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Clinical Review
Clinician's Corner
May 4, 2005

Outcomes of Routine Episiotomy: A Systematic Review

Author Affiliations

Clinical Review Section Editor: Michael S. Lauer, MD. We encourage authors to submit papers for consideration as a “Clinical Review.” Please contact Michael S. Lauer, MD, at lauerm@ccf.org.


Author Affiliations: Center for Women’s Health Research (Drs Hartmann and Thorp and Ms Palmieri), Department of Epidemiology, School of Public Health (Dr Hartmann and Ms Palmieri), Department of Obstetrics and Gynecology, School of Medicine (Drs Hartmann and Thorp), and Cecil G. Sheps Center for Health Services Research (Drs Hartmann and Gartlehner), University of North Carolina at Chapel Hill; Research Triangle Institute, Research Triangle Park, NC (Drs Viswanathan and Lohr).

JAMA. 2005;293(17):2141-2148. doi:10.1001/jama.293.17.2141

Context Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use.

Objective To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy.

Evidence Acquisition We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality.

Evidence Synthesis Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function—pain with intercourse was more common among women with episiotomy.

Conclusions Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.