Episiotomy in the United States: has anything changed?

OBJECTIVE: The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice. STUDY DESIGN: The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy. RESULTS: The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004. CONCLUSION: Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.