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Abstract Source:
Relationship of Episiotomy to Perineal Trauma and
Morbidity, Sexual Dysfunction, and Pelvic Floor Relaxation
Klein MC, MD; Gauthier RJ, MD;
Robbins JM, PhD; Kaczorowski J, MA; Jorgensen SH, MB; Franco ED, MD;
Johnson B, BSN; Waghorn K, RN; Gelfand MM, MD; Guralnick MS, MD; Luskey
GW, MD; Joshi AK, MD
Am J Obstet Gynecol. 1994;171:591-598
Key Words: Episiotomy, pelvic floor functioning, third- and fourth-degree tears, sexual functioning, perineal pain
Purpose of Study: To compare status 3 and 6 months postpartum in women receiving vs those not receiving median episiotomy, using as outcomes perineal pain, urinary and pelvic floor functioning, and sexual functioning, and to analyze the relationship between episiotomy and third- and fourth-degree tears.
Materials & Methods: Study design and management methods have been described in detail in a previously published report of the same clinical trial (Klein MC, et al, 1992), which found no evidence supporting the use of episiotomy for preventing perineal trauma, urinary and pelvic floor symptoms, or sexual outcomes in a cohort of 697 women. This analysis compares perineal pain and sexual and pelvic floor functioning among four groups of patients who had (A) intact perineum; (B) no suturing or suturing for spontaneous tears; (C) episiotomy alone; and (D) episiotomy extending to third- or fourth-degree tears. Patient eligibility was based on the following criteria: parity of 0-2; age between 18 and 40; carrying a single fetus; and speaking English or French. All women were interviewed approximately 3 months post partum, were asked to fill out a questionnaire, and underwent electromyographic perineometry. Perineal pain was assessed on the basis of the type of pain relief used during the first 10 days post partum (eg, pain medication, ice packs, heat treatments). Assessment of urinary incontinence and sexual dysfunction relied on subjective self-reporting and numerical scale scoring by patients.
Results: Of the total of 697 women included in the study, 356 were primiparous, the rest were multiparous. Women in group A had slightly smaller babies than those in the other three groups. There were no statistically significant differences between women who had spontaneous perineal tears and those receiving episiotomy alone. Perineal pain severity was ranked as follows among the four groups: D>C>B>A. Perineal pain was present 3 months post partum in 79% of group D, 54% of groups B and C, and 42% of group A women. A significantly higher number of women in group A resumed sexual intercourse by 6 weeks post partum than among the other groups, and women in groups A and B tended to have less dyspareunia on the first postpartum intercourse. Primiparous women in group A had the strongest pelvic floors ante partum. At 3 months post partum these women made the most rapid pelvic floor muscle recovery, similar to the recovery of those who had had a cesarean birth. Women in groups C and D had the slowest recovery, while those in group B were in an intermediary category. There was no evidence among either primi- or multiparous women that episiotomy had contributed to preventing pelvic floor relaxation. There was no correlation between third- and fourth-degree tears and any of the demographic characteristics of the patients, but there was a strong correlation with birth weight and hospital. Of the trial physicians, 40% used episiotomy in 89%-93% of their primiparous patients. Primiparous women in the care of physicians with the lowest episiotomy rates had the lowest rate of third- and fourth-degree tears and were most likely to be in group A. The rate of third- and fourth-degree tears among primiparous women cared for by high episiotomy users was 20.9%.
Conclusion: The results of the first North American randomized controlled trial indicate that the routine use of episiotomy has no justification. Median episiotomy fails to prevent trauma or relaxation of the pelvic floor; furthermore, in primiparous women it appears to be causally associated with third- and fourth-degree tears. This procedure should be limited to specific maternal and fetal indications.
Reprint Requests: Department of Family Practice, British Columbia's Women's Hospital and Health Centre Society and British Columbia's Children's Hospitals, 4500 Oak St, Room F412B, Vancouver, BC, Canada V6H 3N1 (Dr Klein).
The authors have provided us with an outstanding
randomized clinical study that analyzes the outcome of perineal
management at the time of vaginal delivery in 356 primiparous and 341
multiparous women. This study confirms prior work that clearly related
median episiotomy to a marked increase in third- and fourth-degree
(severe) perineal lacerations. Pelvic support, urinary incontinence,
and sexual dysfunction were the same in the two groups. Their
conclusion that episiotomy should be restricted to specific
fetal-maternal indications is well-founded. Also important is the high
rate of urinary incontinence that occurred regardless of perineal
management. This study should urge us to examine the reasons for this
maternal morbidity more closely, rather than relying on routine
episiotomy for prevention that turns out to be ineffective.
--Linda Brubaker, MD