Why Are Episiotomies On The Decline When It Can Reduce Vaginal Tearing?

For over a decade, doctors have been warned against performing episiotomies on their patients. An episiotomy is a surgical incision made in the area between the vaginal opening and anus to aid in difficult childbirths by enlarging the birth canal. Doctors were cautioned against this incision on the basis that it prolongs recovery time and increases pain.

A new study published in the Canadian Medical Association Journal re-evaluated this practice with regards to assisted births involving forceps or a vacuum. It found that in such a case, episiotomies should be considered.

More than 2.5 million Canadian births from between 2004 and 2017 were analyzed to determine the trend. The data uncovered that episiotomies were declining, both among assisted and unassisted births, even when severe tears can be avoided through episiotomy in assisted births.

The researchers also looked at obstetric anal sphincter injury (OASI) ⁠— which is severe tears caused to the perineum. OASI rates have gone up by up to 15 percent in recent years in Canada and other countries. In 2017, around 18 percent of women in Canada suffered such injuries caused by forceps or vacuum.

"The pronounced decrease in the episiotomy rate among vaginal deliveries assisted by instruments suggests that this may be an example of 'clinical creep,' where the recommendation to move away from routine episiotomy among unassisted vaginal deliveries may have been overgeneralized to apply to all vaginal deliveries, including those where instruments are involved and where there may be a benefit," Dr. Giulia Muraca, the study's lead author and a postdoctoral fellow with University of British Columbia's Department of Obstetrics and Gynaecology, and with the Clinical Epidemiology Unit at the Karolinska Institute in Stockholm, said.

Episiotomy can reduce OASI risk by up to 42 percent in cases of vaginal birth.

Obstetricians should take caution when applying the same episiotomy guidelines to all patients, Dr. Muraca said, citing the findings.