This past week, a news story gained traction in the media, about a woman who received an episiotomy against her will. The story raised several important questions.
Episiotomies are performed less frequently these days than they were in the past because of the injury they can cause, sometimes unnecessarily. This story has raised several questions from pregnant women and individuals in general: Just how often are episiotomies performed? When are they necessary and how often are they simply part of the routine? And what about patients’ rights?
An episiotomy is a surgical incision made in the perineum (the space between the vagina and rectum) that’s intended to create extra room for a baby’s head to emerge from the birth canal. Back in the 50’s and 60’s, episiotomies were a routine part of most hospital deliveries. It was thought that a “snip” was better than a tear and that an episiotomy would be easier for an obstetrician to stitch back together after delivery.
Gradually, the practice of routine episiotomies for most mothers gave way to more prudent practice as doctors came to understand that routine episiotomies actually did more harm than good. As The Agency for Healthcare Research and Quality states in The Use of Episiotomy in Obstetrical Care: A Systematic Review: Summary (May 2005): routine use is harmful to the degree that it creates a surgical incision of greater extent than many women might have experienced had episiotomy not been performed. In addition, many women tear beyond the episiotomy, which may not occur if their perineum had not already been cut.
In 1979, episiotomies were part of 61% of vaginal deliveries. In 2005, only 25% of births included episiotomies. The American College of Obstetricians and Gynecologists revised episiotomy guidelines in 2006 and rates dropped to 17%. By 2012 (most recent stats available), only 12% of births included a “snip.”
When is an episiotomy necessary? ACOG’s Episiotomy Procedure and Repair manual states: Indications for episiotomy are based primarily on the clinical situation at the time of delivery and, therefore, vary greatly depending on the opinion of the obstetrician. In general, [it] is indicated when shortening of the second stage of labor [pushing stage] and expediting the delivery of the infant is indicated. Situations that may fall in this category are clinical circumstances such as a nonreassuring fetal heart rate pattern, shoulder dystocia, or operative vaginal delivery [forceps].
Do you have the right to refuse an episiotomy? Absolutely. Every patient has the right to informed consent, defined as: The process by which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, including clinical trials, and then agrees to receive the treatment or participate in the trial.
The issue that seems to be at the heart of the matter in this case and pending lawsuit is whether informed consent automatically includes a patient’s right to informed refusal. And really, if there is no such thing as a right to informed refusal, is there such thing as informed consent?