ACOG Recommends Restricted Use of Episiotomies

March 31, 2006

Washington, DC -- The use of episiotomy during labor should be restricted, with physicians encouraged to use clinical judgment to decide when the procedure is necessary, according to a new Practice Bulletin published by The American College of Obstetricians and Gynecologists (ACOG) in the April issue of Obstetrics & Gynecology. According to ACOG, "The best available data do not support the liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries."

Episiotomy is a surgical incision made into the perineum—the region between the vagina and the anus—to widen the vaginal opening for delivery. Episiotomy was performed in more than one-fourth of all vaginal deliveries in 2002. Although rates of episiotomy have decreased in recent years, it is still one of the most commonly performed procedures in obstetrics.

Recent studies show that common indications for episiotomy were based on limited data. Additionally, there was a general underestimation of potential adverse consequences associated with the procedure, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and painful sex. Data suggest that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one. Without sufficient data to develop evidence-based criteria for performing episiotomies, clinical judgment remains the best guide to determine when its use is warranted, according to ACOG.

Historically, the procedure has been indicated in circumstances such as abnormal labor progression, non-reassuring fetal heart rate pattern, vacuum- or forceps-assisted vaginal delivery, and shoulder dystocia. It also was believed to hasten the second stage of labor and reduce the risk of spontaneous perineal tearing, subsequent pelvic floor dysfunction, urinary and fecal incontinence, and sexual dysfunction.

"In the case of episiotomy, as with all medical and surgical therapies, we need to continually evaluate what we do and make appropriate changes based on the best and most current evidence available," said the document's author, ACOG Fellow John T. Repke, MD. "We should avoid the pitfall of letting anything in medicine become 'routine' and therefore, outside the realm of review and critical analysis."

Practice Bulletin #71, "Episiotomy," is published in the April 2006 issue of Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists is the national medical organization representing over 49,000 members who provide health care for women.