Katherine E. Hartmann, MD, PhD
Director, Center for Women's Health Research, University of North Carolina at Chapel Hill
Wednesday, May 4, 2005; 1:00 PM
One of the most common surgical procedures performed in the United States -- an incision many pregnant women receive to reduce the risk of tissue tears during delivery -- has no benefits and actually causes more complications, according to the most comprehensive analysis to evaluate the practice, Washington Post staff writer Rob Stein reports in Wednesday's article, " Procedure On Women In Labor Adds Risk (Post, May 4) Katherine E. Hartmann , director of the Center for Women's Health Research at the University of North Carolina at Chapel Hill, led the analysis published in today's issue of the Journal of the American Medical Association. Hartmann was quoted in Stein's article: "The evidence is clear: Routine use of episiotomy is not supported by research and should stop," said Hartmann. "Women need to know this information so they can talk with their care providers before they are in labor." Katherine E. Hartmann was online Wednesday, May 4, at 1 p.m. ET to answer your questions about the study she led on episiotomies. A transcript follows. ____________________ Washington, D.C.: I am having my first baby this summer and just reading about this procedure made me practically hope for a c-section, but I did not believe I had any ability to object to it if it was what my doctor thought best. In light of this study, would it now be reasonable to include in a birth plan that one does not want this procedure performed? I am not assured that my doctor will actually deliver me and so even if I discuss with her and we are on the same page, I want to be prepared for dealing with another doctor's views at the hospital and understand how insistent I can reasonably be about not wanting this done. Thanks. Katherine E. Hartmann: Don't give up hope yet. The good news is that the majority of women having vaginal births are not having episiotomies. It is perfectly appropriate to talk with your care provider about what your hopes are for your birth experience. You can include your preference that barring an emergency or other concerning circumstances you would like not to have an episiotomy. If you have a written birth plan, also include that information in your birth plan. Within groups, care providers tend to have similar practice styles and philosophies. Even if you won't meet all of the team who could be at your birth it is worth having the discussion during your prenatal care. If you want more information for yourself or your doctor, a summary of the evidence we reviewed is available at www.ahrq.gov. _______________________ Alexandria, Va.: I have a friend who's a maternity ward nurse, and sometime before my wife gave birth, my friend and I were talking about what to expect (first-time dad here). My friend said the worst sound she'd ever heard was the tearing of tissue when a patient had refused an episiotomy, and that the damage that was caused was a real problem to fix. How can it be that a controlled, surgical cut is worse than tearing under childbirth stress? It just isn't logical. Katherine E. Hartmann: Routine use of episiotomy was predicated in part on the logic that a controlled incision would be preferable for exactly that reason. However a more apt analogy may be that the incision can serve much like a cut with scissors in fabric - the initial incision can serve as a pathway that makes rapid extension possible. That is thought to be why episiotomy is associated with higher probability of severe tears that involve the rectum and anal sphincter. Spontaneous tears can be difficult for the provider to repair but generally take a path not as likely to involve the rectum or deep tissues. Overall the evidence suggests that careful, slow delivery of the baby's head, without an episiotomy will have a better result. _______________________ Bethesda, Md.: Do health insurance companies pay obstetricians for this procedure now? Should episiotomy not be paid for? Katherine E. Hartmann: In most cases the reimbursement for births is provided as a "global fee" - the care provider does not generally receive additional compensation for doing or repairing an episiotomy. I am not aware that there is any financial incentive that encourages episiotomy use. _______________________ Washington, D.C.: I am curious to know whether your study looked at the episiotomy rates of doctors versus those of midwives. I feel much more comfortable with the approach midwives take to birth. Katherine E. Hartmann: We did not investigate rates by type of provider in our study. However, other data suggest wide variation within and among provider groups. Some physicians have very low rates and some midwives make use of episiotomy almost as often as the national average of 35%. Overall, midwives are less likely than others to use episiotomy; but many family physicians and obstetricians have similarly low rates. Knowing what your provider's practice style is the key. _______________________ Chapel Hill, N.C.: What is the effect of episiotomy on the health of infants, rather than mothers? Does episiotomy offer any benefits to babies? Katherine E. Hartmann: We were not able to focus on fetal indications for episiotomy. Episiotomy facilitates more rapid birth. In an emergency that can be very important. However, there is little research that allows an estimate of the benefits for babies. Certainly some use of episiotomy in urgent and emergent situations for the baby is necessary. _______________________ Frederick, Md.: I was very surprised to read about the study. My experience (quite a few years ago) was for my first two deliveries I had episiotomies, and my third came too fast and I actually tore. So what you are saying is that my experiences aren't the norm? Actually, that would be great as I believe the episiotomies were the cause of the pain post-childbirth. Katherine E. Hartmann: We did find that the results of spontaneous tears, if they happen as in your case, are not worse than routine use of episiotomy. Because some women may have no tears at all that require stitches, and all episiotomies need stitches, routine use of episiotomy deprives some women of the possibility (25 to 30+%) of not needing any intervention. _______________________ Washington, D.C.: I haven't read the whole report -- just the Post story about it. I'm curious to know what the conclusion is for deliveries with interventions. I had a baby last summer and was very opposed to an episiotomy and discussed that pre-delivery with my obstetrician. I ended up having one anyway when the baby's heart rate dropped and the doctors decided to do a vacuum delivery. So I'm curious to know what the study recommends in that sort of situation. Katherine E. Hartmann: We focused only on routine use. Your birth fits the category in which speed of delivery prompted use of both episiotomy and vacuum. Not enough research has been done to know if episiotomy is providing benefit, or how much, in circumstances like yours. Since episiotomy does help speed birth, it is likely best to err on assuring a timely birth when there is fetal distress. _______________________ Arlington, Va.: I read the article and am fascinated. The article states: "If you have a piece of fabric, it doesn't tear well until you get it started. The episiotomy can have that effect of actually being the starting place for a tear," Hartmann said. If I opt to not have an episiotomy, then am I actually increasing the chance of not having any tear at all during delivery. (This will be my first delivery) Katherine E. Hartmann: Not having an episiotomy does allow for the possibility that you won't have any tear that requires stitches - small stretches and tears that don't need stitches are almost universal. Even first time moms have a good chance of no serious tears with slow and careful delivery of the baby's head. Even if you do have a spontaneous tear, this evidence suggests that you will do as well or better than women who have a routine episiotomy. Wishing you and all the others online today the very best for a safe and very special birth. _______________________ Fairfax, Va.: Hi - my wife gave birth last month to our son. I wish we had this info sooner. Her doctor performed an episiotomy after she said my wife began to tear (big baby, small wife) ... so far there doesn't appear to be any complications, but is there anything we should look out for in the next couple of months? Katherine E. Hartmann: On average, healing is prompt with day-to-day improvement in pain and then discomfort. Unless new symptoms arise - pain, fever, or swelling or redness in the area of the incision - the odds are overwhelmingly in your favor for a good and complete recovery. If you have any specific concerns make sure your wife is in contact with her care provider. Congratulations on your new addition. _______________________ Missing the point: The real point that mother should consider is how good their providers are at providing perineal support during labor. Some docs and most midwives are geared to making sure there is no damage, whether surgical or spontaneous. I had great support while delivering my 9lb. 3 oz. baby and had no problems. Mothers should know that laying flat on your back while pushing increases the chance of tearing. Katherine E. Hartmann: This is a great point for all the questions relating to other options to reduce injury. Studies we did not review show that gentle support of the perineum and controlled delivery of the head are keys to good outcomes. As this reader notes, even very large infants can often be born with very little injury. Being in an appropriate position and not being required to push strenuously in the final moments before birth are clearly helpful. _______________________ Washington, D.C.: From my understanding, this procedure is to help along a "stuck" baby (for lack of a better term). If the parents do not want this procedure, is the only alternative the natural tearing of the skin? Or can the OB switch to a c-section? What I'm asking is: Can the doctor ever tell this will be needed beforehand so it can be avoided altogether? Katherine E. Hartmann: The use of episiotomy in a purely routine fashion remains common, meaning they are done as part of most every birth that some providers attend. Potential indications such as a difficult birth of a large baby or with fetal distress fall outside what is meant by "routine". However, if tears happen spontaneously, the evidence suggests these spontaneous tears are no worse than the episiotomy and potentially associated extensions of the episiotomy. _______________________ Arlington, Va.: What percentage of women do not tear? Katherine E. Hartmann: In studies we included in our review as many as 34% of women did not need stitches if they were in the research group with restricted rather than routine use of episiotomy. So at least 25 to 30%, or more, of women will not have any serious tears. _______________________ Washington, D.C.: How can one obtain a full copy of the study? Katherine E. Hartmann: The following will get you to the article as well as the full Agency for Healthcare Research and Quality evidence report and summary done by the RTI-UNC Evidence-based Practice Center: PDF of JAMA article http://www.cwhr.unc.edu/pdf/Hartmann-Episiotomy-2005.pdf PDF of Executive Summary http://www.ahrq.gov/clinic/epcsums/epissum.pdf PDF of Full Report http://www.ahrq.gov/downloads/pub/evidence/pdf/episiotomy/episob.pdf Thanks for your interest. _______________________ Piscataway, N.J.: My thoughts in reading about this was to think, why did it take them so long to figure this out? I remember reading that episiotomies were unnecessary in "Our Bodies, Ourselves" decades ago. When I delivered my two children in the '80s I was given episiotomies and was not happy about it, I favor the least intervention necessary (I went with natural childbirth but in a hospital with a regular obstetrician). Hooray that this has finally come out! Katherine E. Hartmann: Thanks for your enthusiastic endorsement. Sometimes a very focused review of the current evidence can be the critical ingredient to prompt further change in practice. We are gratified by the interest in the topic and glad the information is getting the attention of both women and their care providers. _______________________ Washington, D.C.: Why did the obstetrics and gynecology group work with the government to get this study done, rather than do it themselves? What is this government agency and how do they do studies like this? Katherine E. Hartmann: The government agency, the Agency for Healthcare Research and Quality, or AHRQ is in the US Department of Health and Human Services and it runs a program called the Evidence-based Practice Program. That program has several centers (Evidence-based Practice Centers, or EPCs)that do complex reviews of published information or evidence about many different clinical topics and health policy issues. AHRQ supports these these reviews on behalf of professional associations or societies, such as this one for obstetrics specialists (American College of Obstetricians and Gynecologists, or ACOG), because of the very rigorous and intensive effort needed to do an independent and unbiased report of use across the nation. In this case, AHRQ asked the RTI International - University of North Carolina Evidence-based Practice Center, located in Research Triangle Park in North Carolina, to do this review. AHRQ is publishing the full report, which is more extensive than the JAMA article, and it is available on the AHRQ website: www.ahrq.gov. _______________________ Roslyn, Va.: Will your findings mean that doctors may stop doing episiotomies and then might be in trouble if anything bad happens to the mother or the baby? Katherine E. Hartmann: I certainly hope not - we don't want to have care providers questions their judgment in the birth suite, many and varied circumstances may call for episiotomy. However, if all is well and on track, without any apparent difficulties, a care provider cannot be faulted for not doing a routine episiotomy - without fetal indications, there is no evidence of benefit. _______________________ Falls Church, Va.: How do you know you have all the right information in your study to make these recommendations about episiotomy? Did you talk with doctors who actually deliver lots of babies? Katherine E. Hartmann: Medicine is certainly both an art and a science. We do many things based on sound logic intending to have the best outcomes for our patients. However, when the science suggest that we are not obtaining the benefits we had hoped for, we are obligated to reconsider our practice patterns. Our study includes research by more than 26 research teams that included 5,000 women and many care providers both doctors and midwives. We hope that all of us who provide birth care will take this chance to evaluate how we use episiotomy. _______________________ Katherine E. Hartmann: As researchers focused on women's health, we are especially interested in understanding conditions and interventions that affect large numbers of women. This research underscores the importance of asking questions about the outcomes and benefits of even common events in our medical care. In the absence of benefit and with the potential for harm, routine use of episiotomy should be abandoned. If you are pregnant, talk with your care provider during your prenatal care about how she or he thinks about routine use of episiotomy - you should be an active participant in making this decision. We are wrapping up our hour. If you would like to continue the conversation over the coming days, I can be reached at the Center for Women's Health Research at the University of North Carolina at cwhr@unc.edu. We plan to post additional questions and responses at our Web site, www.cwhr.unc.edu, over the coming weeks. Thanks for all your very thoughtful questions today - wish we had more time. _______________________ Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.