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Episiotomy Trends

It has been several years since the American College of Obstetricians and Gynecologists (ACOG) issued a statement renouncing routine episiotomy -- a procedure that involves making an incision into the perineum, the area between the vagina and the anus, to ease delivery. Prompting the statement was a review of past studies that overwhelmingly shows that the cut poses serious risks to women and offers few benefits, according to an article published in the group's journal, Obstetrics and Gynecology.

ACOG's position wasn't new then, and neither was the article's conclusion: That episiotomy increases a woman's chance for everything from painful infections to persistent sexual problems. And, yet, laboring women admitted to hospitals still have a greater than 40 percent chance of undergoing this dubious procedure when they deliver. Despite two decades of data discrediting the safety and usefulness of episiotomies, doctors keep performing them and women keep paying the price.

Episiotomy has been a mainstay of obstetrical practice since the 1920s, when leading doctors declared that cutting the perineum was best for Baby and Mom, says Ian Graham, Ph.D., assistant professor of medicine at the University of Ottawa and author of Episiotomy: Challenging Obstetric Interventions. Despite a lack of good data, doctors claimed the incision not only protected against tears, incontinence, and weakened pelvic-floor muscles, but also made delivery easier on the baby.

Now episiotomies are a habit that medicine just can't seem to kick. One reason: They conveniently speed up delivery. In fact, Emma Stephens*, a Chicago mother, believes her doctor's vacation plans may have played an unwarranted role in the decision to perform an episiotomy during the birth of her daughter. "After I had been pushing for less than 20 minutes, she said that the skin was stretched paper-thin and that she had no option," even though there were no indications that the baby was in trouble, Stephens says. Getting sewn up delayed that all-important first meeting. "Worse still, it was horribly painful for weeks," she says. "I remember having to take these long baths while the baby was crying and wanting to nurse."

Many physicians perform episiotomies for no better reason than it's what they learned to do in medical school. Others simply may not have kept abreast of the critical evidence. What's more, some older practitioners tend to be slower in changing their techniques, says Dr. Graham. And to be fair, interpreting fetal heart rates can be difficult during delivery and many doctors just want to get the baby out quickly and safely, says Erica Eason, M.D., an associate professor of obstetrics and gynecology at the University of Ottawa.

However, the bottom line is that this procedure really only needs to be done under certain conditions. According to Dr. Eason, an episiotomy is warranted when the baby is in distress; when forceps or a vacuum extractor is used; when the baby is breech, or when the baby's head has emerged from the birth canal but his shoulders are stuck. Otherwise, the perineal tissue should be allowed to stretch on its own. Even if there is tearing (which is possible), the wound is likely to be less severe, says Dr. Eason.

Beth Howard lives in New York City and is the author of Mind Your Body: A Sexual Health and Wellness Guide for Women.

*These names have been changed.

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