Episiotomy
| Rationale for Compliance |
Evidence Grade |
|
|---|---|---|
| Although these rationales are given for routine or frequent use of episiotomy, in fact, compared with no episiotomy: | NEB | |
| • Neither median nor mediolateral episiotomy reduces the incidence of anal sphincter lacerations (Eason, 2000; Hartmann, 2005; Hudelist, 2005; Larsson, 1991; MCA, 2004; Renfrew, 1998). | Quality: | B |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy improves neonatal outcomes (Argentine Episiotomy Trial Collaborative Group, 1993; Dannecker, 2004; Klein, 1992). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy causes less pain than spontaneous tears (Eason, 2000; Hartmann, 2005; Renfrew, 1998). | Quality: | B |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomies heal better or faster than spontaneous tears (Hartmann, 2005; Klein, 1994). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy prevents urinary stress incontinence in either the short- or the long-term (Eason, 2000; Ewings, 2005; Hartmann, 2005; MCA, 2004; Renfrew, 1998). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy prevents anal incontinence (Hartmann, 2005; MCA, 2004). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy preserves pelvic floor strength (Eason, 2000; Hartmann, 2005; MCA, 2004; Renfrew, 1998). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| • Neither median nor mediolateral episiotomy improves sexual functioning (Eason, 2000; Hartmann, 2005; MCA, 2004; Renfrew, 1998). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| Episiotomy causes more pain than spontaneous tears (Hartmann, 2005; Klein, 1994; Larsson, 1991). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| Women with episiotomies experience more problems with healing compared with women experiencing spontaneous lacerations (Larsson, 1991; McGuinness, 1991). | Quality: | A |
| Quantity: | B | |
| Consistency: | A | |
| Women with intact perineums experience the least pain, have the strongest pelvic floors, and experience the best sexual functioning after childbirth (Klein, 1994). | Quality: | A |
| Quantity: | B | |
| Consistency: | NA* | |
| Both median and mediolateral episiotomy adversely affect sexual functioning (Hartmann, 2005; Klein, 1994). | Quality: | B |
| Quantity: | A | |
| Consistency: | A | |
| Median episiotomy predisposes to anal sphincter lacerations (Eason, 2000; Klein, 1992, 1994; Renfrew, 1998). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| Anal sphincter injury is associated with anal sphincter weakness and defects seen on ultrasound. Anal sphincter weakness or defect increases the risk of anal incontinence (MCA, 2004). | Quality: | A |
| Quantity: | A | |
| Consistency: | A** | |
| Both median and mediolateral episiotomy increase the risk of anal incontinence (Hartmann, 2005; MCA, 2004). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| Median episiotomy weakens the pelvic floor (Klein, 1994). | Quality: | A |
| Quantity: | B | |
| Consistency: | NA* | |
| Performing mediolateral episiotomy for “imminent tear” does not decrease anal injury rates (Dannecker, 2004; Larsson, 1991). (Performing median episiotomy for this reason would increase anal sphincter laceration rates because of its predisposition to extend.) | Quality: | A |
| Quantity: | B | |
| Consistency: | A | |
| Avoiding median episiotomy during vaginal instrumental birth (forceps or vacuum extraction) reduces the likelihood of anal laceration (Combs, 1990; Helwig, 1993). | Quality: | A |
| Quantity: | A | |
| Consistency: | A | |
| Episiotomy rates in mixed-risk, mixed-parity women can be less than 1% among all provider types (obstetricians, family practitioners, midwives) (Albers, 2005). | Quality: | A |
| Quantity: | NA to reporting a rate | |
| Consistency: | NA to reporting a rate | |
| Episiotomy rates in low-risk, mixed-parity women can be 5% or less (Johnson, 2005; MCA, 2004). | Quality: | A |
| Quantity: | NA to reporting a rate | |
| Consistency: | NA to reporting a rate | |
| Episiotomy rates in low-risk nulliparous women can average 9% and can be as low as 2% (MCA, 2004). | Quality: | A |
| Quantity: | NA to reporting a rate | |
| Consistency: | NA to reporting a rate | |
A = good, B = fair, NA = not applicable, NEB = no evidence of benefit
Quality = aggregate of quality ratings for individual studies
Quantity = magnitude of effect, numbers of studies, and sample size or power
Consistency = the extent to which similar findings are reported using similar and different study designs
*
only 1 study
**
multiple studies in SR