BehindTheMedspeak: Episiotomies are bad medicine

A new study demonstrates unequivocally that routine episiotomies — surgical incisions in the vaginal wall during childbirth to widen the birth canal — offer no benefits and, in fact, result in more complications than if the procedures hadn't been performed at all.

No surprise here: the data have been out there for decades, but old practices die hard.

The new research was published in the May 4 issue of the Journal of the American Medical Association.

It won't make a whole lot of difference to obstetricians who "see the world through fetal–distress glasses," said Dr. Michael Klein in André Picard's story in the May 4th Toronto Globe and Mail.

Klein, now a professor emeritus of family practice and pediatrics at the University of British Columbia, published a groundbreaking study in the early 1990s demonstrating the damage caused by routine elective episiotomies.

Since then the number of women having them has dropped from 66% to about 25%.

The number should be 0.

But just as hundreds of thousands of women who've had total hysterectomies go in for their annual Pap smears, which are both unnecessary and, in fact, demonstrable proof that the doctors obtaining them are ignorant, incompetent, or committing fraud (if a hysterectomy has been performed the chance of having cervical cancer is zero, because there is no cervix present; hence no Pap smear is ever again needed by such women), elective episiotomies continue to be performed.

I trained back in the day when such procedures were considered good medicine, and did many elective episiotomies during medical school in the course of my third–year obstetrics rotation.

I also repaired them.

It wasn't pretty.

Trust me — I wasn't yet a doctor then, but I do know that.

The Washington Post had a good editorial on the subject on May 5; it follows.

Bad Medicine

According to a newly published analysis of the effectiveness of episiotomies, the procedure has no benefits whatsoever.

In fact, an episiotomy — a pre–emptory incision, theoretically intended to prevent pregnant women from experiencing torn tissue during labor — probably makes such complications more likely and causes more pain and worse side effects as well.

This result was not surprising to the scientists who wrote the report, published this week in the Journal of the American Medical Association, because the most important research on the subject has already been done.

The scientists carrying out the analysis did not conduct new clinical studies but rather sifted through the results of more than 900 medical articles on the subject, picked the most informative and pooled the information.

When looked at as a whole, the evidence against this unnecessary and damaging procedure, in widespread use since the 1930s, was overwhelming.

But although the results were already "obvious," in the words of the epidemiologist leading the study, they will clearly come as a surprise to the doctors who still carry out some 1 million episiotomies in this country every year — if they ever hear about it.

Indeed, that scientists' long–standing doubts about the medical value of episiotomies weren't already well known underlies the profound problems with the transmission of new medical information within our health care system.

Just like recent large–scale studies showing that the common prescription of estrogen to post–menopausal women carried serious health risks, this one is further proof of the value of testing even the most common assumptions — and of the need for the wider use of evidence–based medicine.

It is also further proof of the value of the Agency for Healthcare Research and Quality, which commissioned the episiotomy study at the behest of the American College of Obstetricians and Gynecologists.

The agency is one of the few institutions in the country that does regular, neutral investigations of best medical practices.

Yet it is a tiny agency, by federal government standards, and lives under the shadow of budget–cut threats.

Both money and pain could be saved if its role were quietly expanded and its findings more loudly promoted.