Howden, Nancy L. S. MD; Weber, Anne M. MD, MS; Meyn, Leslie A. MS
From the University of Pittsburgh Health Sciences Center, Magee-Womens Hospital, Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Specialties, Pittsburgh, Pennsylvania.
Received July 10, 2003. Received in revised form September 20, 2003. Accepted October 17, 2003.
Presented at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in May 2002, and the abstract published in a supplement to Obstetrics & Gynecology (Obstet Gynecol 2002; 99(4):S49).
Address reprint requests to: Nancy L.S. Howden, MD, The University of Pittsburgh Health Sciences Center, Magee-Womens Hospital, Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Specialties, 300 Halket Street, Pittsburgh, Pennsylvania 15213; e-mail: firstname.lastname@example.org.
OBJECTIVE: To describe trends in episiotomy use among residents, faculty, and private practitioners at an academic institution.
METHODS: We reviewed data from the Magee Obstetric Medical and Infant database, containing details of every delivery at Magee-Womens Hospital since 1995. The study population was women who had spontaneous or operative vaginal delivery of a singleton, liveborn, vertex-presenting infant, at 37 weeks or more, from 1995 to 2000 (completed data set years). The first delivery recorded for a patient in the database was analyzed. Residents and faculty were described as “academic” practitioners. Data were analyzed with the Fisher exact test, χ2 test for linear trend, and logistic regression models.
RESULTS: There were 27,702 women with 15,190 episiotomies, for an episiotomy rate of 54.8%. The rate of episiotomies decreased from 59.7% to 45.0% during the study period (P < .001). Independent risk factors for episiotomy included age 30 years or more, white race, higher educational status, married, nulliparity, and history of cesarean delivery. The strongest predictor of episiotomy use was practitioner type, with women attending private physicians having an adjusted 7-fold increased risk of episiotomy (odds ratio 7.1; 95% confidence interval 6.5, 7.7). Patient characteristics related to practitioner type included age, race, educational status, marital status, nulliparity, and mode of delivery (P < .001).
CONCLUSION: High rates of episiotomy use were found among private practitioners, despite current evidence-based literature that supports restricted use of episiotomy.
LEVEL OF EVIDENCE: III
Episiotomy has been routinely used in the United States for nearly a century. It became widely accepted after DeLee1 proposed that mediolateral episiotomy would “by incising the fascia at its most vulnerable point, and reuniting it after delivery … eliminate all damage to the pelvic floor.” As deliveries moved from the home to the hospital setting, and the practice of anesthesia and operative deliveries increased, the use of episiotomy increased as well. As recently as 1987, episiotomy was used in 62% of all vaginal deliveries.2
A comprehensive review by Thacker and Banta3 in 1983 called into question the use of routine episiotomy. Within the past decade, multiple studies have provided evidence against episiotomy. In randomized trials and retrospective cohort studies, midline episiotomy has been strongly associated with increased rates of third- and fourth-degree lacerations when compared with women not receiving an episiotomy.3–5 Postpartum pain is less with spontaneous lacerations, compared with episiotomy.6 Return to sexual function without complaints occurs earlier in patients with intact perineums or spontaneous tears.7 Preservation of normal pelvic floor function and support through episiotomy use has not been substantiated. Carroli and Belizan8 for the Cochrane Database Systematic Review (2000) concluded that restrictive use of episiotomy was associated with decreased posterior perineal damage, perineal pain, extent of repair, and complications. Current evidence favors restricted use of episiotomy.
Given considerable evidence that routine episiotomy increases maternal morbidity and without evidence to support maternal or neonatal benefit, has episiotomy use changed among obstetricians? The goal of this study was to evaluate trends in episiotomy use in a large urban academic center over time, and specifically, episiotomy use among residents and faculty compared with private practitioners.
MATERIALS AND METHODS
At Magee-Womens Hospital, the Department of Obstetrics, Gynecology, and Reproductive Sciences established the Magee Obstetric Medical and Infant database in 1995. The purpose of this database is to collect comprehensive maternal, fetal, and neonatal outcomes. All women delivering at Magee-Womens Hospital are included in the perinatal database. Electronic and medical record data on these women are obtained and collated from prenatal records and hospital charts, including delivery records. Information on race, marital status, and educational status are by patient declaration on admitting forms. The existence of personal identifying information in the perinatal database is eliminated to ensure that confidentiality of all patient records is maintained. In addition to Magee-Womens Hospital policy regarding confidentiality, perinatal database personnel are trained in the importance and meaning of research information confidentiality and have signed Magee-Womens Hospital Agreement to Maintain Confidentiality forms as well as University of Pittsburgh Certification in compliance with the Health Insurance Portability and Accountability Act of 1996 and regulation. The database is surveyed periodically to maintain its accuracy by direct comparison at random with patient charts and by examining frequencies for variables that contain data outliers upon download, which once identified are verified or corrected by means of medical chart review. This study was institutional review board–exempt given the use of database information only without associated chart review.
The study population consisted of women having their first delivery recorded in the database, restricted to vaginal deliveries (spontaneous or operative) of vertex-presenting, singleton, liveborn infants at greater than or equal to 37 weeks of gestation. Residents, faculty, and midwives were grouped together as academic practitioners; all other providers were categorized as private practitioners. Operationalization of outcome variables was done for statistical analysis and interpretation. Educational status was broken into greater or less than 12 years of schooling to designate high school graduation. Age was broken into greater or less than 30 years because of the relationship of increasing age to increased morbidity and mortality. Infant birth weight was divided according to accepted definitions of low, normal, and high birth weight infants.
All statistical analyses were performed with SPSS 10.1.4 statistical software (SPSS, Inc., Chicago, IL). The association between year of delivery, practitioner, and demographic and clinical characteristics with episiotomy use were tested by using the Fisher exact test or χ2 test for linear trend, where appropriate.9 Multivariable logistic regression models were developed to identify factors independently associated with episiotomy use. Models were developed with forward stepwise regression based on the likelihood ratio test statistic. Variables were retained in the model if the Wald χ2 test statistic had a P value of 0.05 or less.
There were 27,702 women identified in the Magee Obstetric Medical and Infant database that satisfied our entry criteria between 1995 and 2000. There were 141 private practitioners and 38 academic practitioners during the study period. Three midwives accounted for 1% of academic deliveries. Four family physicians accounted for 0.5% of private practice deliveries. There were no private midwives. Residents and maternal-fetal medicine fellows were captured under the academic grouping because they are linked to the faculty attending the delivery.
The average rate of episiotomy use was 54.8%, or 15,190 episiotomies. The use of episiotomy decreased over time (Figure 1). The rate of episiotomy in 1995 was 59.7%, compared with 45.0% in 2000 (P < .001). The average rate of episiotomy use among academic practitioners was 17.7%, compared with 67.1% among private practitioners. The χ2 test for linear trend demonstrated a significant decrease in episiotomy rate for the overall group, as well as the practitioner type grouping (Figure 1).
Demographic and clinical characteristics of women by type of practitioner are illustrated in Table 1. Women with private practitioners were, on average, older than women in the academic practitioner group, had a higher level of education, and were more likely to be white and married (P < .001). Most deliveries were spontaneous in both groups, although a significantly greater percentage of operative deliveries occurred in the academic practitioner group compared with private practitioners (P < .001). Episiotomy use at the time of operative vaginal delivery was significantly increased (23%) when compared with spontaneous delivery (16.7%) in the academic group (P < .001); no difference was found in episiotomy use between the types of deliveries among private practitioners (65.3% versus 67.3%, respectively; P = .06). There were more multiparous women in the academic group (P < .001).
Using logistic regression, we assessed the independent effects of practitioner type on episiotomy use while controlling for year of delivery, maternal age older than 30 years, race, infant birth weight, mode of vaginal delivery, nulliparity, and history of cesarean delivery (Table 2). This model revealed that the attendance of a private practitioner at vaginal delivery conferred a 7-fold increased risk of episiotomy, or an odds ratio (OR) 7.1 (95% confidence interval [CI] 6.5, 7.7). The OR associated with white race was 1.9 (95% CI 1.8, 2.1), which is interpreted as a 90% increased risk of a white patient having an episiotomy at delivery than a nonwhite patient. Other significant variables were age 30 years or older, educational level more than 12 years, married marital status, nulliparity, history of cesarean delivery, and infant birth weight of 2,500 grams or more.
The most important finding of this study is the persistently high rate of episiotomy use at deliveries attended by private practitioners at our institution. Available literature has found that, compared with family practitioners and midwives, obstetricians have higher rates of episiotomy use.10 Other interventions within obstetrics that have seen variations in use among different types of clinicians include suturing with polyglycolic acid, external fetal monitoring, and artificial rupture of membranes, to name a few.11,12 Arguments can be made for and against the use of such interventions, because there are no clear answers. Those arguments do not hold true when discussing the use of episiotomy, given the current body of literature available demonstrating the detrimental effects of episiotomy to women.
Before clinical practice can be influenced, the necessary knowledge must first be transmitted to physicians and time allowed for attitudes to change. Finally, changes in practice follow.13 In a study evaluating the use of evidence-based literature, family practitioners and obstetricians were more inclined to seek the input of respected authorities than to perform a MEDLINE search.14 A randomized trial from Canada assessed the value of an educational visit to the lead obstetrician or midwife within an obstetrical practice, compared with no visit at all. The visit consisted of a discussion of evidence-based obstetrics and Cochrane reviews. The goal was to determine rates of change for select interventions as a marker of dissemination and implementation of the educational visit information. Authors were unable to demonstrate significant change in obstetrical practice as a result of the evidence-based educational visit.15
There are no American College of Obstetricians and Gynecologist’s practice bulletins concerning episiotomy use. Even if a practice bulletin did exist, the publication of guidelines is often not enough to change clinical practice. One group of investigators determined that changes in physician practice were seen only when a multifaceted approach to education was applied, including mail reminders, didactic visits to the office, and suggested practice strategies for the implementation of change.16
A limitation of this study is that it was performed within a single hospital. However, both the practitioner and patient base are diverse, thereby providing a broad look at obstetrical practice in this region.17 This database has been used in previous studies. In an abstract presented at the 2001 Society of Maternal-Fetal Medicine, authors from this institution reported outcomes of vaginal deliveries, specifically rectal injury, in 1995 to 1997. Rates of episiotomy use among academic and private practitioners were similar to those presented in this study (Simhan HN, Krohn MA, Heine RP. Obstetric rectal injury: the role of physician experience. BJOG, manuscript in press). Regional differences in episiotomy use have been identified by other studies. It is also important to remember that, when dealing with such large numbers of subjects, small differences can become statistically significant. For example, educational status more than 12 years increased the risk of episiotomy by 10%, with OR 1.1 (95% CI 1.04, 1.2). An effect this small is not likely to carry clinical significance.
The higher rates of episiotomy among private practitioners may be linked to the period in which they trained. Limitations of our study include the inability to obtain information on age, race, and gender distribution of practitioner, or year of practitioner graduation from residency. We are also unable to comment on the amount of episiotomy teaching that existed at the residency programs of each practitioner in this study.
Management of the perineum is to be individualized by clinical scenario, patient, and practitioner. One author proposed the motto, “Don’t just do something, sit there!”,18 which may be the ideal way of thinking critically about the decision to perform an episiotomy. Physicians practicing obstetrics will certainly have this question posed to them by their patients, because the use of episiotomy has gained much attention in the popular news. Use of episiotomy as a standard in vaginal deliveries is changing, and the rate at the end of this demonstrates a favorable downward trend. An ideal rate of episiotomy, if there is one, has yet to be defined that balances optimal maternal and fetal outcomes. Future studies should determine how to choose a candidate for episiotomy.
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