Surge of episiotomies in Pakistan: a call for better practices

Abstract

Dear Editor,

An episiotomy is a planned incision made through the perineal body to widen the vaginal opening and facilitate delivery during the second stage of labor. This intervention is among the most frequently performed procedures in the delivery room. It has been suggested that episiotomy may benefit the fetus by shortening the second stage of labor and reducing the risk of fetal skull fractures and cephalohematomas. Although episiotomy is a frequently performed surgical procedure globally, the decision to perform it depends on various factors and indications, such as fetal position, shoulder dystocia, breech delivery, fetal macrosomia, and assisted vaginal delivery using instruments like vacuum extractors or forceps.

As childbirth transitioned from a home-based natural process to a hospital-based medical procedure, episiotomy was initially recommended by clinicians to prevent maternal injury and improve fetal outcomes.¹ Current guidelines now advocate a more restrictive use of episiotomy, with the World Health Organization (WHO) recommending that it be performed in no more than 10% of normal deliveries. ² Despite this, there is an alarming increase in the rate of episiotomy, particularly among primigravida women in resource-limited countries such as Pakistan. A study by Majeed T, et al., reported an incidence of routine episiotomy of 80% in primigravida during normal vaginal delivery.³ A similar rate of 78% was reported by Khan N, et al., in Karachi,⁴ raising concerns regarding obstetric practices and emphasizing the need for a restrictive rather than routine use of episiotomy.

In comparison, rates in developed countries such as the United States have significantly declined, reaching 4.6% in 2022 compared to 67% in 2012. In France, the prevalence of episiotomy has been reported at 19.4%, while in the United Kingdom it ranges between 12% and 15%. In contrast, developing countries such as India, Oman, and Taiwan continue to report widespread use of episiotomy, with high rates of the procedure performed during vaginal deliveries.⁵

While episiotomy was originally intended to prevent complications such as postpartum pain, incontinence, and sexual dysfunction, evidence suggests that it may, in fact, contribute to these outcomes. Consequently, many experts recommend limiting the procedure to cases where significant perineal trauma is imminent. Modern medical practice has therefore shifted towards a more restrictive approach, abandoning the traditional liberal use of episiotomy.

The routine practice of episiotomy should be discouraged, as evidence shows no significant difference in outcomes between women undergoing vaginal delivery with or without episiotomy.⁶ Pregnant women should receive comprehensive antenatal counseling regarding the potential complications associated with episiotomy during and after delivery. Furthermore, regular training and awareness programs should be conducted for healthcare personnel and traditional birth attendants, such as LHVs and Dais, to highlight the benefits of normal vaginal delivery and discourage the routine use of episiotomy. In developing countries like Pakistan, where hospital-acquired infection rates are high and follow-up attendance is often poor, the routine use of episiotomy is particularly questionable. Adoption of evidence-based practices is essential to reduce its unnecessary use.