Introduction 

Episiotomy, incision of the perineum at the

time of vaginal childbirth, is a common surgical

procedure experienced by women in the United

States.1 Based on national hospital discharge data

for 1999, just over 35 percent of women who

gave birth vaginally had an episiotomy

performed; the figure was approximately 33

percent in 2000.2,3

Despite several decades of research, which

many interpret as definitive evidence against

routine (or “liberal”) use of episiotomy, little

professional consensus has developed about the

appropriateness of routine use. Lack of consensus

is illustrated by variation in rates of use, ranging

from 13.3 percent to 84.6 percent in one study

with a prospectively enrolled low-risk population,

with an average of 51 percent among spontaneous

term births.4 Variation has been reported by type

of clinician,4 time of day,

5 and facility type, size,

and location.6 Wide practice variations suggest

that episiotomy use is heavily driven by local

professional norms, experiences in training, and

individual provider preference rather than

variation in the physiology of vaginal birth. The

goal of this synthesis is to inform care providers,

professional organizations, advocates, and

individual women about the current state of the

evidence on routine use of episiotomy.

Key Questions

The RTI–UNC EPC addressed the following

Key Questions (KQs):

KQ 1. Does the practice of liberal or routine

episiotomy, compared to more selective

use of episiotomy, influence maternal

postpartum outcomes?

KQ 2. Does episiotomy incision type (i.e.,

midline or mediolateral) influence the

risk of maternal morbidity?

KQ 3. Does the repair of the perineal defect (i.e.,

suture type and repair approach)

influence the risk of maternal morbidity?

KQ 4. Does episiotomy have a long-term impact

on urinary incontinence, fecal

incontinence, or pelvic floor defects? 

KQ 5. Does episiotomy or incision type, or

both, influence future sexual function? 

Methods

Inclusion and Exclusion Criteria

We excluded studies that (1) did not report on

women of reproductive age, (2) were published in

languages other than English, (3) did not report

information pertinent to the key clinical

questions, (4) had fewer than 40 subjects, and (5)

were not original studies. Criteria for study

design were based on sufficiency and quality of

evidence. KQs 1 and 3 have been more

commonly examined in randomized controlled

trials (RCTs); thus, we elected to limit searches to

RCTs. KQs 2, 4, and 5 have been studied less

extensively in trials; therefore, we included both

RCTs and prospective cohort studies. 

Literature Search and Retrieval

Process

We used standard electronic databases:

MEDLINE®, Cochrane Collaboration resources,

and the Cumulative Index to Nursing and Allied

Health Literature (CINAHL®). We reviewed

Evidence Report/Technology Assessment

Number 112

The Use of Episiotomy in Obstetrical Care: A

Systematic Review

Summary

Authors: Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson T, 

Lohr KN, Gartlehner G, Thorp J Jr 

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

reference lists of relevant articles and consulted with the

Technical Expert Advisory Group (TEAG) to obtain additional

relevant articles. We conducted a dual review for abstracts and a

single review for full articles to decide inclusion according to

preset criteria.

Development of Evidence Tables and Data

Abstraction Process

Abstractors trained themselves on entering data into evidence

tables by abstracting several articles and then reconvening as a

group to discuss the utility of the table design. After several

iterations and TEAG review, the final table design had all

needed, appropriate categories for systematically recording

information on the articles. 

All team members did initial entry of information onto data

abstraction forms. Another team member reviewed articles and

edited all initial table entries for accuracy, completeness, and

consistency. The two abstractors reconciled all disagreements

concerning information in the abstraction tables. We then

entered data from the abstraction forms into evidence tables

and again checked for consistency and accuracy.

Quality and Strength of Evidence Evaluation

Rating the Quality of Individual Articles 

Two article abstractors independently rated each article on

each of the categories on our quality assessment form. A third

reviewer reviewed the scores and flagged studies with differences

in scoring on individual components. We reconciled these

differences by consensus. 

Grading the Strength of Available Evidence 

Our scheme follows the criteria utilized by Berkman et al.7

That system included three domains: quality of the research,

quantity of studies (including number of studies and adequacy

of the sample size), and consistency of findings. Grades were

assigned by consensus of the four senior staff members. 

External Peer Review 

As is customary for all evidence reports and systematic

reviews done for AHRQ, the RTI–UNC EPC requested review

of this report from a wide array of outside experts in the field

and from relevant professional societies and public

organizations. We compiled comments from 18 respondents

and addressed each one individually, revising the text as

appropriate.

Results

Literature Search Yield

The literature search yielded 986 articles. Of these, we

excluded 659 articles after reviewing the abstracts. Of the

remaining 327 articles, we included 45 in our evidence report.

Of these, 7 address KQ 1, 1 addresses KQ 2, 20 address KQ 3,

15 address KQ 4, and 10 address KQ 5. 

Key Question 1: Episiotomy and Maternal

Postpartum Outcomes

Seven primary publications of RCTs addressed liberal versus

restrictive use of episiotomy.8-14 Each trial compared two study

arms or groups: (1) an intention to restrict routine use of

episiotomy and (2) a liberal-use policy that endorsed routine

use. Use of episiotomy in the restrictive groups ranged from

lows of 7.6 percent9 and 10.2 percent8 to highs of 44 percent11

and 53 percent.13 We emphasize that these trials compared

policies of episiotomy use, not episiotomy to no episiotomy; six

of the seven studies used mediolateral episiotomy. 

This literature has high internal consistency with respect to

the postpartum effects of differing strategies for episiotomy use.

Compared to women in liberal-use groups, women in the

restrictive-use groups had less severe posterior perineal trauma,

less need for suturing, higher probability of having an intact

perineum, no greater or lesser risk of wound healing

complications, and higher likelihood of resuming intercourse

earlier. 

Key Question 2: Episiotomy Incision Type and

Maternal Morbidity

Only one RCT compared outcomes of midline episiotomy

to those of mediolateral episiotomy.15 An additional focused

literature search did not reveal any prospective cohort studies

on this issue. Women in the midline group began sexual

intercourse significantly earlier and had a significantly better

cosmetic appearance of the scar than women in the

mediolateral group. The groups did not differ significantly on

pain or satisfaction from sexual intercourse. Women receiving

midline episiotomy also had a significantly greater probability

of anal sphincter injuries than women in the mediolateral

episiotomy group. This study did not assess fecal incontinence

as a long-term health outcome. Because of considerable

methodologic flaws, any conclusions must be drawn cautiously. 

Key Question 3: Repair of Perineal Defect and

Maternal Morbidity

We included 17 RCTs (in 21 articles) examining various

methods and materials for repairing perineal defects; virtually

all episiotomies in these trials were mediolateral.16,17,17-35

Four trials investigated techniques of repair.17,27,29,32,35 Two

compared a two-layer approach (leaving the perineal skin

unsutured) with a three-layer approach (suturing the perineal

skin); two others compared a continuous (subcutaneous)

technique with an interrupted (transcutaneous) technique. 

Fourteen trials investigated materials for repair;19 16,17,20-23,25-28,30-

34 eight compared polyglycolic-acid sutures with chromic-catgut

sutures, both absorbable; two compared absorbable sutures (one

polyglycolic acid and one chromic catgut) with an enbucrilate

tissue adhesive (Histoacryl®); two compared standard

absorbable suture material with its rapidly absorbed
counterpart; and one compared untreated chromic catgut with

a glycerol-treated “softgut” chromic catgut. In addition, two

trials compared nonabsorbable and absorbable sutures: one

compared silk sutures with polyglycolic-acid sutures and one

compared silk sutures with both polyglycolic-acid and chromiccatgut sutures.

Finally, two trials combined comparison of both techniques

and materials in their design.18,24

Most of these trials randomly allocated participants to one of

two groups. However, three trials incorporated a factorial

design of randomization. Using a 2x2 design, both the socalled Ipswich Childbirth Study29,30,32 and the Kettle et al. trial36

randomized to methods of repair and type of sutures. The

Mahomed et al. perineal suture study used a 2x3x2 design and

randomized to suture type for deep tissue repair (two groups),

suture type for the perineal skin (three groups), and method of

repair (two groups).27

Methods 

Two-layer vs. three-layer repair. The trials provided

consistent evidence that favored the two-layer approach;

differences between the two approaches were not always

statistically significant.29,32,35

Despite some limitations, collectively these trials suggest that

less overall perineal morbidity is associated with the two-layer

repair approach than with the traditional three-layer approach.

The reduction in pain, need for analgesia, wound healing

problems, and sexual morbidity as well as a decrease in the time

and cost required for initial suturing of the perineal skin,

removal, and possible resuturing, may make the two-layer

approach more beneficial than the three-layer approach.

Continuous vs. interrupted sutures. Two good-quality

trials produced inconsistent evidence that the continuous

method of repair has less perineal morbidity and more patient

satisfaction associated with it than the interrupted method.17,27

In both trials, the authors describe greater familiarity with the

interrupted method of repair. One clinical group even suggests

that their inconsistencies with other trials might be attributable

to lack of practice with the method and subsequent

unpopularity with the operators that performed the repair.27

Whether such differences in outcome arise for clinicians and

women outside the United Kingdom, where methods of repair

and training of those performing the repair could be different

than in other countries, remains to be seen. 

Materials 

Absorbable vs. tissue adhesive. These two trials were small

(n < 65 in both trials) and of poor quality because of poor

randomization,16,33 but they defined and measured perineal pain

well and achieved good followup. They contribute possible

evidence that repair with tissue adhesive may decrease perineal

pain in the immediate postpartum. 

Absorbable sutures: standard vs. rapidly absorbed.

Mixed results from a good trial36 and lack of significant

differences between groups in a poor trial31 yielded insufficient

evidence, pointing to a difference in perineal pain between

standard and rapidly absorbed sutures. Stronger evidence

indicated that women who had rapidly absorbed sutures

required less removal of the material, presumably because it was

absorbed into the skin quickly in the postpartum period.

Although the two trials evaluated sexual functioning at different

times, rapidly absorbed sutures may decrease the amount and

severity of dyspareunia in the puerperium. 

Untreated catgut vs. treated catgut. Only one trial

addressed treated and untreated chromic catgut.25 It produced

no evidence that treated catgut is superior to untreated catgut

with regard to perineal morbidity; in fact, treated catgut may be

associated with higher morbidity (more perineal pain in the

immediate postpartum period; painful sexual intercourse in the

longer term). 

Nonabsorbable vs. absorbable suture. Because of the

study design of the fair-quality trial23 and lack of control for

possible confounding by method of repair, we cannot draw

conclusions about the role of silk sutures in perineal morbidity

from this trial. The authors concluded that the subcuticular

method lent itself to short-term advantages but did not present

supporting data. Thus, although this trial may contribute to a

body of evidence about combinations of materials and

methods, it does not contribute to the overall understanding of

the role of suture materials in perineal morbidity, separate from

methods of repair. The Mahomed et al. trial27 found no

differences between the two groups in the short-term

postpartum period, but did find differences at 3 months,

indicating a possible delayed effect of the suture material. 

Polyglycolic acid vs. chromic catgut. In 2004, the

Cochrane Library published a systematic review and metaanalysis of information on polyglycolic-acid versus catgut suture

material for repair of perineal trauma.37 The authors reported

that polyglycolic-acid sutures were associated with less pain in

the short-term postpartum period (odds ratio [OR] = 0.62;

95% confidence interval [CI], 0.54-0.71) and with less need

for analgesia (OR = 0.63; 95% CI, 0.52-0.77), but groups did

not differ in long-term pain outcomes or reports of

dyspareunia. 

Our systematic review includes six of the eight trials that

appeared in the Cochrane review and two additional trials.

Overall, the evidence is from a combination of poor, fair, and

good trials; it is consistent with the previous Cochrane review.

Polyglycolic-acid sutures are associated with less perineal pain,

less need for analgesia use, and fewer healing problems in the

short term. Long-term outcomes do not differ substantially

between polyglycolic-acid sutures and chromic catgut. One

trial not in the Cochrane review reported more perineal pain

and dyspareunia in the polyglycolic-acid group at 6 months,34

3
4

an outcome the authors attributed to the slower absorption rate

of polyglycolic-acid sutures; however, these results were neither

statistically significant nor precise. Overall, the body of

evidence about polyglycolic-acid versus chromic-catgut sutures

suggests that polyglycolic-acid sutures offer many short-term

advantages.

Combined methods and materials. Two trials compared

entire approaches, combining both materials and methods in a

single randomization design.18,24 The poor trial18 found no

differences between the groups; the fair-quality trial24 found

that women repaired with polyglycolic-acid sutures using a

continuous, subcuticular approach suffered less perineal

morbidity. This result is consistent with other trials that

investigated subcuticular suturing and polyglycolic-acid sutures

separately, perhaps reinforcing the notion that this method and

suture type are superior to other options available to obstetric

clinicians. 

Key Question 4: Episiotomy and Urinary

Incontinence, Fecal Incontinence, and Pelvic

Floor Defects

Sixteen publications prospectively collected data about some

aspect of continence or pelvic floor muscle function with good

documentation of perineal status and episiotomy use at the

time of the index birth. Outcomes of interest included

physiologic measures of muscle strength, clinical urodynamic

testing, or self-report by interview or questionnaire. 

The 16 publications include four reports from two RCTs of

liberal versus restrictive use of episiotomy and 11 prospective

studies of representative cohorts of women delivering at

particular facilities or with a particular practice group

(including two publications from a cohort of women who

participated in an RCT of perineal massage versus none in the

third trimester). One study of a cohort of all women in a

region who had third-degree lacerations at the time of the index

birth followed them to assess risk of fecal incontinence at 3

months. 

All studies reflect the dominant practice patterns in the

countries in which the studies were conducted. No study

directly compared the influence of mediolateral versus midline

(also called median) episiotomy on pelvic floor function or

continence. For this reason, long-term differences in

continence and pelvic floor muscle outcomes that would be

anticipated secondary to differences in episiotomy type are

unknown. 

Randomized Controlled Trials

Both RCTs (Sleep and colleagues in the United Kingdom8

and Klein and colleagues in Canada11) required providers to

alter their use of episiotomy. These trials randomized women

to “liberal use” or “restricted use” of episiotomy; the latter

category intended to restrict use to circumstances such as fetal

distress or maternal exhaustion with an “unyielding perineum.”

Both trials enrolled singleton, vertex presentation pregnancies at

term and randomized in the delivery suite close to the time of

birth. 

Neither trial showed meaningful differences in varied

measures of urinary incontinence such as subjective sensation of

perineal bulging, perineometry readings, involuntary loss of

urine, use of a pad, loss of urine with coughing, sneezing,

laughing, and loss with urgent need to void. Neither trial

collected data about continence of flatus or stool, descriptive

data from physical examination, or urodynamic studies. Both

research teams concluded that they did not observe any benefits

associated with episiotomy. Klein and colleagues, using

perineometry measures, also concluded that episiotomy fails to

prevent pelvic floor relaxation.11

Prospective Studies

The most global assessment of continence and pelvic floor

function concluded that episiotomy is associated with lower

pelvic floor muscle strength than spontaneous tears.38 The

clinical significance of this finding is unclear because all selfreported symptoms of urinary and anal incontinence and

degree of prolapse on physical examination were equivalent

across groups. Overall, episiotomy apparently did not protect

against incontinence, prolapse, or decrements in pelvic floor

muscle function by 3 months postpartum. 

Studies focused on self-reported urinary continence.

Excluding the clinical trial populations and the Sartore et al.

study above, five studies (in four study populations) evaluated

self-reports of urinary continence.39-43 Overall, episiotomy and

spontaneous-tear groups had the same frequency of

incontinence symptoms; no evidence emerged that episiotomy

prevents pelvic floor damage.

Studies focused on self-reported incontinence of stool or

flatus. Three cohort studies asked women about rectal

incontinence symptoms; one also conducted physical 

examinations.44-46 These authors focused on the high prevalence

of anorectal dysfunction at 3 months with episiotomy as a key

risk factor. None of these research teams found episiotomy to

be statistically associated with reduced risk.

Studies focused on physiologic measures of pelvic floor

function. Overall, none of these research teams concluded that

episiotomy had advantages,29,47,48 and one identified a decrease

in functional muscle strength. As intermediate measures, these

findings concur with the self-report and clinical examination

findings of other studies: essentially, episiotomy confers no

benefits with respect to preserving continence or pelvic floor

muscle function.

Key Question 5: Episiotomy and Future

Sexual Function 

Nine studies (in 10 publications) prospectively collected

outcome data about sexual function among women who did or
did not have a routine episiotomy. One study compared

incision type and assessed sexual function;15 three RCTs

examined restrictive versus liberal use of episiotomy;8,11,49 one

trial studied mediolateral versus median episiotomy;15 and five

were prospective cohort studies.38,42,50-52 One study (the only

study conducted in the United States), described by the authors

as “retrospective,” included a single followup time point (6

months) with prospective data collection about sexual

function.53 Two publications reflect a primary analysis from an

RCT with 3 months of followup8 and a secondary analysis after

3 years49 in the same UK study population. In two

publications with analyses of the same study population, a

Canadian research team reported analyses of 3-month followup

data: one on randomization to liberal or restrictive episiotomy

groups, and the other on perineal trauma at the time of delivery

by exposure group.11,52

Apart from the one study directly comparing mediolateral to

median episiotomy, all studies reflect the dominant practice

patterns of the countries in which they were conducted. Thus,

the literature reflects two distinct types of procedures, the

effects of which need to be addressed separately. 

Randomized Controlled Trials

Two publications from RCTs of restrictive compared to

liberal use of episiotomy reported intention-to-treat analyses of

long-term effects on the sexual outcomes of populations of

women. In one study,8 by 1 month after delivery, 37 percent of

the restrictive group and 27 percent in the liberal group had

resumed sexual intercourse (P < 0.01). The proportion of

women with resumption of intercourse by 3 months, current

dyspareunia at 3 months, or any dyspareunia within the 3

months of followup did not differ significantly by group. By

the third year of followup, the likelihood of “ever suffering

painful intercourse” remained comparable across groups.49

Klein and colleagues found less episiotomy use in the

restrictive group with higher rates of spontaneous lacerations.11

Women in the restrictive group resumed intercourse an average

of 1 week earlier that those in the liberal group; however, all

other measures of sexual function were equivalent by 3

months.11 This team conducted a separate analysis of the

relationship between degree of perineal trauma and sexual

function using 3-month interview data. They regrouped

participants by perineal status that had been systematically

documented at the time of the index birth, creating a

prospective cohort. Women with episiotomy had the slowest

return to intercourse. Pain with the first intercourse followed a

similar pattern.

Prospective Cohorts 

These cohort studies did not find large or statistically

significant differences in sexual function. Only one study

identified lasting differences in dyspareunia at 3 months.

Current dyspareunia at 3 months can be estimated from three

of the cohort studies using 818 women with episiotomy and

938 women without episiotomy.38,50,51 A meta-estimate from

the combined cohorts suggests that women with episiotomy are

54 percent more likely to have pain with intercourse 3 months

after delivery, with an absolute increase in risk of dyspareunia of

5 percent among women who had episiotomy. The two studies

that assessed any dyspareunia during the 3 months after

childbirth revealed no difference in the overall probability of

having had painful intercourse. 

Discussion

Findings by Key Question

Key Question 1: Episiotomy and Maternal Postpartum

Outcomes

Trials of fair to poor quality provide consistent findings that

clearly support limited use of episiotomy. Routine episiotomy

achieves no short-term goals that it has been hypothesized to

achieve. Indeed, routine use is harmful to the degree that it

creates a surgical incision of greater extent than many women

might have experienced had episiotomy not been performed. 

Key Question 2: Episiotomy Incision Type and Maternal

Morbidity

A single study found that women with midline episiotomy

had a significantly greater rate of anal sphincter injuries than

women with mediolateral episiotomy.15 Treatment groups did

not report differences in pain or satisfaction with intercourse at

3 months. Because of considerable methodological flaws in this

trial (poor internal validity), any conclusions must be drawn

cautiously. However, because differences in sphincter injury

rates are clinically important, we consider the finding of

increased risk of severe injury with midline episiotomy

compared to mediolateral episiotomy to be relevant

observational evidence. 

Key Question 3: Repair of Perineal Defect and Maternal

Morbidity

Limited but consistent evidence favored two-layer repair over

three-layer repair; limited and inconsistent evidence favored

continuous over interrupted sutures. Evidence was insufficient

to comment on comparisons between standard and rapidly

absorbed sutures, tissue adhesive and absorbable sutures, or

nonabsorbable and absorbable sutures. We found no evidence

that treated catgut is superior to untreated catgut with regard to

perineal morbidity; the former may in fact be associated with

higher morbidity. The evidence suggests short-term advantages

for perineal repeat associated with the use of polyglycolic-acid

sutures compared to chromic-catgut sutures. 

Three major classes of suture material (nonabsorbable,

absorbable, and tissue adhesive) and two subtypes of sutures

(treated versus untreated and standard versus rapidly absorbed)

were studied, all in the presence of different approaches to the

method of suturing; thus, individual effects of the materials

themselves cannot be examined. Likewise, methods of repair

5
were examined in the context of different materials both among

and within studies for different stages of repair. We are unable

to assess the true effects of a certain method of repair because

we cannot tell whether outcomes are confounded or modified

by suture material. 

Key Question 4: Episiotomy and Urinary Incontinence,

Fecal Incontinence, and Pelvic Floor Defects

These prospective studies did not identify improvements in

continence for urine or stool or in pelvic floor muscle function

among women who had had episiotomy compared to those

who had not. This finding includes comparison to women

who had spontaneous lacerations of similar severity. Several

authors reported decrements in pelvic floor function among

women who had had episiotomy. Only a single study, using

multivariable models, found that episiotomy was an

independent predictor of urinary continence.41 In the majority

of other studies using multivariate models, adjusting for factors

such as parity, neonatal weight, and length of second-stage

labor, episiotomy was not an independent risk factor for

incontinence. Taken in total, this literature, predominantly of

fair to poor quality, does not support use of episiotomy for the

purpose of preventing pelvic floor defects, urinary

incontinence, or incontinence of stool or flatus. 

These studies are limited because they do not follow women

long enough to detect disease occurrence. At present, the

assumption that intermediate variables, such as pelvic muscle

strength measured by perineometry, urodynamic test results, or

early reports of symptoms, can predict later disease has not

been validated. Prospective evaluation only during the months

after birth when the pelvic floor is still in a recovery and

stabilization period may be misleading. Conclusions about

whether episiotomy prevents or increases risk for incontinence

and prolapse later in adult life cannot be reached from currently

available randomized and cohort studies.

Key Question 5. Episiotomy and Future Sexual Function 

The studies addressing this question need to be considered in

two groups: mediolateral episiotomy and median episiotomy.

From the clinical trials of episiotomy strategy—liberal versus

restrictive—one trial addressed each type of incision and one

directly compared the two incision types. None found

substantive differences in sexual function. The preponderance

of the studies, however, supported a conclusion that degree of

perineal trauma is associated with probability of pain with

intercourse, in a dose-response fashion such that greater

perineal injury is associated with greater probability of pain. 

Measures that are more complex than those typically used in

this literature are needed to understand properly the

relationships between perineal trauma and future sexual

function. Specific factors such as prior sexual function and

current libido, in addition to factors such as duration of

second-stage labor, size of infant, and lactation status, need to

be incorporated into multivariable models to derive more

informative and less biased estimates of the long-term effects of

episiotomy or to determine that they do not exist.

Limitations

Deficiencies in the Literature

The available studies that met our inclusion criteria for this

systematic review contained numerous (and commonly

encountered) deficiencies. These included variations in

episiotomy rate, violations of protocol, inconsistent reporting of

the definitions of measures, inadequate reporting of statistics,

infrequent a priori designation of primary and secondary

outcomes, infrequent masking of the assessor, infrequent use of

multivariate modeling, and infrequent use of validated outcome

measures. In all, much of this literature could be regarded as

fair in quality, with some studies of good quality and a few of

poor quality. 

Limitations to Our Review Procedures

Our review process also had some limitations. Because of

time and resource constraints, we did not conduct dual,

independent, blinded review of articles for inclusion or

abstraction of information into evidence tables. Instead, one

reviewer performed the initial review, and a second reviewer

examined that input and recommended changes. Differences

were reconciled between the two reviewers. We used dual

review for grading the quality of individual articles, allowing us

to evaluate rigorously systematic bias in these assessments. 

Future Research

Currently, the evidence suggests that the putative benefits of

episiotomy do not outweigh its harms. Instead, outcomes from

episiotomy are worse because some proportion of women who

would have had lesser injury instead had a surgical incision. 

If episiotomy were restricted to indicated uses, an important

question remains for women and their care providers: Which,

if any, of the prevailing indications for episiotomy are

supported by an adequate research base? A two-stage research

agenda could address this need. First, a systematic review may

clarify current knowledge about outcomes of episiotomy for the

leading presumed indications. Second, primary data collection

may be needed to fill in research gaps identified by such a

review and to improve understanding of whether these are

indeed indications for episiotomy. 

Work relating to this latter part of such a research agenda is

under way on several topics. This work includes a recent

publication of a retrospective cohort study that suggests that

episiotomy conferred no benefit in averting neonatal injury at

the time of births that had been complicated by shoulder

dystocia.54 Additional evidence will be required to investigate

fully what circumstances should be considered indications for

episiotomy.

6
Furthermore, if the professional community accepts that

routine episiotomy is not an effective means to reduce perineal

injury, then that attitude should enable them to redouble

efforts to understand fully various other approaches to

attending the second stage of labor that can promote maternal

and infant safety, minimize perineal trauma, and maximize

maternal comfort. These steps might include giving attention

to maternal position, avoiding fundal pressure, reducing

coached pushing, providing perineal support, and employing

“hands poised” versus “hands on” techniques to support the

perineum. The role for lubrication and types of lubrication for

use during crowning of the infant head are other important

research topics that warrant more rigorous investigation. 

To understand pelvic floor defects and childbirth experiences

properly, including history of episiotomy, studies need to be

designed to identify populations of women who have a known

episiotomy history. In this way, researchers can evaluate

continence and pelvic organ prolapse status in the age groups

between 40 and 70 years. 

Conclusion

Our systematic review finds no health benefits from

episiotomy. We found fair to good evidence suggesting that the

immediate outcomes for routine (liberal-use policies)

episiotomy are no better than those for indicated use of

episiotomy under more restrictive-use policies. Indeed, routine

use is harmful to the degree that it creates a surgical incision of

greater extent than many women might have experienced had

episiotomy not been performed. Weak trial evidence,

consistent with observational data, suggests that the harms of

midline episiotomy are greater than the harms of mediolateral

episiotomy. 

For episiotomy repair, fair to good evidence, albeit across

different comparisons of methods and materials, suggests that

leaving the perineal skin unsutured may confer some benefit; if

suturing is indicated, then a continuous, subcuticular method is

better than an interrupted, transcutaneous method. Regarding

suture material, the evidence is consistent and clear that

absorbable sutures are preferred and that polyglycolic-acid

sutures have significantly less perineal morbidity associated with

them. Newer materials, such as tissue adhesive, may offer

further benefits, but the data are at present wholly inadequate

to inform care practices.

The level of evidence for long-term sequelae, specifically fecal

and urinary incontinence, pelvic floor function, and future

sexual function, is fair to poor. Nonetheless, it is consistent in

demonstrating the lack of benefit of the procedure in a

comparatively early timeframe. For women in later adult life,

when morbidity is most likely to occur in the form of severe

and persistent incontinence or pelvic organ prolapse, the

expected results of routine episiotomy are unknown. 

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the RTI-UNC Evidence-based Practice

Center, under Contract No. 290-02-0016. It is expected to be

available in May 2005, The Use of Episiotomy in Obstetrical

Care: A Systematic Review. In addition, Internet users will be

able to access the report and this summary online through

AHRQ's Web site at www.ahrq.gov.

Suggested Citation

Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson

T, Lohr KN, Gartlehner G, Thorp J Jr. The Use of Episiotomy

in Obstetrical Care: A Systematic Review. Summary, Evidence

Report/Technology Assessment No. 112. (Prepared by the

RTI-UNC Evidence-based Practice Center, under Contract

No. 290-02-0016.) AHRQ Publication No. 05-E009-1.

Rockville, MD: Agency for Healthcare Research and Quality.

May 2005.

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May 2005

ISSN 1530-440X