Clinician-specific episiotomy rates: impact on perineal outcomes

Recent, large, randomized, controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum. Yet episiotomy remains the most common surgical procedure women undergo. This article examines if clinician experience, rather than scientific evidence, forms the basis for continuing this practice. Perineal outcome data are analyzed for 865 low-risk women who were attended at birth by the staff nurse-midwives or faculty obstetricians at a university-based, tertiary-care hospital. Data were collected under routine, nonexperimental conditions such that the circumstances of the labor and the clinician's preferences were allowed to determine management decisions regarding the use of episiotomy or other techniques of perineal management. Multivariate findings indicate that in the absence of episiotomy, rates of perineal integrity were highest among clinicians who usually had the lowest rate of episiotomy use. When an episiotomy was done, rates of third- and fourth-degree extensions were highest among clinicians who used episiotomy most frequently. This finding challenges the idea that clinicians who were very experienced with the use of episiotomy would avoid complications such as extensions. Future research should explore the use of nonsurgical techniques such as those employed by midwives to promote perineal integrity. Then interdisciplinary research and evidence-based education regarding these techniques can occur to improve perineal outcomes for all women.