Episiotomies: when and if they help.(Obstetrics)(care and treatment)

WASHINGTON -- Often, the best episiotomy may be no episiotomy, Dr. Lily A. Arya noted at the annual meeting of the American College of Obstetricians and Gynecologists.

That said, episiotomies are needed in some cases, and sometimes wound dehiscence requires additional repair, said Dr. Arya, a urogynecologist at the University of Pennsylvania Medical Center in Philadelphia.

The need for episiotomies remains a subject for debate. Dr. Arya cited a recent study that compared routine episiotomy, selective episiotomy, and no episiotomy, and found no significant difference in the incidence of minor lacerations or fecal incontinence (Acta Obstet. Gynecol. Scand. 2004;83:364-8).

"Sometimes, if you let nature take its course you will only end up with minor lacerations," Dr. Arya said, although she added that she favors selective episiotomies. The surgeon's challenge lies in trying to deduce whether significant tearing might occur.

Mediolateral episiotomy has several advantages over median episiotomy if the surgeon decides to proceed, Dr. Arya said. Although the midline episiotomy involves less bleeding, pain, and dyspareunia, the median technique tends to cause more fecal incontinence and a greater risk of anal sphincter injury.

Mediolateral episiotomy, on the other hand, will not prevent tears, but it will not cause tearing, either.

The traditional strategy in dehiscence cases has been to reopen the wound and perform a secondary repair in 3-4 months.