Friday, May 06, 2005

Episiotomy and the Husband Stitch

I've been asked to do a post on episiotomy. I don't have time to do a detailed review, but let me briefly address the topic.

Tears (lacerations) of the vagina/perineum are classified as 1st (superficial, skin and mucous membrane), 2nd (fascia and muscles of perineal body), 3rd (anal sphincter involvement), and 4th degree (through the rectal mucosa, to the lumen of the rectum; often accompanied by periurethral tears). Think of an episiotomy as a controlled laceration of the pudenda. [Ignore the anatomical terms; we'll look at some very good drawings in a moment.]

There are two types of episiotomies: midline, and mediolateral. Except for the important issue of third- and fourth-degree extensions, midline episiotomy is superior.

Characteristic... Midline... Mediolateral

Surgical repair... Easy... More difficult

Faulty healing... Rare... More common

Postop pain... Minimal... Common

Anatomical results... Excellent... Occasionally faulty

Blood loss... Less... More

Painful intercourse... Rare... Occasional

Extensions... Common... Uncommon

With this oh-so-brief overview out of the way, first, a comment about the recent JAMA study: reporters are clueless when it comes to reporting health news.

One of the most common surgical procedures performed in the United States - an incision many pregnant women receive to make childbirth less damaging - has no benefits and causes more complications, according to the most comprehensive analysis to evaluate the practice.

Contradicting the long-accepted rationale for the operation, called an episiotomy, the analysis found that it increases the risk of tissue tears during delivery, leading to more pain, more stitches and a longer recovery after childbirth. In addition, it increases the risk of sexual difficulties later and does not reduce the risk of incontinence, the federally sponsored study found.

As a result, the researchers concluded, routine use of the procedure undergone by more than 1 million U.S. women each year should be discontinued, and the incision should only be considered to speed delivery when the health of the baby is at risk.

No, no, and no. The study didn't look at the benefits of episiotomy. It reviewed the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. The findings on tears, pain, and risk of incontinence:

Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae.

The study concluded that: Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. [Here's another review study of restrictive vs. routine episiotomy use.] In other words, when compared to restrictive episiotomy, doing routine episiotomy for certain maternal indications (to prevent severe perineal tears, or pain) is not supported by the available evidence.

An aside: As a rule, a laceration is harder to repair vs. an episiotomy. The problem isn't the 3rd/4th degree perineal lacerations--the ones affecting the rectum. Those are relatively easy to repair: you have good exposure, nice planes, and minimal to little bleeding. The big problem is the vaginal tears, in particular those deep inside the vagina. The space is difficult to expose, the tissue is engorged with blood, and tends to be quite friable [imagine having to suture tissue the consistency of a soaked marshmallow].

Last, but not least, just because this procedure is [o]ne of the most common surgical procedures performed in the United States, does not mean that it is routine.

While still a common obstetrical procedure, the use of episiotomy has decreased remarkably over the past 20 years. Through the 1970s, it was common practice to cut an episiotomy for almost all women having their first delivery.

The percentage of episiotomy with vaginal deliveries ranged from 65.3% in 1979 to 38.6% in 1997. ... [The national] rate is 39 per 100 vaginal deliveries (depending on the hospital, ranging from approximately 20% to 73%).

Moreover, an episiotomy is not recommended as a routine procedure:

The procedure should be applied selectively for appropriate indications, including fetal indications [stuck shoulder, feet first]; instrumental delivery [using a vacuum, forceps]; and in instances where it is obvious that failure to perform an episiotomy will result in perineal rupture. The final rule is that there is no substitute for surgical judgment and common sense.

Just to be clear: surgical judgment and common sense do not equal delusions of grandeur, hating your patient, performing unnecessary, or unconsented surgery on your patient, or concern over enhancing the sexual pleasure of your patient's partner. Which brings us to the so called "husband stitch".

This is how an episiotomy repair* looks like [WARNING, graphic drawing]. Basically, it's a two stage repair: first [A] you suture the vagina (think a ~horizontal axis, from back, inside the vagina, to front--towards the outside), then [B, C, D, or E] you suture the perineum (think ~vertical axis, from top, at the vaginal opening, to bottom, towards the anus, and back up).

[*If the link doesn't work for you: go here; click "Search inside this book"; enter "repair of median episiotomy" in Search box and click "GO"; click on "Page 327". I know, a bit cumbersome, but I assure you, the drawing is worth it.]

As you can deduce from the drawing, when you reapproximate the cut margins of the hymenal ring [A], with a final stitch, you bring the edges together, and up. This last throw is the famed, yet quite misunderstood "husband stitch". To be clear: you do not add extra stitches, and you do not alter the anatomy:

There are many ways to close an episiotomy incision, but hemostasis [control of bleeding] and anatomical restoration without excessive suturing are essential for success with any method.

I think a lot of misinformation stems from confusing episiotomy repair with other types of area procedures (e.g., repair of a torn, virginal hymen, repair of a poorly healed perineal laceration [a lot of medspeak, but look at pics 4, and 5 to get an idea; WARNING, graphic OR pictures]).

Bottom line: An episiotomy is not a cosmetic procedure, done to enhance the patient's, or her partner's sex life. It is also not indicated as a routine procedure. To insure the best possible outcome, discuss episiotomy with your doctor before the time of delivery, and, most importantly, make sure you have confidence in your doctor's clinical judgment. If you don't feel comfortable that he/she is guided by your best interest, pick another doctor.

[Tip: If you've had an episiotomy/laceration repair, keep some Dermoplast spray handy.]

Williams, 21ed p 325-8


At 11:30 AM, Anonymous Anonymous said...

Are you taking requests? I would love to hear about the standard of care as it relates to prescribing The Pill. I have endometriosis, and it's been easier for me to get prescriptions for narcotics than for The Pill!

At 12:41 PM, Anonymous missmeridian said...

thanks so much for this!

At 6:43 PM, Anonymous V's Herbie said...

::squirm:: really trying not to think about the physical realities of birthing a baby right now, but, wow, very thorough information as usual. thanks for being frank about things that so many doctors are uncomfortable with.

At 7:56 PM, Anonymous Anonymous said...

I had an episiotomy with (probably) a "husband stitch" -- made sex almost impossible for a year afterwards due to the pain and tightness. The doc stated after he stitched me up that "your husband is going to like this". Well, neither of us got any pleasure from it.

When I had my second child, I told the (different) doc to let me tear -- and it healed more quickly and was not at all painful once it did heal.

This was in the 80s, not all that long ago.

At 10:44 PM, Anonymous Anonymous said...

Yeesh. Yet another reason why I didn't go back to my OB-GYN after my daughter was born -- he did "the snip" as a matter of routine. (My husband did make sure to tell him not to "tighten her up" when the doc was sewing me back together.)


At 2:01 PM, Anonymous missmeridian said...

thanks again for your incredible website. i have another request - could you do a post on "premature puberty" [wherein girls begin menses at the age of 8-10] and the causes/treatment thereof?

At 5:51 PM, Anonymous Anonymous said...

So what, exactly, are the benefits of episiotomy? How do you define "restrictive use"?

As a former L&D nurse, I differ with your interpretation of the "husband stitch". Yes, it exists, though it is done somewhat less frequently than when our mothers were giving birth, and no it is not a result of confusion with other surgeries on the part of lay people.

One question about ease of repair-when you say an episiotomy is easier to repair than a vaginal tear, do you mean that it is less likely to be incompletely repaired (d/t the difficulty of approximating tissues with a tear) or easier in that it requires less attention and time from the physician?

What methods besides episiotomy are taught to prevent tearing?

At 7:24 PM, Blogger ema said...

Restrictive use means performing an episiotomy selectively, for either a maternal (in instances where it is obvious that failure to perform an episiotomy will result in perineal rupture), or fetal (shoulder dystocia) indication, rather than routinely.

As a former L&D nurse, I differ with your interpretation of the "husband stitch". Yes, it exists, though it is done somewhat less frequently than when our mothers were giving birth, and no it is not a result of confusion with other surgeries on the part of lay people.

Could you please give a brief description of what you believe to be the "husband stitch", and its relationship to episiotomy repair?

One question about ease of repair-when you say an episiotomy is easier to repair than a vaginal tear, do you mean that it is less likely to be incompletely repaired (d/t the difficulty of approximating tissues with a tear) or easier in that it requires less attention and time from the physician?

Neither. An episiotomy is easier to repair because you have better exposure to the area, and less bleeding. [?Incomplete repair: you either repair a tear, or you don't.]

What methods besides episiotomy are taught to prevent tearing?

Still the same ones; nothing new. Unfortunately, as you probably already know, it's still to be established if they work.

At 8:12 PM, Blogger ema said...


Not really taking requests, but let me see if I can help out with some information. Having endometriosis is not a contraindication for using the Pill. Quite the opposite. Women with symptomatic (e.g., pain) endometriosis can benefit from suppressing their period, hence they can benefit from using the Pill. [By preventing the cyclical hormone fluctuations, the Pill prevents cyclical flare ups in endometriotic tissue, and all the associated problems.]

Based on the limited info in your comment, quite frankly, it's unclear why you wouldn't be prescribed OCPs. The only explanation I could think of (OK, a bit of a stretch) is if you're currently trying to become pregnant.

I've heard of doctors not prescribing OCPs for women with uterine fibroids (because they're not aware it's not a contraindication), but endometriosis? Do you recall what reason the doctor gave you for not prescribing OCPs?

At 8:28 PM, Blogger ema said...


Still not feeling well enough to do a full post, but here's a good review article on precocious puberty.

At 6:53 PM, Anonymous Anonymous said...

Question about episitomy for shoulder dystocia: in shoulder dystocia, the shoulder is stuck on the pelvis. How is episiotomy helpful in resolving this? Have you seen or tried the Gaskin maneuver for shoulder dystocia?
My concern with restrictive use is that it is a pretty vague term-I've known docs who considered their use "restrictive" but I saw them cut nearly every time. It's still a step in the right direction from routine use.

The "husband stitch" is an extra stitch in the vaginal mucosa, performed during episiotomy repair. I'm glad to hear it isn't taught as standard practice any longer. Unfortunately, I've heard docs offer it or state they were placing it, as recently as the late 90s.

So is an episiotomy easier for the doctor or for the patient? If women have less pain and faster healing from a properly repaired tear, is that worth more effort and time from the doctor? I'm aware that the ideal is not to incompletely repair a laceration, but it obviously happens.

But what are the alternatives to episiotomy that you state are not been effective? I'm referring to upright positioning, pushing with the urge rather than coached pushing, slow delivery of head and shoulders, and perineal support during birth (as opposed to ironing or massaging the perineum). Are those things taught in med school, or are those the things you don't believe are effective? Have you seen/tried them? I've personally had good success with those techniques-at home and in the hospital. I've also had the opportunity to assist with both hospital and home births in which those interventions were major differences. (home birth moms were upright, pushed with the urge, panted to slow delivery of the head, mw supported perneum) There is a great difference in the number and severity of tears.

At 4:30 AM, Blogger ksjmom said...

Fascinating! Two of my children had shoulder dystocia - one had his shoulders completely transverse (9 lb., 10 1/2 oz. at 38 weeks) and the other who knows why. Neither time did I have an episitomy, but did have pretty significant lacerations. A 4th degree with our last, who was induced 2 weeks early due to her suspected size and the size of her older brother at birth. After repair of the initial laceration, I assume it was from the repair, my perineal body shortened - literally. My rectum moved. So, when #3 came along there was little "wiggle" room before I tore significantly anyway. I found your site looking for the name of the episiotomy used in shoulder dystocia, but to answer someone's question, they used on me McRobert's maneuver, suprapubic pressure, and gravity to help resolve the dystocia. With the first baby, he grabbed him under the arm pit and pulled him out, but the second one (who is #3), she was "stuck" with her head delivered for over 2 minutes and I'm not entirely sure how she reduced. She was, too, OP and asynclitic with a nuchal cord x 1. Anyway, that's my story. No husband stitch. :)

At 4:38 AM, Blogger hsvmom said...

My obgyn gave me the "husband stitch" in 2006 and again in 2008. Both times she told me that it was to "tighten me up" and used the term "husband stitch."


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