Episiotomy Revisited.... The Case Against its Routine Use -- A review of literature,
Unauthorized Reprint of an article  by Robert J. Woolley, MD**	"Extraordinary claims require  extraordinary proof"

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**Editor's NOTE:  The following article and literature review on episiotomy is a reprint of an email originally posted 9/13/97on OBGYN.NET, an Internet discussion group for obstetricians and professional midwives. Its contents reveals the truth about the historical and contemporary use of episiotomy, which is a painful, detrimental and potentially fatal surgical procedure unnecessary to normal childbirth but none the less used routinely by the medical profession. Despite a total lack of scientific basis for its routine use and the pain and complications associated with it, routine episiotomy has been the "management of choice" by the obstetrical community for the last 100 years. 

Episiotomy is associated with an statistically significant increase in 3 and 4th degree lacerations (into or through the rectal sphincter), perineal edema, inability to urinate after the birth (requiring caterization and increased rate of urinary tract infections), on-going perineal pain requiring medications and interfering with maternal mobility and breastfeeding and difficulty or pain in resuming normal sexual intercourse postpartum. Episiotomy does not protect the mother from pelvic floor damage or future incontinence of bladder or bowel. It does however increase the likelihood of immediate post-op infections and perineal lacerations in future pregnancies. It increase the cost of maternity care and the length of recovery for the mother. 

The only medical justification for its use is to hasten the birth of a baby suffering from fetal distress during the last few minutes of the birth process or in response to maternal exhaustion (and then only after informed consent information is provided and after obtaining the mother's permission). Its emergency use is extremely rare and when necessary is often a consequence of non-physiological (i.e., medical) management of the second stage of labor including the use of pain medications or anesthesia or requiring the mother to push while lying on her back while instructing the mother in prolonged breath-holding (longer than 5 or 6 seconds per inspiration). 

In addition to the physical and psychological damage done to individual mothers by inappropriate use of episiotomy (extensively documented in this treatise by Dr. Woolley), its historical acceptance by the medical profession as the basis of the "normal" management of birth resulted in a serious deficiency in medical education with long term consequences. Contemporary obstetricians have never been taught (nor chosen to learn on their own) these protective principles which are far more appropriate than episiotomy and necessary to preserve the normalcy of the pelvic floor. Appropriate non-surgical (i.e. midwifery-based) protective methods require a through understanding of how to facilitate the normal physiology of birth to the benefit of the mother's perineal tissue, which includes such principles as patience with nature, right use of gravity, delivery in a side-lying position, and techniques such as maintaining flexion of the fetal head and supporting the perineum during the birth of the baby's head and again during the delivery of the shoulders. A side-lying delivery technique was recommended historically to the medical profession and demonstrated by Dr. DeLee in photographs in his 1924 obstetrical textbook "Principles and Practice of Obstetrics". However, the medical profession has always ignored this recommendation, preferring to put women in a lithotomy position (mother on her back with feet in stirrups) and depend on episiotomies instead. 

Having chosen to surgically cut open the perineum, the obstetrical profession has never acknowledged the traditional midwifery principles and non-medical management techniques which were naturally successful at preventing perineal trauma during childbirth, These protective principles requires that upright and mobile positions be used for second stage (right use of gravity). The right use of gravity stimulates labor, dilates the cervix and helps the baby descend through the bony pelvis. Encouraging the mother to be upright and mobile not only helps labor progress normally but diminishes the mother's perception of pain, perhaps by stimulating endorphins. To ignore the well-known relationship of gravity to spontaneous progress is to do so at the peril of mother and baby. Specifically, it is critical that doctors do not place the mother in a position for delivery (i.e. on her back) which includes weight bearing on the maternal sacrum as this closes down the bony pelvis by approximately one third while requiring the baby to be pushed uphill against gravity at a 60 degree angle through a partially closed door. This can result in fetal distress, maternal exhaustion, unnatural perineal lacerations, edema, pain and inability to urinate immediately after the birth and pain in resuming normal intercourse postpartum. The baby as well as the mother may suffer from this institutionalized ignorance and require care in a neonatal intensive care nursery for several days after birth or even have permanent neurological damage from a trip through the birth canal make unnaturally perilous by imposing non-physiological and  

As if the inappropriate use of episiotomy for the last 100 years was not bad enough already, things have taken a desperate (and potentially fatal) turn for the worse within the last few years via a call by obstetricians for "prophylactic" cesareans as the delivery method of choice. Because obstetricians do not utilize "good technique" in managing the perineal stage of the birth (a combined problem of inappropriate use of episiotomy and failure to make right use of gravity with an increased rate of perineal lacerations when episiotomy is not done) there is a marked increase in pelvic floor difficulties, especially for older women, such as incontinence, uterine prolapse, etc. This problem is so pervasive that 33% of obstetricians in the United Kingdom who were asked for their personal birth preference (or for wives and daughters) between normal vaginal birth or elective cesarean, identified elective cesarean as the one they would choose. They attributed this to a fear of pelvic floor damage subsequent to normal birth. Obviously these iatragenically-created problems are considered by doctors to be unpreventable and to represent the "collateral damages" of childbirth -- proof of a fatal design flaw that can only be overcome by avoiding vaginal birth all together! 

The possibility of pelvic floor damage subsequent to vaginal birth is now being cited by the president of ACOG as a rationale for medically unnecessary "elective" cesarean becoming the delivery method of choice.  Logically-speaking this means that absence of ability of modern obstetrics to utilize historically successful non-surgical protective methods of perineal management translate into the use of Cesarean surgery as a bizarre indirect way to "protect" the pelvic floor, However Cesareans are not a simple perineal "protective" procedure but instead are a life-threatening surgical intervention associated with many complications for both mothers and babies. In addition to complications of the time of the original surgery, complications can occur in a subsequent pregnancy such as placenta previa, placenta percreta and uterine rupture with fetal demise or a baby with permanent neurological damage. It is a classic domino situation in which ignorance by physicians of successful midwifery techniques for perineal management can, for some childbearing women, cause extremely detrimental or even fatal consequences. The 1966 edition of Davis Obstetrics' puts things very succinctly "There can be no alibi for not knowing what is known."  Surely this situation should be rectified sooner rather than later. 

In an attempt to address this generally pernicious situation I reprinted Dr. Woolley's emailed article on the GoodNewsNetWork web site at the time it was published on the OBGYN.NET (September 1997). Dr. Woolley subsequently informed me of his plan to publish this important material in a peer review journal. At his request I removed the material from the web site as I did not want any way to compromise his ability to publish this extremely important information. It is now four years later and his article has still not been published. The obstetrical community still does not utilize "good technique" in managing the perineal stage of the birth (combined problems of inappropriate rate of episiotomy, lack of patience and failure to make right use of gravity). Pelvic floor disorders, especially for older women continue to be far too frequent. The president of ACOG is now promoting the use of medically unnecessary "elective" cesarean as the delivery method of choice and arguments against VBAC are being circulated in medcial journal and in the public press and national media. Single Closure method of uterine repair after CS increases the rate of uterine rupture in subsequent pregnancies, putting mothers and babies at risk in future pregnancies. This a totally unacceptable situation which must be rectified sooner rather than later. 

Therefore I have again posted Dr Woolley's artice, without his permission and over his vigorous objections (made via email and telephone). He considers its inclusion to be an ethical violation of his rights as its author. I consider the unnecessary and unwise use of episiotomy by the medical profession to be an ethical violation (if not a crime!) against childbearing women and believe that women have the right to know what doctors already know (but do not put into practice) or at very best, give merest lip service but without the knowledge or skills to carry out safely. 

Under the copy write principle of "fair use" I have posted Dr. Woolley's academic research on the wrongful use of episiotomy on this web site. I receive no personal, professional or financial benefit whatsoever from the presentation of this material. Circulating this important information is the only way to inform childbearing women of their need to protect themselves from this unnecessary medical procedure by providing them with an irrefutable source of information (that is, data compiled and presented by another physician) that they may reprint and give to their doctor, along with a directive to their physician to reframe from the routine use of episiotomy and additional instructions for their physician on non-medical methods to protect the mother's perineum from accidental laceration during the birth of their baby.     

As web wife to www.CollegeofMidwives.org, I  apologize for upsetting Dr. Woolley. I continue to hope that he will actually publish this important material and receive the recognition due to him for his excellent academic research and writing skills and his willingness to tell the truth about an institutionalized form of malpractice that is the "dirty little secret" of the medical profession.  It is too good a piece of writing to languish on a not-for-profit web site read by the few hundred midwives and childbearing women who visit this Internet site each year. 

Excerpts of Immediate interest:

It is axiomatic in our profession [i.e., practice of medicine] that the burden of proof of the safety and efficacy of a surgical procedure falls on those who perform or advocate it. This burden clearly has not been met for episiotomy; why has practice not changed? Obstetrics not only follows this trend, but may lead it. "Obstetrics has been rated as the least scientifically -based specialty in medicine" [Chalmers 1987]. "the hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases" ..Adopt a more scientific view of the evidence available on the subject of episiotomy, disclose this information to our patients, listen to their perspective, and, when the moment comes, choose to heed the evidence over our prejudices, we could hardly fail to reduce dramatically the use of this injurious procedure. [Brody 1981]. [Goodell 1871]: "When one sees, for the first time, the maternal soft parts stretched out to a diaphanous thinness by the presenting portion of the child, to all appearances just upon the point of cracking open, the impulse to place the hand upon the bulging flesh becomes almost an instinct. We must not, however, forget that these tissues are not only elastic, but living and sentient; and--what is of still greater weight--that the process of labour is a strictly physiological act. Nature in all her operations intends to adapt means to ends, and the perineum was certainly not created to be torn, unless shored up by the hand of the physician. It unfortunately labours under the disadvantage of lying on the external surface of the body, and its distension is really the only visible process of parturition. Were the os uteri or the uterus itself equally visible and tangible, I doubt not we would be frightened into encircling them with our hands, greasing them, folding towels about them, etc. etc. Fortunately for their integrity they lie out of sight and out of reach. I am unable to conceive of any generally applicable remedy for this defective impulse. I believe it could be prevented, but only by methodically teaching its suppression throughout medical education. Brody and Thompson adopted a term from game theory --"maximin strategy"-- to explain part of this tendency: we choose "the alternative that makes the best of the worst possible outcome, regardless of the probability that that outcome will occur," believing that "the hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases" [Brody 1981].

In a message dated 9/13/97, you wrote:

>I really would like others honest thoughts on this [episiotomy rates] because I for one can work out these conflicts more effectively if I can understand why the behavior occurs.>

a physician replies:

One of the most interesting and important questions in medicine today, I think. I wish I had a definitive answer. I've thought a lot about it, and have several partial answers, but nothing definitive.

As everybody is sick of hearing by now, episiotomy is the one area of OB I have investigated most thoroughly. In fact, it was precisely the question you're asking that got me interested in it. I was in a medical school that had a CNM as an instructor in the OB department, and by chance I was assigned to her for my first OB rotation. She prejudiced me forever to be a non-interventionist, and she was the one who first gave me a copy of Thacker and Banta's seminal 1983 review on the subject, which showed no evidence of benefit from the procedure. That was the first subject anywhere in medicine where I noticed a big discepancy between the state of practice and the state of evidence, and that fascination never left me.

When I wrote my update to T&B's article in 1995, I included a long editorial comment speculating on why there continues to be this discrepancy, 12 years (then) after the article which should have had a dramatic change on practice. I ended up excising it due to space limitations. I still have in mind to publish it as a separate editorial someday, when I get around to polishing it up some more. But here's the original draft

Comment

The essence of knowledge is, having it, to apply it; not having it, to confess your ignorance.

--Confucius

A. What is the optimal episiotomy rate?

Thacker and Banta reviewed the published episiotomy rates and postulated that its use in 20% of patients "may represent a reasonable minimum" [Thacker and Banta 1983]. Since then, many other groups have reported their figures. The Argentine Episiotomy Trial Collaborative Group concluded that "rates above the 30% found in the selective group of our study cannot be justified" [Argentine 1993]. Rates of less than 8% were seen in the restrictive arm of the RCTs by Harrison et al [Harrison] and Sleep et al [Sleep], with no increase in maternal or fetal adverse effects. In a randomized trial in California, midwives used episiotomy in only 10.8% of cases, with no worse outcomes than the more interventionist physicians [Chambliss]. Buekens et al infer from their data that "episiotomy is needed in no more than one in every five deliveries" [Buekens 1985].

There exist in the literature many comparable uncontrolled observations:

Ten Belgian hospitals in the mid-1970s had an overall rate of 28.4% [Beukens 1985].

The majority of both certified and lay midwives surveyed in New Mexico report performing episiotomy in less than 25% of their cases (this was the lowest category respondents could select) [Graham 1990].

At the University of Michigan, midwives perform episiotomy in 24% of births [Mayes 1987], and in a large multicenter U.S. study, midwives used it in about 23% of their patients [Rooks].

At least one Swedish hospital in 1989 used episiotomies in only 9.0% of primiparas; the national average was 29.9%, and about one-fourth of hospitals reported rates of less than 20% [Rockner 1991b].

At least one hospital in France claimed a rate of 7% among primiparous patients; one in the United Kingdom 5% [Maratos 1986].

Other British maternity units report overall frequencies as low as 14% in primiparas and 16% in multiparas [Sleep, 1984a].

National statistics for France in 1979 were 28.2% [Buekens 1986]; by 1985 this was down to around 22% [Mascarenhas].

One Jamaican hospital in 1991 used episiotomies in only 0.3% of its parturients; only 17.3% suffered a laceration in need of suturing [Doherty 1993]. Most remarkably, of 2447 low-risk women delivering in rural maternity hospitals in Brazil, there were no episiotomies, no third-degree tears, and only a 5.7% rate of second-degree tears [Dunn 1985]!

Clearly, episiotomy rates under 30% have been accomplished on national scales, and rates under 10% at the scale of individual institutions. But what is the optimal rate, the rate at which maternal and fetal risks are minimized? The answer to this depends entirely on two other questions: What are appropriate indications for episiotomy and what is the prevalence of these indications?

Were we to use strict criteria for the former question--that is, any clinical indications must be supported by the preponderance of the evidence for both safety and efficacy--the answer would be that there are are no valid indications, maternal or fetal, for episiotomy, and therefore the only appropriate rate of its use is zero.

If episiotomy were a new, experimental procedure, and its initial results were those described in this review, there can be no doubt that the research would be halted and episiotomy relegated to a brief and ignominious place in the annals of medical history. However, there may be practical, though not strictly logical, reasons to evaluate widespread practices somewhat differently from new ones. "[I]f modern standards of evidence were applied to all medical practices, a large proportion would be thrown into limbo, hundreds of 'standard and accepted' practices would be disrupted, and medical practice would be in chaos" [Eddy 1993].

Even if we therefore adopt a different standard--accepting the use of episiotomy for any indication not yet adequately demonstrated to be ineffective--the list might be essentially as given by Reynolds [Reynolds 1993]: "fetal distress, maternal exhaustion, or shoulder dystocia." To this one could reasonably add the occasional cases of what Goodell referred to as "broad and distorting cicatrices resulting from burns, sloughs, abscesses, etc." [Goodell 1871]

In modern obstetrics, this might most commonly be caused by ritual childhood genital surgery. (I have seen one such case; the patient physically could not have delivered without either an episiotomy or extensive tearing because of the absolute lack of distensibility of the vulvar scar tissue. Other such cases have also been reported [Williams 1993, McSwiney 1992, DeSilva 1989].) Because of the imprecision in definitions of all of these conditions and wide inta-observer variability in diagnosing them, it will be impossible to ascertain their "true" prevelences. However, it is inconceivable that these circumstances would encompass more than 30 percent of deliveries, and unlikely that they would collectively occur in more than about ten percent of births.

B. Why has practice not changed?

It is axiomatic in our profession that the burden of proof of the safety and efficacy of a surgical procedure falls on those who perform or advocate it. This burden clearly has not been met for episiotomy; its safety and efficacy had not been demonstrated at the time of Thacker and Banta's review [T&B 1983], and they have not been any better established since then. In the words of Brody and Thompson, "the body of controlled evidence to support these assertions [of the benefits of episiotomy claimed by its first American practitioner] is essentially the same as when Taliaferro performed his pioneering feat in 1852" [Brody 1981]. On the contrary, the preponderance of the evidence demonstrates that, with the single exception of preventing anterior perineal lacerations, none of the commonly cited benefits of episiotomy can withstand scientific scrutiny.

The episiotomy rate in the United States should have fallen in the years since the publication of Thacker and Banta's review, as word spread of the lack of the procedure's foundational evidence. It did not; episiotomies were used in an essentially constant 61% to 64% of all births in this country from 1980 to 1987 [Kozak 1989]. (If the data collection methods are comparable, the 1990 figure of 56% [Kaufman 1992] may indicate that a change is finally nderway.) Our international colleagues appear to be doing better in this egard; several papers report declining rates in Canada [Enkin 1984, Reynolds 1993, Ruderman 1993], Great Britain [Reynolds 1987a, Sleep 1984a, Fleissig

1993, House 1986], France [Buekens 1986, Mascarenhas 1992] and Sweden [Larsson 1991, Rockner 1991b]. It is instructive to note that physicians are capable of avoiding episiotomies when given incentive to do so. Alger et al documented that only 40% of patients with known risk factors for HIV infection, and only 25% known seropositive for the virus, received an episiotomy, compared to 75% in their hospital generally [Alger 1993]. Jacoby found that episiotomy was less likely to be performed in women who had wanted to avoid it, though she did not investigate whether that wish had been communicated to care providers, which would bolster a causal inference [Jacoby 1987].

American physicians' beliefs about the benefits of episiotomy also show no sign of acquiescence, according to the survey published by Graham et al in 1990 [Graham 1990]. Thirty-seven percent of obstetricians and 20% of family physicians believed that episiotomy should be performed "for nearly all deliveries," and 82% and 70%, respectively, believed this "for nearly all primigravidas." There was near unanimity among physicians that an episiotomy "should be performed for anyone who would tear." Large fractions cited the rationally claimed benefits of episiotomies as reasons for doing them.

Small minorities believed that episiotomies caused more postpartum pain than spontaneous lacerations. One obstetrician responded to the survey with this accusation: "I think you who don't do episiotomies are lazy, barbaric, and practicing poor obstetrics." Textbooks, too, have lagged severely behind the evidence. Although the 1993 edition of the renitent Williams Obstetrics has finally acknowledged the existence of studies indicating that the performance of an episiotomy increases the risk of a third-degree laceration, it continues to prescribe the procedure for a large number of unproven indications: preterm delivery, shoulder dystocia, breech delivery, operative delivery, occiput posterior position, "and in instances where it is obvious that failure to perform an, episiotomy will result in perineal rupture" [Conduct 1993]. Ironically, one of its editors now lists Williams as the reference for the statement "there appears to be little justification for routine performance of episiotomy..." and approvingly cites Thacker and Banta's review [T&B], which initially drew only scorn from the textbook [Ramin 1994].

Williams' chief American competitor, the 1994 edition of Danforth's Obstetrics and Gynecology, has not come even that far. It mentions almost none of the research published in the last decade, and continues to display a strong bias in favor of episiotomy: "In a parous patient with moderate perineal relaxation and a small baby, it may be apparent as the head extends hat the perineum will yield and that an incision will not be necessary. In most nulliparous women at term, this will not be the case.... It usually becomes apparent that laceration is inevitable. An episiotomy is generally preferable" [Zlatnik 1994] [emphasis added]. And as late as 1992, the American College of Obstetrics and Gynecology's official position was as ollows: "The presence of a short perineum, a large baby, and the need to [the use of an episiotomy]" [AAP&ACOG 1992].

What accounts for the vast discrepancy between the current state of the evidence and the current state of practice and teaching? I see several explanations, each partial.

1. Lack of a scientific mindset

The agonizingly slow pace of implementation of new data into clinical practice is an embarrassing fact of modern medicine, at least in the United States [Woolf 1993]. The reasons for this, even were they fully understood, are beyond the scope of this paper. Obstetrics not only follows this trend, but may lead it. "Obstetrics has been rated as the least scientifically-based specialty in medicine" [Chalmers 1987]. Several pitfalls that leave us open to such condemnations are outlined by Grimes in a paper that should be read regularly by all who wish to maintain scientific integrity in their obstetric practice [Grimes 1986]. A variety of opinions for proper management of the perineum--all without a shred of scientific validity--was listed by Goodell in 1871, in a famous harangue [Goodell 1971].

"To sum up, then: there are those who make pressure upon the perineum to retard the head; those who make pressure to accelerate its advance; those who deny that any such effects can be thus produced; and those who conscientiously use support because something must be done.

Again; there are those who direct all the pressure at the fourchette; others who reprehend this, and as carefully guard the posterior perineum; and others who will not touch the perineum on any account. Further, there those who push the perineum backwards; and those who, for equally plausible reasons, push it forwards. Some dilate the sphincter vaginae; some the sphincter ani; and some who plug it up. Some place their hands transversely cross the perineum; some longitudinally, with the fingers looking upwards; some longitudinally, with the fingers looking downwards; some who attack it with their knuckles. Some scoop out the head with the vectis; others drag it out by the ears; and yet others who rely on the forceps. Finally, there are those who use the right hand, and those who swear by the left hand. Some who advocate a folded napkin; some an unfolded napkin; and others again who frown down upon all napkins, folded or unfolded....

This is disheartening enough; but, alas! we have not yet done. When there are congenital peculiarities complicating the mechanism of labour; when the perineum is rigid; the presenting part of the child's body too large, or in an unfavorable position; when from any cause laceration seems imminent, again commences another clash of opinion.

Michaelis advises incision at the posterior commissure; Siebold and Ritgen, where the tension is least, and the head presses the least. Penrose, Eichelbury, Dubois, Blundell, Barnes, Hewitt, Butignot, and Chailly Honore make lateral or oblique incisions. Simpson nicks the sides of the vulva with his finger nails; whilst Scanzoni and Clay do the same thing with a blunt instrument. Cohen cuts subcutaneously through from one-third to one-half of the fibers of the constrictor muscle near the clitoris. On the other hand, Wallace, Moreau, Busch, Hodge, Huetter, and a host of other authors, object to the use of the knife, and depend upon either the forceps or upon such measures as are usually adopted for relaxing undue rigidity of the maternal soft parts.

Does not this discordance in the rank and file of the profession show a lame cause?"

We laugh easily at the primitive bickerings of our predecessors, but do we really have a more sophisticated approach? In 1994, the official journal of the American College of Obstetrics and Gynecology could still publish an earnest proposal from one of its fellows, a medical school professor of obstetrics, for a new type of episiotomy, more extensive than a usual midline incision [May 1994]. It appears to trouble neither the journal editors nor the professor--who presumably teaches his innovation to students and residents--that there is not a scintilla of scientific evidence supporting his claims for this procedure. Simply declaring oneself to have had "excellent results," as he did, is a level of discourse more befitting the promulgation of a new underarm deodorant than a new surgical procedure. We must embrace the tenets of "evidence-based medicine" if we are to claim advantage over our nineteenth-century forebears [Evidence-based 1992].

2. Inclination to intervention

It is a general and regrettable tendency for clinicians to prefer active intervention over watchful waiting, even when our only available interventions are known to be ineffective. Again quoting Goodell [Goodell 1871]:

"When one sees, for the first time, the maternal soft parts stretched out to a diaphanous thinness by the presenting portion of the child, to all appearances just upon the point of cracking open, the impulse to place the hand upon the bulging flesh becomes almost an instinct. We must not, however, forget that these tissues are not only elastic, but living and sentient; and--what is of still greater weight--that the process of labour is a strictly physiological act. Nature in all her operations intends to adapt means to ends, and the perineum was certainly not created to be torn, unless shored up by the hand of the physician. It unfortunately labours under the disadvantage of lying on the external surface of the body, and its distension is really the only visible process of parturition. Were the os uteri or the uterus itself equally visible and tangible, I doubt not we would be frightened into encircling them with our hands, greasing them, folding towels about them, etc. etc. Fortunately for their integrity they lie out of sight and out of reach.

I am unable to conceive of any generally applicable remedy for this defective impulse. I believe it could be prevented, but only by methodically teaching its suppression throughout medical education. Brody and Thompson adopted a term from game theory--"maximin strategy"-- to explain part of this tendency: we choose "the alternative that makes the best of the worst possible outcome, regardless of the probability that that outcome will occur," believing that "the hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases" [Brody 1981].

We tend to believe that we are more likely to be criticized (by patients, peers, and plaintiffs' attorneys) for failure to use a tool than for its complications. And there may be practical reason for this fear: I have listened to many critical peer reviews of hospital cases for neglecting to take a patient to cesarean section promptly, but rarely any similar scrutiny for its use in marginal indications, undoubtedly a more frequent event.

At the risk of further raising the level of scrutiny already brought to bear on obstetric cases, I must point out that episiotomy rates would make appropriate targets for quality audits, both at the institutional level and for individual providers. Such pressure might accomplish what publication of scientific data has not.

3. Self-deception

Physicians have no less capacity for self-deception than other humans. Regarding episiotomy, we can easily convince ourselves that we can correctly predict that a given patient will suffer a tear of sufficient severity as to warrant surgical prophylaxis. (There is, of course, no evidence that any individual possesses this talent, and a comparison of the actual risk of a severe spontaneous laceration with the frequency of episiotomy amply demonstrates our fallibility.) When the episiotomy is cut and no extension suffered, we congratulate ourselves for preventing more extensive damage. In so doing we overlook the evidence that our act, in all likelihood, caused more perineal injury than would have occurred without meddling [Gass 1986].

Self-deception shows in publications as well as in our own behavior.

Consider these examples:

* Two 1940s papers discussing third-degree tears freely acknowledged an obvious association between midline episiotomy and this complication, but conclude that the blame lies with every factor except the episiotomy (forceps, experience, presentation, pelvic dimensions, etc.) [Kaltreider 1948, Ingraham 1949].

* More recently, Legino et al blithely accept that their hospital will never see a third-degree laceration rate below 17% (!) because of the use of midline episiotomy in 82% of deliveries [Legino]. They recognize that the incision predisposes the patient to this complication, but appear oblivious to the possibility of reducing the number of complications by reducing the number of unnecessary procedures.

* In one paper reporting a series of puerperal hematomas, this complication was blamed on faulty repair of the episiotomy [Cheung 1991]. While this is not implausible, no mention was made of the equally likely possibility that the episiotomy itself was the cause.

* The level of (false) confidence in the benefits of episiotomy is high enough that respected investigators have difficulty convincing funding agencies that it is a topic worthy of study [Klein 1988, Enkin 1984].

* An obstetrics journal editor in 1990 advocated liberal use of "episiotomy + forceps delivery when the head is low" to "reduce the number of perinatal deaths and minimize the risks of hypoxia, so improving the intellectual quality of survival" [Editorial Comment 1990].

4. Lack of informed consent

Kitzinger states, polemically but correctly, that episiotomy "is the only surgery likely to be performed without her consent on the body of a healthy woman in Western society" [Kitzinger 1986 Intro]. It is puzzling and troubling that this is so.

I would certainly not advocate the mandating of a formal consent document, especially one thrust at a woman between contractions. How much better it would be to include episiotomy in a general prenatal discussion with the patient of one's views and practices of a variety of commonly used labor interventions. Obviously not every contingency can be anticipated, but if a physician performs episiotomies in a substantial fraction of his cases, it is unethical not to apprise the patient of this fact and its justifications (if any).

Our involvement of patients in the episiotomy decision has been so abysmally neglectful that one reviewer of the subject could write "Perhaps yet another relative contraindication to episiotomy is a patient's absolute refusal to consent to the procedure" [Varner 1986] (emphasis added). It is difficult to imagine that the name of any other surgical procedure could be substituted into that sentence without raising a storm of objection, but for episiotomy it appears to be accepted without hesitation.

5. Failure to listen to patients

I mean, by this, our patients both individually and collectively. In the clinical setting, most women will accept their incision and its sequelae with great equanimity. Yet I have found, when informally surveying female friends, that outside the physician-patient relationship, women will often reveal a startling depth of enmity for this procedure, tempered only by the reassurance they received that it was "necessary." Some of this resentment has been reported formally [Reading 1982, Kitzinger 1986 chapter, Kitzinger 1981 book].

"'Do not refuse,' says Hippocrates, 'to believe women on matters concerning parturition'" [Goodell 1871].

If we were to adopt a more scientific view of the evidence available on the subject of episiotomy, disclose this information to our patients, listen to their perspective, and, when the moment comes, choose to heed the evidence over our prejudices, we could hardly fail to reduce dramatically the use of this injurious procedure.

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