by Dr. Nicole Calloway Rankins
This post on episiotomy originally appeared on KevinMD.com. KevinMD is "social media's leading physician voice" with over 3 million monthly page views, and over 250,000 followers on Facebook and Twitter.
I have been an ob/gyn hospitalist at a busy suburban community hospital for almost one year. I truly love my job. However, I've noticed something unexpected that's prompted me to pause. There are several physicians - good, clinically competent, kind physicians - who frequently perform episiotomies. Routine episiotomy is not recommended. In my training and 8 years of practice prior to becoming a hospitalist I rarely saw it used. So this experience has been surprising. There are a number of reasons physicians with high episiotomy rates is bothersome, and it brings to mind issues we all face in medicine.
An episiotomy is a cut in a woman’s perineum (the tissue between the vagina and anus). It is made at the time the fetal head is crowning in a vaginal delivery. Episiotomy increases the amount of soft tissue space, and as a result will decrease the amount of time for delivery of the fetal head. The increased space also allows more room to perform maneuvers to relieve a shoulder dystocia. Episiotomy is, in general, not frequently performed. It was done in 12% of vaginal deliveries in 2012 (compared to 61% in 1979). Although the ideal episiotomy rate is undefined, restrictive use of episiotomy is preferred over routine use. Since 2006 the American Congress of Obstetricians and Gynecologists has recommended against routine episiotomy use.
It is troublesome to see any physicians with high episiotomy rates, as the procedure is not necessary for the majority of vaginal births. Purported benefits of episiotomy include less severe perineal lacerations, easier laceration repair, better wound healing, and preservation of the pelvic floor support by preventing a spontaneous, irregular laceration. Data however does not support this. A 2005 systematic review found that pain, severity of perineal laceration, and pain medication use were not better with routine episiotomy use. There was also no demonstrated benefit from routine episiotomy use for prevention of urinary or fecal incontinence, or pelvic floor relaxation. A 2009 Cochrane Review found similar results, and that restrictive episiotomy use was associated with less suturing and fewer healing complications than routine use.
Frequent episiotomy also gives me concern because women don’t want an episiotomy, and they explicitly express that. I routinely see “no episiotomy” in birth plans. It’s similar for women who don’t have a formalized birth plan. As a hospitalist, one of my standard questions to help establish trust and rapport is “Is there anything you want with your birth experience that you would like me to know?” Not wanting an episiotomy is a frequent response. Most women aren’t pushy or overbearing about their desires. They are overwhelmingly reasonable and want whatever is best to have a healthy baby. But it is understandably important to them to avoid an episiotomy unless truly necessary.
Frequently performing episiotomy may erode trust in a relationship that is already taking a beating. Obstetricians face backlash that we over-medicalize an event that for the majority of women is low risk. Patients are concerned that doctors manipulate the birth process to suit their personal schedules. Women are increasingly turning to midwives or even home births with the belief that their wishes will be better respected, and they will have more freedom and autonomy during labor. Add to this that technology gives patients access to tremendous amounts of medical information. Technology also gives women an unprecedented ability to share their pregnancy and birth experiences. As a result, women are often familiar with standards of care (including episiotomy use), along with other women’s experience with episiotomy. Thus, I worry that in a background of eroded trust, even when episiotomy is medically indicated, suspicions may arise as to why it was done.
Why are there physicians at my hospital with high episiotomy rates? A recent large study examined factors associated with episiotomy use. It concluded that variation in episiotomy is related to non-medical factors. Multivariable modeling showed that patients who are white or have commercial insurance have higher episiotomy rates. Rates were lower at rural and teaching hospitals. Being a private practitioner is also associated with higher episiotomy rates (as high as a 7 fold increase in one study). The patient and hospital demographics where I practice as well as the doctors with high rates fit these characteristics.
It is obvious that this needs to change. No patient should receive a procedure that is largely unnecessary and unwanted. So what can be done? Hospitals track episiotomy rates and many report the data as part of quality improvement initiatives. Public reporting and peer pressure certainly help. My hospital is aware of its statistics, wants to make change, and is working on how to best address it. An honest, non-confrontational conversation about it would be great. In this era of more data, reports, and initiatives, the act of talking with (not to) doctors feels like it’s getting lost. It would be ideal to initiate conversation without the threat of being judged by a metric attached to it.
This brings to mind larger implications beyond episiotomy. We practice in an environment where increasing clinical demands (seeing more patients in less time, more charting requirements, challenges with electronic medical records) leave less time to stay updated on best practice. We have to find a way to navigate this landscape so that we consistently give our patients the best evidence based care. Equally important is that we acknowledge and respect patients wishes, and honor them whenever it is clinically appropriate and doesn’t impede best care.