Episiotomy Rates Dropping in U.S.
Fewer than a third of women now cut during labor
TUESDAY, May 7, 2002 (HealthDayNews) -- The rate of episiotomies in this country has plunged from almost 60 percent of in-hospital vaginal deliveries in the late 1970s to less than a third, a new study has found.
The surgical cuts of the perineum -- the patch of skin between the vagina and the rectum -- are intended to make room for the baby's head as it moves down the birth canal. They had for decades been routine in American labor and delivery suites, on the theory that a scalpel swipe is easier to stitch than an unruly rip.
That's generally true. But in recent years doctors and women alike have rejected the procedures, allowing the perineum to tear naturally, if at all. The trend is a shift in birth culture and physician habits, driven largely by evidence showing that episiotomies can lead to rectal problems and fecal incontinence with little if any advantage for the mother or her baby.
The latest study, by University of Pittsburgh researchers, analyzed hospital discharge data from 1979 though 1997. It found that the number of episiotomies performed in the nation's hospitals fell from a peak of more than 1.9 million in 1981 to a little shy of 1.1 million in 1997.
The rate dropped for both spontaneous and surgical labors, though among the latter, the procedure remained frequent (69 percent in 1997, off from 87 percent in 1979).
Women who underwent the procedure tended to be younger, white mothers with private insurance. The researchers presented their findings yesterday at the American College of Obstetricians and Gynecologists meeting in Los Angeles.
Dr. Anne Weber, a Pitt obstetrician and a collaborator on the study, said the downward trend in episiotomies has probably continued since the late 1990s. Where it will ultimately rest, however, isn't clear.
"No one knows what the perfect rate would be to enhance the mother's outcomes and the baby's outcomes," Weber said.
Studies by midwives have shown that practitioners with episiotomy rates in the single digits aren't more likely to have negative outcomes -- suggesting that those who make the cuts more frequently are doing so unnecessarily. "It's safe to say that [the rate] is still too high. It can be driven much lower," she said.
Weber said that as younger doctors enter obstetrics, the number of episiotomies falls. In a study at Pitt's Magee-Womens Hospital, for example, she and her colleagues found that between 1995 and 1999, residents and faculty physicians had an episiotomy rate of 17 percent. But among doctors in private practice, the rate was 66 percent.
"I think that reflects the great difficulty there is in changing clinical practice once it becomes established, even in the face of growing evidence that this is not in the best interest of women," Weber said.
Episiotomy does have a logic, however flawed.
"We really thought we were protecting the perineum and keeping [women] from having tissue damage," said Dr. Gerald Joseph, Jr., a obstetrician in Springfield, Mo., and a spokesman for the American College of Obstetricians and Gynecologists. "We were focused on the tissue damage we could see, not what we couldn't see and what would have happened regardless."
In addition to the issue of healing and wound repair, the practice was intended to hasten slowed labors. Although babies get oxygen through the umbilical cord until it's cut, the cord can get pinched in the birth canal, endangering the infant. In theory, the incision gave the descending baby a wider opening and speed up delivery.
Susan Moray, a certified midwife in Portland, Ore., and spokeswoman for the Midwives Association of North America, said that while midwives are trained to perform episiotomies, her field has long been loath to make the cuts.
Some pregnancy books advocate perineal massage during the latter stages of pregnancy. But Moray said research shows that technique won't prevent tearing and may in fact make it more likely by weakening the tissue. "It doesn't need to be done until the opening [of the vagina] is quite wide" during labor, she said.
Tissue tears because it's weak, Moray said. "There's a philosophy that midwives have had that you're cutting into the unknown. Some tissue is healthy, some is weak. A small tear is weak tissue, but you don't want to destroy healthy tissue" with an incision.
No one can predict in advance which women will tear during labor. Moray said she once delivered an 11-pound infant to a mother whose perineum held up fine.
But there are some things that women can do during pregnancy to reduce the risk of tearing, Moray said. These include wearing loose skirts with no underwear while at home to allow air to circulate in the vaginal region. Eating a healthy diet and drinking ample water are also good for the perineal tissue.