otomy or of episiotomy type, we lim-
ited searches to randomized clinical
trials. For longer-term outcomes, such
as incontinence, pelvic floor defects, and
sexual function, we included both trials
and prospective cohorts.
In collaboration with a research li-
brarian, we searched MEDLINE, Coch-
rane Collaboration resources, and the
Cumulative Index to Nursing and Al-
lied Health Literature using the search
terms episiotomy and labor stage, sec-
ond. We then hand-searched refer-
ence lists of research articles, reviews,
and texts and consulted with our ad-
visory group to ensure full identifica-
tion of relevant articles from 1950
through May 2004. We conducted dual
independent reviews of abstracts and
a single review of full articles to apply
the inclusion criteria. Initial data ab-
straction was done by K.H., M.V., R.P.,
G.G., and J.T. and a second team mem-
ber assessed initial entries for accu-
racy, completeness, and consistency.
The 2 abstractors, with the full team as
needed, reconciled discrepancies.
To rate quality of individual ar-
ticles, 2 authors independently rated
each article. A third author reviewed
scores and flagged differences. We rec-
onciled any differences in component
or overall quality classification by con-
sensus. To grade the global strength of
evidence relevant to specific out-
comes, we used the approach de-
scribed by West and colleagues.
14
That
system encompasses 3 domains: (1)
quality of the individual studies as as-
sessed by examination of a checklist of
specific elements of study design and
conduct; (2) quantity of relevant stud-
ies identified (including number of
studies and adequacy of the sample
size); and (3) consistency of findings.
Grades for strength of evidence were as-
signed by consensus.
13
Although meta-analysis was not the
primary goal, we calculated summary
measures when possible. Variation be-
tween studies was assessed using tests
of homogeneity, including exact tests
as required. Scarcity of studies with
similar exposure categories, outcome
measures, and timing of measurement
often prohibited calculation of sum-
mary measures and examination of
sources of heterogeneity. For sum-
mary estimates, we required similar
measures in the same time frame. When
heterogeneity was observed (P⬍.10),
we used DerSimonian and Laird ran-
dom-effects models to generate sum-
mary measures.
15
If no meaningful het-
erogeneity was found, we applied
Mantel-Haenszel fixed-effects models
to estimate summary measures.
EVIDENCE SYNTHESIS
Our search identified 986 articles; 659
were excluded after reviewing the ab-
stract. We reviewed the full texts of
327 articles. Twenty-six met inclu-
sion criteria.
Maternal Postpartum Outcomes
Seven randomized trials, with a total of
5001 participants, compared restric-
tive vs routine use of episiotomy.
16-22
Six
of the 7 trials used mediolateral episi-
otomy. The only North American trial,
conducted in Canada, used midline epi-
siotomy, which is more conventional in
the United States.
19
Each trial com-
pared 2 groups: a group in which the ob-
stetric health care practitioner was to re-
strict use of episiotomy and a group with
a liberal use policy that endorsed rou-
tine use. The strictest definition of re-
strictive use was to avoid episiotomy un-
less indicated for fetal well-being.
16,22
Other definitions pivoted on instruc-
tions to “avoid episiotomy,” use only
when “medically necessary,” or not per-
form episiotomy for the purpose of
avoiding a laceration.
17-19,21
The largest
trial defined restrictive use as only for
fetal indications or to avoid severe lac-
erations.
20
Routine use groups were de-
fined in terms such as “routinely con-
ducted,” “usual care,” and “elective.”
17-21
Two studies described routine as use to
preempt a tear.
16,22
Overall, inclusion criteria for these
studies were poorly specified. Gener-
ally, participants had term births of
singletons with vertex presentation.
Three studies enrolled only women
having a first birth, which eliminates in-
fluence of prior perineal trauma on trial
outcomes.
17,21,22
In studies without par-
ity restrictions, the proportion of
women who were primiparous ranged
from 40% to 68%, with good balance
between study groups.
16,18-20
In 1 ex-
ception, multiparous women were
somewhat more likely to be in the re-
strictive use group.
18
Each study focused on normal spon-
taneous vaginal births. To reduce the
number of operative vaginal deliveries
or cesarean births, most trials allocated
women as close to birth as feasible. The
OUTCOMES OF ROUTINE EPISIOTOMY
2142 JAMA, May 4, 2005—Vol 293, No. 17 (Reprinted) ©2005 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
proportion of assisted vaginal births
ranged from 0 to 5%
16,19-21
up to
15%.
17,18,22
In 2 cases, authors noted the
number of cesarean births and exclu-
sion from further analyses.
19,22
Both of
these studies enrolled women during
prenatal care, an approach that im-
proved representativeness of the popu-
lation, making exclusion from analysis
logical.
Perineal Outcomes. The strongest
trial (good quality) was the first con-
ducted,
16
which achieved a wide gra-
dient of episiotomy use: 10.2% in the
restrictive use group and 51.4% in the
routine use group. Women in the re-
strictive use group were more likely to
have an intact perineum; 33.9% in the
restrictive use group had neither pos-
terior perineal lacerations nor episi-
otomy compared with 24.3% in the rou-
tine use group. Third- and fourth-
degree lacerations were rare (0.5%
overall) and did not differ by group.
Among nulliparous women, 74% of the
restrictive use group compared with
89% of the routine use group required
any suturing, including for anterior or
labial lacerations. For multiparous
women, 66% of the restrictive use gr oup
and 69% of the routine use group re-
quired sutures.
16
The largest trial was a multisite
Argentine study of fair quality, with
2606 participants.
20
This study docu-
mented decreased risk of posterior peri-
neal surgical repair (relative risk [RR],
0.72; 95% confidence interval [CI],
0.68-0.75) and a 2.4-fold increase in risk
of anterior tears among women in the
restrictive use group (95% CI, 1.89-
2.94) compared with routine use. Sixty-
three percent of women in the restric-
tive use group had a surgical repair
compared with 88% in the routine use
group. Pain and healing complica-
tions were less frequent in the restric-
tive use group.
Results of the remaining trials were
compatible with these findings
(T
ABLE 1): intact perineum was uni-
formly less common in the routine com-
pared with the restrictive use group (RR,
0.46; 95% CI, 0.30-0.70).
16,18,19,21,22
W ith
2 exceptions,
16,19
studies reported mor e
third- and fourth-degree lacerations in
the routine use group. All trials were
underpowered to distinguish differ-
ences, with a total of 105 rectal injuries
among 5001 participants (RR for rou-
tine vs restrictive use, 1.13; 95% CI, 0.78-
1.65).
16-22
Anterior lacerations, includ-
ing anterior labial lacerations, wer e more
common in the restrictive use groups in
4 studies
16,19,20,22
and in the routine use
group in 1 study.
21
Anterior lacerations
did not contribute to overall higher use
of suturing, suggesting that these tears
were less severe than posterior tears.
Need for any suturing was 26% higher
in the routine use gr oups (RR, 1.26; 95%
CI, 1.08-1.48).
16,20,21
Pain Outcomes. Five studies as-
sessed pain outcomes (T
ABLE 2).
16,18-20,22
Sleep and colleagues used midwives
masked to group to assess pain at 10
postpartum days.
16
Participants re-
ported their pain severity in the prior 24
hours. Severity was virtually identical be-
tween groups: in the routine use group,
14.6% had mild pain, 7.8% had moder -
ate pain, and 0.2% had sever e pain; r e-
spective propor tions for the restrictive
use group were 14.1%, 7.5%, and 0.9%.
Use of oral analgesics by postpartum day
10 was rar e and comparable at 2% and
3%, respectively. Pain outcomes were
also comparable at 3 months.
House and colleagues reported that
level of pain was more severe on the
third postpartum day in the routine use
group.
18
They assessed pain using a vi-
sual analog scale during an interview
conducted by an author (masking was
not noted). On day 3 in the routine use
group, 11% had severe pain, 34% had
moderate pain, and 55% had mild pain;
respective categories for the restric-
tive use gr oup were 10%, 22%, and 68%.
The restrictive use group had less ten-
derness on examination on the third
postpartum day: 79% had mild or mini-
mal pain, 18% had moderate pain, and
3% had severe pain compar ed with 51%,
39%, and 10% in the routine use group,
Table 1. Perineal Injury Outcomes of Clinical Trials of Routine vs Restrictive Episiotomy Use
Source
Total No. of
Participants Group No.
Intact
Perineum, %
Episiotomy
Performed, %
Third- or
Fourth-Degree
Tear, %
Anterior
Tears, %
Any Use of
Suturing, %
Sleep et al,
16
1984 1000 Routine 502 24.3 51.4 0.2 17.3 78.0
Restrictive 498 33.9 10.2 0.8 26.3 69.0
Harrison et al,
17
1984 181 Routine 89 . . . 44.9 5.6 . . . . . .
Restrictive 92 20.6 7.6 0.0 . . . . . .
House et al,
18
1986 165 Routine 71 11.3 69.0 1.4 . . . . . .
Restrictive 94 42.6 18.1 0.0 . . . . . .
Klein et al,
19
1992 703 Routine 350 12.6 93.7 7.4 10.6 . . .
Restrictive 353 19.2 43.8 7.7 14.9 . . .
Argentine Episiotomy Trial 2606 Routine 1298 . . . 82.6 1.5 8.1 88.1
Collaborative Group,
20
1993
Restrictive 1308 . . . 30.1 1.1 19.2 63.0
Eltorkey and Nuaim,
21
1994 200 Routine 100 7.0 83.0 0.0 18.0 85.0
Restrictive 100 28.0 53.0 0.0 12.0 67.0
Dannecker et al,
22
2004 146 Routine 76 10.0 76.7 8.3 41.7 . . .
Restrictive 70 28.6 40.8 4.1 55.1 . . .
Abbreviation: Ellipses indicate data not reported.
OUTCOMES OF ROUTINE EPISIOTOMY
©2005 American Medical Association. All rights reserved. (Reprinted) JAMA, May 4, 2005—Vol 293, No. 17 2143
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
respectively. These differ ences were sta-
tistically significant and likely to be
clinically relevant. Differences in pain
by group were r esolved by 6 weeks and
3 months.
The only trial using midline episi-
otomy found no difference in McGill
Pain Scale scores for perineal pain or
pain with urination on days 1, 2, and
10.
19
The Argentine study
20
did not ad-
equately define how they measured pain
and reported “pain on the day of dis-
char ge.” The routine use group was de-
scribed as 42.5% with pain and the re-
strictive use group as 30.7% with pain.
The most recent study pr ovided the
most nuanced approach to pain assess-
ment.
22
The investigators used a 100-mm
visual analog scale to assess pain with
4 activities. During bed rest, women in
the routine use group reported mean
scores of 39 mm (SD, 28 mm) com-
pared with 22 mm (SD, 21 mm) in the
restrictive use group; during sitting, 69
mm (SD, 23 mm) compared with 51 mm
(SD, 25 mm); during walking, 56 mm
(SD, 24 mm) vs 37 mm (SD, 24 mm);
and during defecation, 36 mm (SD, 30
mm) vs 21 mm (SD, 21 mm). Across all
activities the restrictive use group ex-
perienced less perineal pain (P=.005-
.048), with differences likely to be clini-
cally significant.
None of the 5 studies found pain to
be lessened by routine episiotomy. No
summary measures were appropriate
given the variety of methods and tim-
ing of pain measurement.
Healing Outcomes. Two trials re-
ported physical examinations. The Ar-
gentine trial reported no differences in
hematoma prior to discharge and, at 7
days, infection, healing complica-
tions, or dehiscence. Only 44% of the
women were evaluated at 7 postpar-
tum days.
20
House and colleagues
18
ex-
amined participants at 3 days and at 6
weeks. Risk of infection was assessed
for all participants on day 3. Poor
wound apposition and granulation tis-
sue, indicating secondary healing, were
assessed at the later visit, which in-
cluded 53% of participants. Each ad-
verse outcome was equivalent.
Other Outcomes. Two studies esti-
mated maternal blood loss. One found
no difference in change in maternal he-
moglobin.
22
The other found that esti-
mated blood loss (method not de-
fined) was 58 mL greater in the routine
use group, a statistically but not clini-
cally relevant difference.
18
Incision Type
Only 1 trial and no prospective co-
horts compared midline and mediolat-
eral episiotomy.
23
The trial allocated
women having a first birth to midline
episiotomy (“incisions divided 2 cm to
3 cm of the perineal tissue in the mid-
line”) or mediolateral incisions (“made
from the midline and carried to the right
of the anal sphincter for about 3 cm to
4 cm”).
23
This study received a poor
quality rating. We noted an inad-
equate randomization method, lack of
allocation concealment, and failure to
mask outcome assessors as potential
sources of bias.
More complications occurred in the
midline group (P⬍.001). Twenty-
four percent of the midline group had
an extension of the episiotomy into or
through the sphincter compared with
9% of the mediolateral group. The mid-
line group had less bruising of the peri-
neum (P⬍.001). The investigators did
not find differences in pain. Of partici-
pants, 76% attended 3-month follow-
up. Women in the midline group be-
gan sexual intercourse earlier (P⬍.01)
and had a better cosmetic appearance
of the scar (P⬍.02) than the mediolat-
eral group. No differences in pain or sat-
isfaction from sexual intercourse were
identified.
Urinary Incontinence,
Fecal Incontinence,
and Pelvic Floor Defects
Sixteen publications prospectively col-
lected data about continence or pelvic
floor muscle function (T
ABLE 3). These
publications include 4 reports from 2
trials of restrictive vs routine episi-
Table 2. Perineal Pain Outcomes of Clinical Trials of Routine vs Restrictive Episiotomy Use
Source
No./ Total
Participants Assessment
Timing of
Assessment
Outcome
Group
Study Group
Routine Restrictive
Sleep et al,
16
1984 885/1000 Pain severity in prior 24 h, % 10 d Mild 14.6 14.1
Moderate 7.8 7.5
Severe 0.2 0.9
House et al,
18
1986 165/165 Pain severity using VAS (1-3,
minimal; 4-6, moderate;
7-10, severe), %
3 d Minimal 54.9 68.1
Moderate 33.8 22.3
Severe 11.3 9.6
Klein et al,
19
1992 703/703 Mean perineal pain severity score
using 6-point McGill Pain
Scale*
1 d 1.56 1.50
2 d 1.10 1.16
10 d 0.40 0.40
Argentine Episiotomy
Trial Collaborative
Group,
20
1993
2422/2606 Any perineal pain (not defined), % Discharge 42.5 30.7
Dannecker et al,
22
2004 53/146 Mean (SD) maximum pain score
using 100-mm VAS scale
(0 = “not at all”; 100 = “very
much”)
1-5 d Bed rest 39 (28) 22 (21)
Sitting 69 (23) 51 (25)
Walking 56 (24) 37 (24)
Defecation 36 (30) 21 (21)
Abbreviation: VAS, visual analog scale.
*Mean perineal pain scores were calculated from stratified numbers in the original article and weighted by parity (primiparous = 359; multiparous = 344).
OUTCOMES OF ROUTINE EPISIOTOMY
2144 JAMA, May 4, 2005—Vol 293, No. 17 (Reprinted) ©2005 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
otomy
16,19,24,25
and 12 additional pro-
spective cohorts.
26-37
Neither trial found meaningful dif-
ferences in measures of urinary incon-
tinence, including perineometry, and
self-report of involuntary loss of urine,
use of a pad, and loss of urine with
coughing, sneezing, and laughing at
3 months
16,19
or 3 years.
24
Among pro-
spective studies, Sartore and col-
leagues
29
conducted the most global as-
sessment of continence and pelvic floor
function. At 3 months, women who had
episiotomy had reduced pelvic floor
muscle strength as assessed by perine-
ometry compared with women with
spontaneous tears. The clinical signifi-
cance of this finding is unclear be-
cause all self-reported symptoms of uri-
nary and anal incontinence and degree
of prolapse on physical examination
were equivalent.
In addition to trials, 6 studies (5
study populations) evaluated self-
reports of urinary continence.
26-29,32,33
Episiotomy and spontaneous-tear
groups had the same frequency of in-
Table 3. Urinary and Rectal Continence Outcomes*
Source
No./ Total
Participants
Timing of
Assessment Self-reported Symptoms Outcome Group Study Group
Urinary Incontinence: Clinical Trials of Routine vs Restrictive Episiotomy Use
Routine Restrictive
Sleep et al,
16
1984 895/1000
Routine,n=457
Restrictive,n=438
3 mo Involuntary loss of urine, % 19.0 18.9
Pad use for loss of urine, % 5.9 5.9
Sleep and Grant,
24
1987
643/1000
Routine,n=333
Restrictive,n=310
3 y Involuntary loss of urine, % Less than once per wk 24.6 22.3
1-2 times in prior wk 10.5 11.9
ⱖ3 times in prior wk 2.1 1.9
Pad use, % Sometimes 7.2 8.4
Daily 1.2 1.6
Klein et al,
19
1992 674/703
Routine,n=337
Restrictive,n=337
3 mo Involuntary loss of urine, % Primiparous 14.5 21.1
Multiparous 21.5 12.9
Urinary Incontinence: Prospective Cohorts Comparing Women With vs Without Episiotomy†
Episiotomy
No
Episiotomy‡
Rockner,
26
1990 182/205
Episiotomy,n=140
No episiotomy,n=42
4 y Involuntary loss of urine, % Occasionally 26.4 28.6
Once per wk 7.1 2.4
2-3 times per wk 1.4 2.4
⬎3 times per wk 0.7 2.4
Karacam and
Eroglu,
27
2003
100/100
Episiotomy,n=50
No episiotomy,n=50
3 mo Stress incontinence (not
defined), %
24.0 30.0
Eason et al,
28
2004 835/949
Episiotomy,n=223
No episiotomy,n=612
3 mo Involuntary loss of urine, % Any 29.1 35.0
Sartore et al,
29
2004 519/519
Episiotomy,n=254
No episiotomy,n=265
3 mo Stress incontinence (not
defined), %
13.0 12.1
Rectal Incontinence: Prospective Cohorts Comparing Women With vs Without Episiotomy†
Episiotomy
No
Episiotomy
Eason et al,
31
2002 834/1198
Episiotomy,n=223
No episiotomy,n=611
3 mo Involuntary loss of stool
or flatus, %
Stool 5.4 2.5
Flatus 29.1 24.4
Sartore et al,
29
2004 519/519
Episiotomy,n=254
No episiotomy,n=265
3 mo Anal incontinence (not
defined), %
2.8 1.9
Intact ST
MacArthur et al,
30
1997
879/906
Episiotomy,n=188
No episiotomy,
intact, n = 391;
ST, n = 300
10 mo Loss of bowel control, soiling
or staining, %
Primiparous 4.6 5.2 5.1
Multiparous 8.8 2.9 2.7
Abbreviation: ST, spontaneous tear.
*Data exclude intermediate measures such as perineometry and physical examination of rectal sphincter disruption and prolapse.
†Two publications for urinary incontinence
31,32
and 1 publication for rectal incontinence
33
did not provide data by study group.
‡Only those with spontaneous tears in comparison group.
OUTCOMES OF ROUTINE EPISIOTOMY
©2005 American Medical Association. All rights reserved. (Reprinted) JAMA, May 4, 2005—Vol 293, No. 17 2145
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
continence symptoms (RR for trials,
1.02; 95% CI, 0.83-1.26; RR for co-
horts, 0.88; 95% CI, 0.72-1.07).
16,19,27-29
No evidence supports episiotomy to
prevent pelvic floor damage. Four co-
hort studies asked women about rec-
tal incontinence, including 1 that also
conducted physical examinations.
29-31,34
None found episiotomy to be statisti-
cally associated with reduced risk of in-
continence of stool or flatus. Indeed, in
aggregate the 2 studies with compa-
rable measures suggest an almost 2-fold
increase in risk (RR, 1.91; 95% CI,
1.03-3.56).
29,31
Five studies included physiologic
measures of pelvic floor muscle func-
tion. None found an advantage for epi-
siotomy
25,35-37
and 1 identified a de-
crease in muscle strength.
29
These
muscle function measures concur with
self-report and clinical examination
findings of other studies. Episiotomy
confers no benefits with respect to pre-
serving continence or pelvic floor
muscle function within months or years
of birth. Longer-term data are absent.
Table 4. Sexual Function Outcomes
Source
No. of Participants
at Follow-Up
Timing of
Assessment Self-reported Symptoms
Outcome
Group Study Group
Clinical Trials of Routine vs Restrictive Episiotomy Use
Routine Restrictive
Sleep et al,
16
1984 895/1000
Routine,n=457
Restrictive,n=438
3 mo Resumption of intercourse, % 89.9 90.0
Current pain with intercourse, % 18.0 21.8
Pain with intercourse in prior
3 mo, %
51.1 52.0
Sleep and Grant,
24
1987 674/1000
Routine,n=329
Restrictive,n=345
3 y Any painful intercourse since
birth, %
16 13
Klein et al,
19
1992 612/703
Routine,n=303
Restrictive,n=309*
3 mo Time to resumption
of intercourse,
mean (SD), wk
Primiparous 5.8 (2.1) 5.9 (2.5)
Multiparous 5.8 (2.6) 5.4 (2.3)
Pain at first postpartum
intercourse (6-point McGill
Pain Scale), mean (SD)
Primiparous 2.2 (1.3) 2.2 (1.3)
Multiparous 1.3 (1.1) 1.2 (1.0)
Sexual satisfaction scale
(items not provided),
mean (SD)
Primiparous 3.1 (0.7) 3.0 (0.8)
Multiparous 3.3 (0.7) 3.3 (0.6)
Prospective Cohorts Comparing Women With vs Without Episiotomy†
Episiotomy
No
Episiotomy‡
Rockner et al,
38
1988 200/205
Episiotomy,n=154
No Episiotomy,n=46
3 mo Resumption of intercourse, % 92.2 92.0
Current pain with intercourse, % 20.1 19.6
Any painful intercourse since
birth, %
44.2 43.5
Karacam and
Eroglu,
27
2003
96/100
Episiotomy,n=48
No episiotomy,n=48
3 mo Any pain with intercourse
(not defined), %
64.6 54.2
Sartore et al,
29
2004 519/519
Episiotomy,n=48
No episiotomy,n=265
3 mo Current pain with intercourse, % 7.9 3.4
ST Intact
Larsson et al,
39
1991 1037/1889
Episiotomy,n=410
No Episiotomy,
ST, n = 627;
intact,n=852
2-3 mo Pain with intercourse
(not defined), %
16.1 11.0 . . .
Klein et al,
25
1994 607/697
Episiotomy,n=300
No Episiotomy,
ST, n = 200;
intact, n = 107§
3 mo Resumption of intercourse
by 6 wk, %
61.7 62.5 76.6
Pain at first postpartum
intercourse, %
Mild 22.7 27.3 37.6
Discomforting 34.1 27.3 22.8
Distressing 28.8 24.6 6.9
Sexual satisfaction scale (items
not provided), %
Not satisfied 16.7 15.8 5.0
Abbreviation: ST, spontaneous tear. Ellipses indicate data not reported.
*Information not available for all respondents: n = 301 to 303 for routine use group; n = 306 to 309 for restrictive use group.
†One publication did not provide data by study group.
40
‡Spontaneous tear comparison group.
§Information not available for all respondents: n = 263 to 300 for episiotomy group; n = 183 to 200 for ST group; n = 100 to 107 for intact group.
OUTCOMES OF ROUTINE EPISIOTOMY
2146 JAMA, May 4, 2005—Vol 293, No. 17 (Reprinted) ©2005 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
Episiotomy and Sexual Function
Nine studies (10 publications) prospec-
tively collected data about sexual func-
tion: 3 trials of restrictive vs routine use
of episiotomy,
16,19,24
1 trial of mediolat-
eral vs midline episiotomy,
23
and 5 pro-
spective cohorts.
25,27,29,38,39
One study de-
scribed by the authors as retrospective
included a time point at 6 months with
current rather than recalled data about
sexual function.
40
Two trials of restrictive vs routine
episiotomy reported intention-to-
treat analyses of long-term sexual out-
comes (T
ABLE 4). In the first trial,
16
37%
of the restrictive use group and 27% of
the routine use group had resumed
sexual intercourse by 1 month after the
birth (P⬍.01). The proportions of
women with resumption of inter-
course by 3 months, dyspareunia at 3
months, or any dyspareunia within 3
months did not differ by group. By the
third year of follow-up, likelihood of
“ever suffering painful intercourse” re-
mained comparable.
24
Klein and colleagues
19
reported that
women in the restrictive use group re-
sumed intercourse an average of 1 week
earlier than those in the routine use
group. All measures of sexual func-
tion were equivalent by 3 months. This
team conducted a separate analysis of
type of perineal trauma and sexual func-
tion using 3-month interviews. Women
with episiotomy had the slowest re-
turn to intercourse (P=.02). Pain with
first postpartum intercourse was also
most common and severe among
women with episiotomy (P⬍.001).
25
Prospective cohort studies did not find
differences in sexual function (Table 4).
Only 1 study identified differences in
dyspareunia at 3 months.
29
However,
pooled estimates of prevalence at 3
months can be estimated from 2 co-
horts.
29,38
The summary estimate sug-
gests that women with episiotomy tend
to be more likely to report pain with in-
tercourse 3 months after delivery (RR,
1.53; 95% CI, 0.93-2.51).
29,38
The 2 stud-
ies that assessed any dyspareunia dur-
ing the first 3 months after childbirth
also found no difference in probability
of having had painful intercourse.
CONCLUSIONS
Our systematic review finds no ben-
efits from episiotomy. We identified fair
to good evidence suggesting that im-
mediate outcomes following routine use
of episiotomy are no better than those
of restrictive use. Indeed, routine use
is harmful to the degree that some pro-
portion of women who would have had
lesser injury instead had a surgical
incision.
Weak evidence from a single trial sug-
gests that harms of midline episiotomy
are greater than mediolateral episi-
otomy due to greater risk of rectal in-
jury. Multiple retrospective cohort stud-
ies also document higher sphincter
injury rates with midline episi-
otomy.
41-47
Health care practitioners at-
tending births in the United States are
likely to have greater experience per-
forming midline than mediolateral epi-
siotomy. We caution against a shift to
an unfamiliar technique; suggesting
more restrictive use of episiotomy will
avert a larger number of all types of peri-
neal injuries than change in technique.
The overall level of evidence on long-
term sequelae—specifically, fecal and
urinary incontinence, pelvic floor func-
tion, and future sexual function—is fair
to poor. With regard to incontinence,
the research is consistent in demon-
strating lack of benefit in a compar-
atively early time frame. For women in
later adult life, when morbidity is most
likely to occur as severe and persis-
tent incontinence or pelvic organ pro-
lapse, the expected results of routine
episiotomy are unknown. No evi-
dence suggests that sexual function is
improved by episiotomy; those who
have episiotomy may be more likely to
have pain with intercourse in the
months after pregnancy and are slower
to resume having intercourse.
While trials with strong definitions re-
stricting use to fetal indications have
achieved use as low as 8% to 10% (along
with high proportions of births with an
intact perineum),
16,17
in contemporary
practice episiotomy use remains more
than 3-fold higher. In the absence of ben-
efit and with a potential for harm, a pro-
cedure should be abandoned. The ma-
jority of the data we have reviewed have
been available for decades and thought-
fully reviewed by others. As in many dis-
cretionary procedures, practice pat-
terns have been slow to change.
However, in this instance, clinicians have
been the primary agents to exercise
choice to conduct or not conduct an epi-
siotomy, rather than patients.
The time has come to take on the
professional responsibility of setting and
achieving goals for reducing episi-
otomy use. Much as surgical special-
ists have reduced use of procedures like
knee surgery for arthritis and tonsil-
lectomy in children, clinicians must at-
tend to aligning research evidence and
episiotomy use. Rates of episiotomy of
less than 15% of spontaneous vaginal
births should be immediately within
reach. Clinicians need to work within
hospitals, practices, and birthing cen-
ters to better track the prevalence of cir-
cumstances that likely warrant use, such
as fetal distress, to refine target rates that
fit the characteristics and labor expe-
riences of the populations. In doing so,
clinicians must acknowledge that little,
if any, evidence is available to define in-
dications for use; however, it is clear
that maternal benefit is not an indica-
tion. Investigators need to study bar-
riers to decreased use, including the in-
fluence of case-mix on use, and to
investigate approaches to promoting
change in clinician behavior. As episi-
otomy is used less, opportunities will
be gained to better study other tech-
niques intended to prevent or reduce
perineal injury. The goals for quality of
care must remain focused on both op-
timizing safety for the infant and mini-
mizing harm to the mother. Given that
focus, clinicians have the opportunity
to forestall approximately 1 million epi-
siotomies each year that are not im-
proving outcomes for mothers.
Financial Disclosures: None reported.
Funding/Support: This review was supported by con-
tract 290-02-0016 from the Agency for Healthcare
Research and Quality (AHRQ), Task No. 4.
Role of the Sponsor/Disclaimer: This article was devel-
oped through work conducted by the RTI International–
University of North Carolina Evidence-based Practice
Center under AHRQ contract 290-97-0011. The spon-
soring agency provided advice and counsel on the de-
sign and conduct of the evidence report on which this
OUTCOMES OF ROUTINE EPISIOTOMY
©2005 American Medical Association. All rights reserved. (Reprinted) JAMA, May 4, 2005—Vol 293, No. 17 2147
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
article is based, review of the draft evidence report, ac-
ceptance and approval of the final evidence repot, and
review and approval of the draft manuscript of this ar-
ticle. The authors of this article are solely responsible for
its content, including any clinical or treatment recom-
mendations. No statement in this article should be con-
strued as an official position of the AHRQ or the US De-
partment of Health and Human Services.
Also Available: A more detailed systematic evidence
review of episiotomy in obstetrical care will be avail-
able at http://www.ahcpr.gov/clinic/epcix.htm.
Acknowledgment: We acknowledge the continuing
support of Kenneth Fink, MD, MGA, MPH, director
of the AHRQ Evidence-Based Practice Center (EPC)
Program, and Marian James, PhD, the AHRQ task or-
der officer for this project. In addition, we thank the
members of our technical expert panel, who pro-
vided input and advice for the full evidence report on
which this article is based: Leah Albers, CNM, DrPH;
Linda Brubaker, MD; Pierre Buekens, MD, PhD, MPH;
John O. L. DeLancey, MD; William Droegemueller,
MD; David A. Grimes, MD; and Dwight J. Rouse, MD,
MSPH. The investigators deeply appreciate the con-
siderable support, commitment, and contributions of
the EPC team staff at Research Triangle Institute In-
ternational and the University of North Carolina (UNC),
as well as the Center for Women’s Health Research
at UNC. From UNC, we thank Timothy S. Carey, MD,
MPH; B. Lynn Whitener, PhD; Leah Randolph, MA;
Laura Morgan, MA, Richard MacLehose, MPH, and
Anita Baldi, BA. We also express our gratitude to Re-
search Triangle Institute staff: Linda Lux, MPA; Tam-
meka Swinson, BA; Loraine Monroe; and Debra Bost.
REFERENCES
1. Weber AM, Meyn L. Episiotomy use in the United
States, 1979-1997. Obstet Gynecol. 2002;100:1177-
1182.
2. Kozak LJ, Owings MF, Hall MJ. National Hospital
Discharge Survey: 2001 annual summary with de-
tailed diagnosis and procedure data. Vital Health Stat
13. June 2004:1-198.
3. Declercq ED, Sakala C, Corry MP, Applebaum S,
Risher P. Listening to Mothers: Report of the First
National US Survey of Women’s Childbearing
Experiences. New York, NY: Maternity Center Asso-
ciation; 2002.
4. Banta D, Thacker SB. The risks and benefits of epi-
siotomy: a review. Birth. 1982;9:25-30.
5. Woolley RJ. Benefits and risks of episiotomy: a re-
view of the English-language literature since 1980: part
I. Obstet Gynecol Surv. 1995;50:806-820.
6. Woolley RJ. Benefits and risks of episiotomy: a re-
view of the English-language literature since 1980: part
II. Obstet Gynecol Surv. 1995;50:821-835.
7. Thorp JM Jr, Bowes WA Jr. Episiotomy: can its rou-
tine use be defended? Am J Obstet Gynecol. 1989;160:
1027-1030.
8. Webb DA, Culhane J. Hospital variation in episi-
otomy use and the risk of perineal trauma during
childbirth. Birth. 2002;29:132-136.
9. Low LK, Seng JS, Murtland TL, Oakley D. Clinician-
specific episiotomy rates: impact on perineal outcomes.
J Midwifery Womens Health. 2000;45:87-93.
10. Webb DA, Culhane J. Time of day variation in rates
of obstetric intervention to assist in vaginal delivery.
J Epidemiol Community Health. 2002;56:577-578.
11. Kaczorowski J, Levitt C, Hanvey L, Avard D, Chance
G. A national survey of use of obstetric procedures and
technologies in Canadian hospitals: routine or based
on existing evidence? Birth. 1998;25:11-18.
12. Klein MC, Kaczorowski J, Robbins JM, Gauthier
RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and be-
haviour during a randomized controlled trial of episi-
otomy: consequences for women in their care. CMAJ.
1995;153:769-779.
13. Viswanathan M, Hartmann K, Palmieri R, et al.
The Use of Episiotomy in Obstetric Care: A System-
atic Review. Rockville, Md: Agency for Healthcare Re-
search and Quality; May 2005. Evidence Report/
Technology Assessment 112. AHRQ publication 05-
E009-1. Available at: http://www.ahcpr.gov/clinic
/epcix.htm. Accessed April 7, 2005.
14. West SL, King V, Carey TS, et al. Systems to Rate
the Strength of Scientific Evidence. Rockville, Md:
Agency for Healthcare Research and Quality; 2002.
AHRQ Publication 02-E016.
15. Egger M, Smith GD, Altman DG. Systematic Re-
views in Health Care: Meta-analysis in Context. Lon-
don, England: BMJ Books; 2001.
16. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J,
Chalmers I. West Berkshire perineal management trial.
BMJ Clin Res Ed. 1984;289:587-590.
17. Harrison RF, Brennan M, North PM, Reed JV,
Wickham EA. Is routine episiotomy necessary? Br Med
J (Clin Res Ed). 1984;288:1971-1975.
18. House MJ, Cario G, Jones MH. Episiotomy and
the perineum: a random controlled trial. J Obstet
Gynaecol. 1986;7:107-110.
19. Klein MC, Gauthier RJ, Jorgensen SH, et al. Does
episiotomy prevent perineal trauma and pelvic floor
relaxation? Online J Curr Clin Trials. July 1, 1992.
Document 10.
20. Argentine Episiotomy Trial Collaborative Group.
Routine vs selective episiotomy: a randomised con-
trolled trial. Lancet. 1993;342:1517-1518.
21. Eltorkey MM, Nuaim MA. Episiotomy, elective or
selective: a report of a random allocation trial. J Ob-
stet Gynaecol. 1994;14:317-320.
22. Dannecker C, Hillemanns P, Strauss A, Hasbar-
gen U, Hepp H, Anthuber C. Episiotomy and perineal
tears presumed to be imminent: randomized con-
trolled trial. Acta Obstet Gynecol Scand. 2004;83:364-
368.
23. Coats PM, Chan KK, Wilkins M, Beard RJ. A com-
parison between midline and mediolateral episiotomies.
Br J Obstet Gynaecol. 1980;87:408-412.
24. Sleep J, Grant A. West Berkshire perineal man-
agement trial: three year follow up. Br Med J (Clin
Res Ed). 1987;295:749-751.
25. Klein MC, Gauthier RJ, Robbins JM, et al. Rela-
tionship of episiotomy to perineal trauma and mor-
bidity, sexual dysfunction, and pelvic floor relaxation.
Am J Obstet Gynecol. 1994;171:591-598.
26. Rockner G. Urinary incontinence after perineal
trauma at childbirth. Scand J Caring Sci. 1990;4:169-
172.
27. Karacam Z, Eroglu K. Effects of episiotomy on
bonding and mothers’ health. J Adv Nurs. 2003;43:
384-394.
28. Eason E, Labrecque M, Marcoux S, Mondor M.
Effects of carrying a pregnancy and of method of de-
livery on urinary incontinence: a prospective cohort
study. BMC Pregnancy Childbirth. 2004;4:4.
29. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi
E, Guaschino S. The effects of mediolateral episi-
otomy on pelvic floor function after vaginal delivery.
Obstet Gynecol. 2004;103:669-673.
30. MacArthur C, Bick DE, Keighley MR. Faecal in-
continence after childbirth. Br J Obstet Gynaecol. 1997;
104:46-50.
31. Eason E, Labrecque M, Marcoux S, Mondor M.
Anal incontinence after childbirth. CMAJ. 2002;166:
326-330.
32. Viktrup L, Lose G, Rolff M, Barfoed K. The symp-
tom of stress incontinence caused by pregnancy or de-
livery in primiparas. Obstet Gynecol. 1992;79:945-949.
33. Viktrup L, Lose G. The risk of stress incontinence
5 years after first delivery. Am J Obstet Gynecol. 2001;
185:82-87.
34. 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;83:218-
221.
35. Rockner G, Jonasson A, Olund A. The effect of
mediolateral episiotomy at delivery on pelvic floor
muscle strength evaluated with vaginal cones. Acta
Obstet Gynecol Scand. 1991;70:51-54.
36. Fleming N, Newton ER, Roberts J. Changes in post-
partum perineal muscle function in women with and
without episiotomies. J Midwifery Womens Health.
2003;48:53-59.
37. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers
S, Grant A. The Ipswich Childbirth Study, I: a ran-
domised evaluation of two stage postpartum peri-
neal repair leaving the skin unsutured. Br J Obstet
Gynaecol. 1998;105:435-440.
38. Rockner G, Henningsson A, Wahlberg V, Olund
A. Evaluation of episiotomy and spontaneous tears of
perineum during childbirth. Scand J Caring Sci. 1988;
2:19-24.
39. Larsson PG, Platz-Christensen JJ, Bergman B, Wall-
stersson G. Advantage or disadvantage of episi-
otomy compared with spontaneous perineal laceration.
Gynecol Obstet Invest. 1991;31:213-216.
40. Signorello LB, Harlow BL, Chekos AK, Repke JT.
Postpartum sexual functioning and its relationship to
perineal trauma: a retrospective cohort study of pri-
miparous women. Am J Obstet Gynecol. 2001;184:
881-888.
41. Combs CA, Robertson PA, Laros RKJ. Risk fac-
tors for third-degree and fourth-degree perineal lac-
erations in forceps and vacuum deliveries. Am J Ob-
stet Gynecol. 1990;163:100-104.
42. Shiono P, Klebanoff MA, Carey JC. Midline epi-
siotomies: more harm than good? Obstet Gynecol.
1990;75:765-770.
43. Riskin-Mashiah S, O’Brian Smith E, Wilkins IA. Risk
factors for severe perineal tear: can we do better? Am
J Perinatol. 2002;19:225-234.
44. Bodner-Adler B, Bodner K, Kaider A, et al. Risk
factors for third-degree perineal tears in vaginal de-
livery, with an analysis of episiotomy types. J Reprod
Med. 2001;46:752-756.
45. Bodner-Adler B, Bodner K, Kimberger O, Wa-
genbichler P, Mayerhofer K. Management of the peri-
neum during forceps delivery: association of episi-
otomy with the frequency and severity of perineal
trauma in women undergoing forceps delivery. J Re-
prod Med. 2003;48:239-242.
46. Fenner DE, Genberg B, Brahma P, Marek L, DeL-
ancey JO. Fecal and urinary incontinence after vagi-
nal delivery with anal sphincter disruption in an ob-
stetrics unit in the United States. Am J Obstet Gynecol.
2003;189:1543-1549.
47. McLeod NL, Gilmour DT, Joseph KS, Farrell SA,
Luther ER. Trends in major risk factors for anal sphinc-
ter lacerations: a 10-year study. J Obstet Gynaecol Can.
2003;25:586-593.
OUTCOMES OF ROUTINE EPISIOTOMY
2148 JAMA, May 4, 2005—Vol 293, No. 17 (Reprinted) ©2005 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 02/25/2013
