Episiotomy in the United States: has anything changed?

doi:10.1016/j.ajog.2008.11.022

American Journal of Obstetrics and Gynecology

Volume 200, Issue 5, May 2009, Pages 573.e1-573.e7

Presented at the 29th Annual Scientific Meeting of the American Urogynecologic Society, Chicago, IL, Sept. 4-6, 2008.

https://doi.org/10.1016/j.ajog.2008.11.022 Get rights and content

Objective

The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice.

Study Design

The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy.

Results

The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004.

Conclusion

Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

Section snippets

Materials and Methods

The National Hospital Discharge Survey (NHDS) is a federal dataset compiled by the National Center for Health Statistics. This dataset is a national probability sample of nonfederal short-stay hospitals in the United States based on approximately 270,000 inpatient records acquired from 466 hospitals annually. The overall dataset error rate for final diagnoses and procedures is 1.0% and 0.7%, respectively.¹³

This database was used to obtain information regarding spontaneous vaginal deliveries,

Results

During the study period, estimated total annual deliveries per year remained stable (3,089,673-3,338,268). Similarly, age-adjusted rates (AARs) of spontaneous vaginal delivery were stable over the study period (38.1 deliveries per 1000 women to 36.7 per 1000 women). The AARs of all operative vaginal deliveries decreased markedly from 8.7 per 1000 women in 1979 to 4.6 per 1000 women in 2004. Rates of cesarean delivery increased dramatically from 8.3 in 1979 to 17.2 in 2004 (Table 1).

Rate of

Comment

The most important finding of this study is that episiotomy use markedly and consistently declined between 1979 and 2004. Although attention was first drawn to the risks of episiotomy more than a quarter century ago by Thacker and Banta,¹⁰ it appears that attitudes and practices of clinicians have only recently begun to reflect evidence-based recommendations. A lag between dissemination of evidence and change in clinical practice is common.¹⁴ Altering practice patterns regarding episiotomy may

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Cited by (104)

The second stage of labor
2024, American Journal of Obstetrics and Gynecology
The second stage of labor extends from complete cervical dilatation to delivery. During this stage, descent and rotation of the presenting part occur as the fetus passively negotiates its passage through the birth canal. Generally, descent begins during the deceleration phase of dilatation as the cervix is drawn upward around the fetal presenting part. The most common means of assessing the normality of the second stage of labor is to measure its duration, but progress can be more meaningfully gauged by measuring the change in fetal station as a function of time. Accurate clinical identification and evaluation of differences in patterns of fetal descent are necessary to assess second stage of labor progress and to make reasoned judgments about the need for intervention. Three distinct graphic abnormalities of the second stage of labor can be identified: protracted descent, arrest of descent, and failure of descent. All abnormalities have a strong association with cephalopelvic disproportion but may also occur in the presence of maternal obesity, uterine infection, excessive sedation, and fetal malpositions. Interpretation of the progress of fetal descent must be made in the context of other clinically discernable events and observations. These include fetal size, position, attitude, and degree of cranial molding and related evaluations of pelvic architecture and capacity to accommodate the fetus, uterine contractility, and fetal well-being. Oxytocin infusion can often resolve an arrest or failure of descent or a protracted descent caused by an inhibitory factor, such as a dense neuraxial block. It should be used only if thorough assessment of fetopelvic relationships reveals a low probability of cephalopelvic disproportion. The value of forced Valsalva pushing, fundal pressure, and routine episiotomy has been questioned. They should be used selectively and where indicated.
The prevention of perineal trauma during vaginal birth
2024, American Journal of Obstetrics and Gynecology
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity.
Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged.
Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
Influence of introducing a maneuverable vacuum extractor cup on maternal hospital stay after instrumental birth. Retrospective cohort study
2022, Clinica e Investigacion en Ginecologia y Obstetricia
Citation Excerpt :
Mediolateral episiotomy reduces the risk of OASIS compared to midline episiotomy, although it has been linked to an increased chance of long-term perineal pain and dyspareunia.22 There is an international trend toward the reduction of use of episiotomies.23 Routine episiotomy with assisted vaginal birth is not recommended due to poor healing and prolonged discomfort with mediolateral episiotomy.22
The aim of our study is to evaluate the impact of the introduction of a maneuverable vacuum extractor cup on the length of hospital stay after assisted vaginal birth in nulliparous women in a hospital where no vacuum devices were used.
This single center retrospective analytical study included two groups of nulliparous women who had undergone an assisted vaginal birth. The 2 groups differ according to the availability or not of a maneuverable vacuum extractor cup. The first group includes the last 54 instrumental births until May 2017, when only obstetric forceps and Thierry's spatulas were available in our center; the second group includes the first 54 instrumental births since May 2018 in our center, when obstetric forceps, Thierry's spatulas and maneuverable vacuum extractor cup were available. Maneuverable vacuum extractor cups had been available for 12 months in the second group.
In the no vacuum cup group, Kjelland forceps and Thierry's spatulas were used in 29 (53.7%) and 25 (46.3%) of the 54 assisted vaginal births, respectively. In the vacuum available group, a vacuum cup was chosen in 30 (55.6%), Kjelland forceps were used in 18 (33.3%) and Thierry's spatulas in 6 (11.1%) of the assisted vaginal births. 22 women (40.7%) had a postpartum hospital stay longer than 3 days in the group with no maneuverable vacuum extractor cup availability, versus 3 women (5.6%) in the group with availability of a maneuverable vacuum extractor cup, p < 0.001. Average postpartum hospital stay length was 3.17 ± 0.803 days versus 2.81 ± 0.585, p < 0.001. There was also a significant reduction in the number of episiotomies.
The introduction of a maneuverable vacuum extractor cup in a center where only forceps and Thierry's spatulas had been used resulted in a decrease in postpartum hospital stay in nulliparous women.
El objetivo de nuestro estudio es evaluar el impacto de la introducción de una ventosa obstétrica con cazoleta maniobrable en la duración de la estancia hospitalaria tras parto instrumental en mujeres nulíparas en un hospital donde no se utilizaban ventosas obstétricas.
Este estudio de cohortes retrospectivo unicéntrico incluyó 2 grupos de mujeres nulíparas sometidas a parto instrumental. Los 2 grupos se diferencian según la disponibilidad o no de ventosa obstétrica en el centro. El primer grupo se compone de las últimas 54 mujeres a las que se les asistió un parto instrumental hasta mayo del 2017, cuando solo había disponibilidad de fórceps obstétricos y espátulas de Thierry en nuestro centro; el segundo grupo se compone de las primeras 54 mujeres a las que se les asistió un parto instrumental desde mayo del 2018 en nuestro centro, cuando había disponibilidad de fórceps obstétricos, de espátulas de Thierry y de ventosa obstétrica con cazoleta maniobrable (esta última desde hacía 12 meses).
En el grupo sin disponibilidad de ventosa obstétrica, se utilizaron fórceps de Kjelland y espátulas de Thierry en 29 (53,7%) y 25 (46,3%) de los 54 partos instrumentales, respectivamente. En el grupo con disponibilidad de ventosa, se usó la ventosa en 30 (55,6%), fórceps de Kjelland en 18 (33,3%) y espátulas de Thierry en 6 (11,1%) de los partos instrumentales; 22 mujeres (40,7%) tuvieron una estancia hospitalaria tras el parto mayor de 3 días en el grupo sin disponibilidad de ventosa, frente a 3 mujeres (5,6%) en el grupo con disponibilidad de ventosa, p < 0,001. La duración media de la estancia hospitalaria tras el parto fue de 3,17 ± 0,803 días frente a 2,81 ± 0,585, p < 0,001. También hubo una reducción significativa en el número de episiotomías.
La introducción de una ventosa obstétrica con cazoleta maniobrable en un centro donde solo se usaba fórceps y espátulas de Thierry resultó en una disminución de la estancia hospitalaria tras el parto en mujeres nulíparas.
Perineal repair of media-lateral episiotomies and 2nd degree tears by midwives: A randomised controlled trial comparing three suture techniques
2020, International Journal of Nursing Studies
Citation Excerpt :
Other places adopt a policy of 'selective' use of episiotomy where the use of episiotomy is restricted rather than universally performed (Jiang et al., 2017). In the USA, the episiotomy rate decreased from 60.9% in 1979 to 24.5% in 2004 (Frankman et al., 2009). In Finland, the episiotomy rate decreased from 71.5% to 54.9% between 1997 and 1999 and 2006 and 2007 among primiparous women, and from 21.5% to 9.2% between 1997 and 2001 and 2006 and 2007 among multiparous women (Räisänen et al., 2011).
Perineal trauma pain is associated with perineal repair and its subsequent healing. New evidence is required concerning perineal repair techniques that cause less pain and favour healing.
To compare three perineal repair suturing techniques after episiotomy or second degree tearing during a normal birth with respect to reducing pain and improving the perineal healing process.
A randomised controlled trial.
A large public university hospital in Madrid, Spain.
Full term pregnant women older than 18 years-of-age, who required perineal repair after episiotomy or second degree tearing and were attended for normal birth by midwives.
One hundred and eighty-three women were randomly assigned to three groups: the Continuous Suture Group (n = 58), Interrupted Cutaneous Suture Group (n = 53), or the Interrupted Subcutaneous Suture Group (n = 57). The study participants and data collectors were blinded to group allocations. Principal outcome: perineal pain 10 days after birth. Other outcomes: short (2 and 48 h) and long term (3 and 6 months) perineal pain after birth; short term healing; suture time.
At 10 days postpartum, the presence of spontaneous pain, pain when walking or moving in bed, was almost nonexistent in the 3 suture groups. The median (P25-P75) perineal pain on palpation was similar in the 3 groups, with values of 2 (1–4) in the Continuous Suture Group, 3 (2–5) in the Interrupted Cutaneous Suture Group and 2 (1–4) in the Interrupted Subcutaneous Suture Group; also were similar the perineal pain on sitting: 1 (0–3) in the Continuous Suture Group, 1 (0–2) in the Interrupted Cutaneous Suture Group and 1 (0–3) in the Interrupted Subcutaneous Suture Group. There were no statistically significant differences between the groups. Pain measurements throughout the follow-up period only showed statistically significant differences in 2 out of 22 evaluations: pain when sitting 48 h after birth and spontaneous pain at 3 months. The mean times (standard deviation) to carry out suturing were 12.86 (4.9) minutes in the Continuous Suture Group, 13.54 (5.6) in the Interrupted Cutaneous Suture Group, and 15.59 (6.9) minutes in the Interrupted Subcutaneous Suture Group (p < 0.05).
The three suturing methods described for perineal repair after episiotomy or second degree tearing after normal birth are comparable with respect to short, medium and long term perineal pain and the healing process. Use of the continuous suturing technique involved less time than interrupted suture methods.
Tweetable abstract: proper the suturing methods for perineal repair after episiotomy or second degree tearing prevent postpartum perineal pain.
Declined care and discrimination during the childbirth hospitalization
2019, Social Science and Medicine
Many studies have documented poorer patient-provider interactions among people of color compared to Whites, including lower-quality patient-provider communication, less involvement in decision making, and higher chances of perceived discrimination in healthcare encounters. In maternity care, where overuse of medical interventions such as cesarean delivery is a concern, women may try to exert agency by declining procedures. However, declining procedures may brand these women as uncooperative or non-compliant patients. The potential consequences of this are likely worse for women of color, who already expend more effort to manage their image during healthcare encounters in order to avoid stereotypes (e.g. the “angry Black woman”). Using a national sample of women who gave birth in U.S. hospitals in 2011–2012, we examined the relationship between declining procedures and discrimination during the childbirth hospitalization. We found that women who reported having declined care for themselves or their infant during the childbirth hospitalization were more likely to report “poor treatment” based on race and ethnicity, insurance status or having a difference of opinion with a healthcare provider. Moreover, the increase in odds of perceived discrimination due to a difference of opinion with a healthcare provider was significantly larger in magnitude for Black women compared to White women. These results suggest that in the context of childbirth care, women pay a penalty for exhibiting behavior that may be perceived as uncooperative, and this penalty may be greater for Black women.
Trends and Determinants of the Use of Episiotomy in a Prospective Population-Based Registry from Central India
2022, Research Square

View all citing articles on Scopus

: Cite this article as: Frankman EA, Wang L, Bunker CH, et al. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol 2009;200:573.e1-573.e7.

: Reprints not available from the authors.

: This study was supported in part by Grant UL1 RR024153 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at www.ncrr.nih.gov/.

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Meeting paperAUGS paperEpisiotomy in the United States: has anything changed?

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Treatise of midwifery

The prophylactic forceps operation

Am J Obstet Gynecol

Shall we cut and reconstruct the perineum for every primipara?

Am J Obstet Dis Women Child

Fecal and urinary incontinence in primiparous women

Obstet Gynecol

Episiotomy and the perineum: a random controlled trial

J Obstet Gynaecol

The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery

Obstet Gynecol

Meeting paper
AUGS paper
Episiotomy in the United States: has anything changed?