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Cutting Back on Episiotomies

Episiotomies were endorsed by the American College of Obstetricians and Gynecology until 2006. Since then, though, obstetricians have been performing the procedure (in which a small incision is made to the area between the vagina and anus, known as the perineum, to enlarge the vaginal opening during birth) less often.  Originally, doctors thought it decreased the likelihood of tearing, but studies showed that it may do the opposite. Research conducted at the University of Alberta in Canada, found that women who have an episiotomy and undergo a forceps delivery are almost three times as likely to have a serious laceration.

Why? Investigators determined that the cut itself may create the starting point for a tear. "The point of the research findings is not only that routine episiotomy is probably not necessary  -- even for deliveries requiring forceps or vacuum extraction  -- but that it may put a woman at a greater risk for tearing," says lead researcher Helen Steed, M.D., whose study helped convince ACOG that it needed to establish new guidelines.

Other studies support Dr. Steed's findings. Researchers there found that the number of severe vaginal tears experienced by women undergoing delivery assisted by forceps or vacuum extraction actually decreased when fewer episiotomies were performed. The results contradict the widely held belief that episiotomies are most necessary during these types of deliveries.

Doctors took notice, too. In 1997, episiotomies were performed in more than 30 percent of deliveries, according to a study performed at Brigham and Women’s Hospital in Boston. By 2006, the national rate was 9 percent, leading the ACOG to modify its episiotomy-encouraging guidelines in April 2006. The ACOG determined that the best data no longer supported the routine use of episiotomy.

Experts who support the use of episiotomies say the incisions can shorten the second stage of labor and are easier to repair than a ragged tear. They also believe that other countries, where episiotomies are more prevalent, might have the right idea. Women who deliver in Asia, Central and South America are more likely to have episiotomies than women who give birth in English-speaking countries, says Ian Graham, Ph.D., an associate professor at the University of Ottawa. Graham would like to see the episiotomy rate drop even more, especially in Canada, where there are large differences in the episiotomy rate depending on region.

The bottom line: Talk to your obstetrician prior to delivery and agree to a plan of action. If you'd rather not have an episiotomy, make that clear. At the same time, however, you should also ask what type of incision your doctor would perform in case the procedure were unavoidable. The Canadian study found that incisions that extend out toward the thigh, instead of straight back toward the rectum, are less likely to promote tears.