33. Episiotomy Surfaces Yet Again
Given my experience with Ethiopian midwives, and the consequences during my OB/GYN clerkship at Stanford when I was sent to the county hospital for not doing routine episiotomies, it is not surprising that, as our maternity care practice was developing in Montreal, I might again be questioning the routine use of episiotomy. The conventional idea that routine episiotomy helped both the mother and the baby just made no sense. It seemed to me that routine episiotomy would actually increase trauma to the mother, in part by increasing the likelihood that the surgical cut to the base of the vagina would extend into the rectum. Moreover, although the authoritative wisdom in the usual textbooks claimed that a straight surgical cut was easier to repair, this made no sense. Anyone who has had a paper cut knows this—a more irregular injury heals faster and better than a straight cut. That is not to say that there is never a place for episiotomy, but it is rarely needed.
We four family docs at the Herzl Family Practice Centre did not do routine episiotomy. But I wanted to go deeper into the history of the procedure. I began reading the main obstetric textbooks, from the 1920s to the 1980s. I was astonished to find that in the main textbook, the paragraph on the subject of episiotomy had not changed, word for word, since Dr. Joseph B. DeLee, the father of modern obstetrics, first advocated for the routine use of episiotomy in 1920.8
I thought seriously about subjecting episiotomy to formal study, partially inspired by mostly European randomized controlled trials (RCTs) of episiotomy that showed it to be unnecessary. But these RCTs were all midwifery trials and employed a different type of episiotomy than the North American standard. Thus, North American obstetricians could easily reject the results of these trials as irrelevant. I discussed the situation with my mentor and friend Dr. Murray Enkin. Dr. Enkin was an obstetrician and one of the three authors of A Guide to Effective Care in Pregnancy and Childbirth, which became the bible on how to conduct evidence-based obstetrical studies.
I first applied for funding to what was then the Medical Research Council of Canada, which rejected the proposal as irrelevant. Their obstetrical consultants could not understand why the procedure merited study, as they believed that all the evidence pointed to the benefit of routine episiotomy. “What’s to study? We know the benefits of routine episiotomy,” was the response of one reviewer. This was my first experience with how conventional wisdom can undercut any studies that contest the status quo.
Thus began a long saga of seeking funding, researching and publishing findings within an establishment that was determined to prevent change. Our proposed RCT was classic in its structure. It involved three hospitals in Montreal and had a unique feature—the measurement of pelvic floor functioning by electromyographic perineometry (kegelomentry). This resulted in a permanent record of the strength and pattern of pelvic muscle contraction, sort of like an electrocardiogram. No other trial had included this measurement, which added an objective scientific aspect that allowed us to see how episiotomy affected the pelvic floor and perineum. By including this measurement, I knew that, if successful, the results could not be ignored.
I applied to Health Canada for funding. While I was waiting to hear, life upstaged science.
