New Study of Episiotomy and Tearing in Future Births
By Rachel Walden — June 11, 2008
A study in the June 2008 issue of Obstetrics & Gynecology examines what happened when women who had an episiotomy during their first birth went on to have a second vaginal delivery. The researchers were interested in whether women who had an episiotomy were more or less likely to tear during subsequent deliveries.
Records were reviewed for 6,052 women who had their first and second deliveries at a Pittsburgh women’s hospital from 1995-2005 (excluding those who had another episiotomy at the second delivery).
The authors found significantly higher rates of an intact perineum or first degree laceration (71.4% combined) at second delivery in women with no prior episiotomy compared to those who had the procedure at first birth (44.2% of these women had no or first degree laceration). Rates of second, third, and fourth degree tears were significantly higher in those with prior episiotomy.
Although the researchers do not provide information on why episiotomies were chosen in the first deliveries, they make the following observation about demographic factors:
Women who had episiotomy at first delivery were older, more likely to be white, married, and have higher education and commercial insurance. These demographic characteristics were also all associated with having a private practice provider, and notably, 94.6% of women who had an episiotomy at first delivery were patients of private practitioners.”
Other risk factors, such as infant birth weight, are mentioned in the paper, although the primary focus is on whether past episiotomy increases risk of future tearing.
What surprised me, given fairly widespread discussion over the past two decades about reducing routine episiotomy, was that when the researchers compiled the records on first and second births over those recent years, 47.8% of them had an episiotomy at their first delivery. The American College of Obstetricians and Gynecologists released a practice bulletin in 2006 recommending restricted rather than routine use of the procedure (after the period of this study). However, literature questioning routine use began appearing in the early 1980s, so I was surprised that it remained so high at the women’s hospital where this research was conducted.
I would like to think that this indicates that residents, who would be more likely to be delivering women who are not being seen by a private practice doctor, are being trained in an evidence based manner. I have heard that OBs, especially OBs that have been practicing for more than a decade or so, are not very likely to do evidence based medicine, and are more likely to do it the way they were shown years ago.
I agree with Hilary. I have seen this first hand. The residents I work with are great; a great group of evidenced based doctors of our future. On the other hand, a local community hospital where the majority of the MDs are over 50 and male practice old school OB. Episiotomies on all primips, automatic c/s for suspected large babies, pitocin galore….you name it. One doc supposedly has a 75% c/s rate…I don’t have actually proof of this, but my source is very trustworthy and would have first hand knowledge of this. I find this absolutely insane.
I read this article just recently and my first response was, “Duh…scar tissue isn’t as elastic as normal tissue” while my second thought was “How much more documentation of how the risks outweigh the benefits of episiotomies do we need?”
Thanks to both of you for your insights. I was genuinely surprised that the rate would still be so high, but I can definitely see how people continuing to practice how they were taught decades ago might keep rates up. That’s a tricky one for patients, I think, who might be more inclined to trust an older, more experienced physician than a younger/newer resident.
Labor Nurse, maybe we don’t need more studies, we just need people to actually read them! 🙂