The Tragedy of Routine Episiotomy
(all quotes below excerpted from Henci Goer's Obstetric
Myths Versus Research Realities,
1995)
Like
any surgical procedure, episiotomy carries a number of risks: excessive blood
loss, haematoma formation, and infection. . . . There is no evidence . . . that
routine episiotomy reduces the risk of severe perineal trauma, improves
perineal healing, prevents fetal trauma or reduces the risk of urinary stress
incontinence (Sleep, Roberts, and Chalmers 1989).
"Routine
or prophylactic episiotomy (as opposed to episiotomy for specific indication
such as fetal distress) is the quintessential example of an obstetrical
procedure that persists despite a total lack of evidence for it and a
considerable body of evidence against it. All the authoritative pronouncements
in favor of episiotomy descend from a 75-year-old article (DeLee 1920) that
produced not a shred of evidence in its support.
"Most
recently, William's Obstetrics (Cunningham, MacDonald, and Gant 1989) states,
"The reasons for [episiotomy's] popularity among obstetricians are clear.
It substitutes a straight, neat surgical incision for the ragged laceration
that otherwise frequently results. It is easier to repair and heals better than
a tear." Human Labor and Birth (Oxorn-Foote 1986) adds that it averts
"brain damage" by "lessen[ing] the pounding of the head on the
perineum." . . .
"In
a branch of medicine rife with paradoxes, contradictions, inconsistencies, and
illogic, episiotomy crowns them all. The major argument for episiotomy is that
it protects the perineum from injury, a protection accomplished by slicing
through perineal skin, connective tissue, and muscle. Obstetricians presume
spontaneous tears do worse damage, but now that researchers have finally done some
studies, every one has found that deep tears are almost exclusively extensions
of episiotomies. This makes sense, because as anyone who has tried to tear
cloth knows, intact material is extremely resistant until you snip it. Then it
rips easily.
"By
preventing overstretching of the pelvic floor muscles, episiotomies are also
supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes
sexual dissatisfaction after childbirth (the concern was the male partner . . .
hence, the once-popular "husband's knot," an extra tightening during
suturing that made many women's sex lives a permanent misery), urinary
incontinence and uterine prolapse. But older women currently having repair
surgery for incontinence and prolapse all had generous episiotomies. In any
case, episiotomy is not [performed] until the head is almost ready to be born.
By then, the pelvic floor muscles are already fully distended. Nor has anyone
ever explained how cutting a muscle and stitching it back together preserves
its strength.
"Perhaps
the most absurd rationale of all is brain damage from the fetal head's
"pounding on the perineum." a woman's perineum is soft, elastic
tissue, not concrete. No one has ever shown that an episiotomy protects fetal
neurologic well-being, not even in the tiniest, most vulnerable preterm
infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986;
[T.G.] The 1990, both abstracted below).
"Meanwhile,
as Sleep, Roberts, and Chalmers (1989) point out, episiotomy, like any other
surgical procedure, carries the risk of blood loss, poor wound healing, and
infection. Infections are painful. Sutures must be removed to drain the wound,
and later the perineum must be restitched. In their literature survey Thacker
and Banta (1983, abstracted below) found wound infections and abscess rates
ranging from 0.5% to 3%.
"Moreover,
there are two extremely rare gangrenous infections called necrotizing fasciitis
and clostridial myonecrosis reported in the literature. These infections kill
many of the women who contract them and maim survivors. William's Obstetrics
(Cunningham, MacDonald, and Gant 1989) says of them in boldface type,
"Mortality is virtually universal without surgical treatment, and it
approaches 50% even if aggressive excision is performed."
"While
these infections are rare, they make a substantial contribution to maternal
mortality. Between 1969 and 1976 they caused 27% (3/11) of the maternal deaths
in Kern County, California (Ewing, Smale, and Elliott 1979). A fourth woman
survived, spending 23 days in the hospital. Shy and Eschenbach (1979) report on
four cases in King County, Washington, between 1969 and 1977. Three women died,
representing 20% of the maternal mortality rate during those years. The fourth
woman survived, losing most of her vulva to surgical excision and debridement.
Nine additional cases are also reported, of which seven women died and two had
extensive surgeries and prolonged hospitalizations (Soper 1986; Sutton et al.
1985; Ewing, Smale and Elliott 1979; Golde and Ledger 1977).
"Since
all fatalities were in healthy women who had uncomplicated labors, their
episiotomies literally killed them!
"Obviously
an infection could start in a repaired tear, but substantial numbers of women
who do not have episiotomies have intact perineums. There also appears to be an
association between the extent of the wound and these deadly infections. Nine
of the 17 cases, or more than half, involved third- or fourth-degree injuries
(tears [,]or deliberate cuts[,] into or through the anal sphincter). It bears
repeating that women with no episiotomy hardly ever suffer deep tears.
"Despite
two decades of evidence to the contrary, most doctors and some midwives still
cling to the liberal use of episiotomy. The Canadian multicenter randomized
controlled trial (Klein et al. 1992, abstracted below) could not get doctors to
abandon it. Episiotomy rates were reduced by only one-third in the so-called
restricted arm of the study. More than half of primiparas in the restricted
group (57%) still had episiotomies, as did nearly one-third of multiparas
(31%). "The intensity with which physicians adhere to the belief that
episiotomy benefits women is well illustrated by the behavior of many of the
participating physicians in this trial. Many were unwilling or unable to reduce
their episiotomy rate according to protocol."
"If
episiotomy lacks scientific rationale, what drives its use? As Robbie
Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits underlying
cultural beliefs about women and childbirth. It reinforces beliefs about the
inherent defectiveness and untrustworthiness of the female body and the dangers
this poses to women and babies. So DeLee (1920), imbued with these beliefs,
writes:
Labor has been called, and
still is believed by many, to be a normal function. . . . [Y]et it is a
decidedly pathologic process. . . . If a woman falls on a pitchfork, and drives
the handle through her perineum, we call that pathologic--abnormal, but if a
large baby is driven through the pelvic floor, we say that is natural, and
therefore normal. If a baby were to have its head caught in a door very
lightly, but enough to cause cerebral hemorrhage, we would say that it is
decidedly pathologic, but when a baby's head is crushed against a tight pelvic
floor, and a hemorrhage in the brain kills it, we call this normal.
"Having
invented the problem, he proffers a solution: as soon as the head passes
through the dilated cervix, anesthetize the woman with ether, cut a large
mediolateral episiotomy, pull the baby out with forceps, and manually remove
the placenta, then give the woman scopolamine and morphine for the lengthy
repair work and to "prolong narcosis for many hours postpartum and to
abolish the memory of labor." Repair involves pulling down the cervix with
forceps to examine it and stitch any tears and laboriously reconstructing the
vagina to restore "virginal conditions."
"While
few modern obstetricians are willing to go as far as DeLee, these beliefs about
women still pervade obstetrics, and they fuel episiotomy.
"Episiotomy
serves another purpose. Davis-Floyd observes that surgery holds the highest
value in the hierarchy of Western medicine, and obstetrics is a surgical
specialty. Episiotomy transforms normal childbirth--even natural childbirth in
a birthing suite--into a surgical procedure.
"Davis-Floyd
also points out that episiotomy, the destruction and reconstruction of women's
genitals, allows men to control the "powerfully sexual, creative, and
male-threatening aspects of women." This is what lurks behind DeLee's
emphasis on surgically restoring "virginal conditions." It also
partially explains why most trials of episiotomy have been done in European
countries where normal birth is conducted by female midwives, not in the U.S.
or Canada, where birth is conducted (until recently) by male doctors: women are
not subconsciously threatened by birth. Klein et al. attribute the greater
success of a British "restricted" versus "liberal" use of
episiotomy trial in achieving fewer episiotomies and more intact perineums to
"the increased comfort of British midwives in attending births with the
intention of preserving an intact perineum."
"In
short, routine episiotomy has a ritual function but serves no medical purpose.
If any reader believes otherwise, I challenge him or her to find a credible
study done in the past 15 years that supports those beliefs.
"Note:
There are two types of episiotomies: midline or median (straight down toward
the rectum) and mediolateral (down and off to one side) U.S. and Canadian
doctors usually do midline episiotomies while European doctors and midwives
prefer mediolateral ones. According to Williams Obstetrics, (Cunningham,
MacDonald, and Gant 1989) midline episiotomies are less painful, heal better,
are less likely to cause dyspareunia (coital pain), and cause less blood loss,
but they are more likely to extend into the rectum. Mediolateral episiotomies
are the opposite. Because of these differences, I will note which type was
performed after the abstract citation.
"Because
of these differences, I have excluded studies of mediolateral episiotomy where
data were available on median episiotomies. For many areas of interest,
however, they were unavailable. (For those living in countries where
mediolateral episiotomy is the norm, conclusions about the benefits and risks
of episiotomy were similar regardless of type.) This is because until very
recently, U.S. and Canadian doctors were so convinced of episiotomy's value
that they did not feel it necessary to test their theory. This was less true of
European midwives, and by extension, the doctors with whom they work.
"Summary
of Significant Points
"Episiotomies
do not prevent tears into or through the anal sphincter or vaginal tears. In
fact, deep tears almost never occur in the absence of an episiotomy. (Abstracts
1-12, 16, 19-20, 23-28)
"Even
when properly repaired, tears of the anal sphincter may cause chronic problems
with coital pain and gas or fecal incontinence later in life. In addition, anal
injury predisposes to rectovaginal fistulas. (Abstracts 11, 15, 21-22)
"If
a woman does not have an episiotomy, she is likely to have a small tear, but
with rare exceptions the tear will be, at worst, no worse than an episiotomy.
(Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)
"Episiotomies
do not prevent relaxation of the pelvic floor musculature. Therefore, they do
not prevent urinary incontinence or improve sexual satisfaction. (Abstracts
1-4, 7, 12-16)
"Episiotomies
are not easier to repair than tears. (Abstracts 1, 3, 9)
"Episiotomies
do not heal better than tears. (Abstracts 1, 5-6, 12-15, 21)
"Episiotomies
are not less painful than tears. They may cause prolonged problems with pain,
especially pain during intercourse. (Abstracts 1, 2, 7, 12, 14-15, 19-20)
"Episiotomies
do not prevent birth injuries or fetal brain damage. (Abstracts 1, 3, 5-7, 12,
14, 17-18, 27)
"Episiotomies
increase blood loss. (Abstracts 1, 12, 19)
"As
with any other surgical procedure, episiotomies may lead to infection,
including fatal infections. (Abstracts 1, 12, 19, 22)
"Epidurals
increase the need for episiotomy. They also increase the probability of
instrumental delivery. Instrumental delivery increases both the odds of
episiotomy and deep tears. (Abstracts 5, 11-12, 21, 25-26)
"The
lithotomy position increases the need for episiotomy, probably because the
perineum is tightly stretched. (Abstracts 10, 25, 27)
"The
birth attendant's philosophy, technique, skill, and experience are the major
determinants of perineal outcome. (Abstracts 2, 5-7, 9-10, 25-27)
"Some
techniques for reducing perineal trauma that have been evaluated and found
effective are: prenatal perineal massage, slow delivery of the head, supporting
the perineum, keeping the head flexed, delivering the shoulders one at a time,
and doing instrumental deliveries without episiotomy. (Others, such as perineal
massage during labor or hot compresses have yet to be studied.) (Abstracts
23-24, 28)
"Independent
of specifically contracting the pelvic floor muscles (Kegels), a regular
exercise program strengthens the pelvic floor. (Abstract 13)"
* * *
Jock Doubleday
Director
Natural Woman, Natural Man, Inc.
http://www.GentleBirth.org/nwnm.org
http://www.SpontaneousCreation.org
director@spontaneouscreation.org