ACOG Continues to Recommend Against Routine Episiotomy
Washington, DC—Obstetrician-gynecologists should take steps to mitigate the risk of obstetric lacerations during vaginal delivery, rather than using routine episiotomy, according to a new Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG). Although between 53 percent and 79 percent of vaginal deliveries will include some type of laceration, most lacerations do not result in adverse functional outcomes.
The new Practice Bulletin, “Prevention and Management of Obstetric Lacerations at Vaginal Delivery," lays out specific recommendations for obstetric care providers to reduce the risk of severe lacerations, including obstetric anal sphincter injuries (OASIS). Perineal massage, either antepartum or during the second stage of labor, can decrease muscular resistance and reduce the likelihood of laceration. Moreover, use of warm compresses on the perineum during pushing can reduce third-degree and fourth-degree lacerations.
These prophylactic interventions may also be advantageous for women with previous OASIS during future pregnancies. Studies have shown that a majority of women with previous OASIS have had subsequent vaginal delivery. However, cesarean delivery may be offered to a woman with a history of OASIS if: she experienced anal incontinence after a previous delivery, she had complications including wound infections or need for repeat repair, or if she reports experiencing psychological trauma as a result of the previous OASIS and requests a cesarean delivery. However, cesarean delivery may be offered to a woman with a history of OASIS if she experienced anal incontinence after a previous delivery; she had complications including wound infections or need for repeat repair; or if she reports experiencing psychological trauma as a result of the previous OASIS and requests a cesarean delivery. Any women choosing cesarean delivery should be aware of the increased morbidity associated with cesarean delivery, as well as the potential need for cesarean delivery in future pregnancies.
“Without question, a vaginal delivery is an appropriate, safe option for women who have experienced severe obstetric lacerations during previous pregnancies,” said Sara Cichowski, MD, who co-authored the new guidelines. “However, women who have anal incontinence or who have suffered significant physical or emotional trauma as a result of previous experiences may find that a cesarean delivery is the right choice for them.”
National episiotomy rates have decreased steadily since 2006, when ACOG recommended against routine use of episiotomy; data show that in 2012, 12 percent of vaginal births involved episiotomy, down from 33 percent in 2000. Data show no immediate or long-term maternal benefit of routine episiotomy in perineal laceration severity, pelvic floor dysfunction, or pelvic organ prolapse compared with restrictive use of episiotomy. Moreover, episiotomy has been associated with increased risk of postpartum anal incontinence.
“Data show that obstetric care providers can help to lower the severity of obstetric lacerations with simple interventions including avoiding routine episiotomy, but we also know that some women will still experience them,” said Rebecca Rogers, MD, the document’s other co-author. “Because of that, we also want to ensure that obstetrician-gynecologists are taking an evidence-based approach to treating lacerations and performing episiotomy.”
The Practice Bulletin provides recommendations to ob-gyns regarding diagnosis of lacerations, preferred suturing technique, and use of antibiotics at the time OASIS repair, as well as long-term monitoring and pelvic floor exercises.
Practice Bulletin #165 replaces Practice Bulletin #71, “Episiotomy,” and Committee Opinion #647, “Limitations of Perineal Lacerations as an Obstetric Quality Measure.”
Practice Bulletin #165, “Prevention and Management of Obstetric Lacerations at Vaginal Delivery," is published in the July issue of Obstetrics & Gynecology.
Other recommendations issued in the July Obstetrics & Gynecology:
Emergency departments typically have structured triage guidelines for health care providers encountering the diverse cases that may present to their units. Such guidelines aid in determining which patients must be evaluated promptly and which may wait safely, and aid in determining anticipated use of resources. Although labor and delivery units frequently serve as emergency units for pregnant women, the appropriate structure, location, timing, and timeliness for hospital-based triage evaluations of obstetric patients are not always clear. Hospital-based obstetric units are urged to collaborate with emergency departments and hospital ancillary services, as well as emergency response systems outside of the hospital, to establish guidelines for triage of pregnant women. Recently developed, validated obstetric triage acuity tools may improve quality and efficiency of care and guide resource use, and they could serve as a template for use in individual hospital obstetric units.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org