[Episiotomy - Childbirth Org] [Home Birth and Electronic Fetal Monitoring] [Birthing Center]

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Episiotomy: Ritual Genital Mutilation in Western Obstetrics

The practice of routinely cutting the perineum during hospital deliveries in the United States, episiotomy, has been shown to be the principal risk factor for severe tearing during delivery, which is the injury that it is supposed to prevent. Nonetheless American obstetricians continue to overuse this procedure ten times more often than is called for. Episiotomy is also a major risk factor for infection, loss of sexual pleasure, and incontinence. Women who have been subjected to episiotomies take longer to heal from delivery, even compared to women who have equivalent tears.

Given the completely unscientific, ritual approach obstetricians have to this practice, it illuminates the Western outrage over ritual genital mutilation of girls and women in East Africa, which also has many painful and disabling sequelae. Just as we reach out in solidarity with African feminists to stop genital mutilation in Africa, we need to stop the iatrogenic, unscientific practice of episiotomy in American obstetrics.

Outcomes of Routine Episiotomy A Systematic Review

Katherine Hartmann, MD, PhD
; Meera Viswanathan, PhD; Rachel Palmieri, BS; Gerald Gartlehner, MD, MPH; John Thorp, Jr, MD; Kathleen N. Lohr, PhD
JAMA.
 2005;293:2141-2148.
Evidence Synthesis 
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. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function—pain with intercourse was more common among women with episiotomy.
Conclusions 
Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.

 

Procedure On Women In Labor Adds Risk
Study Urges Halt To Episiotomies

By Rob Stein
Washington Post Staff Writer
Wednesday, May 4, 2005; A01

http://www.washingtonpost.com/wp-dyn/content/article/2005/05/03/AR2005050301206_pf.html

One of the most common surgical procedures performed in the United States -- an incision many pregnant women receive to reduce the risk of tissue tears during delivery -- has no benefits and actually causes more complications, according to the most comprehensive analysis to evaluate the practice.

Contradicting the long-accepted rationale for the procedure, called an episiotomy, the analysis found that it increases the risk of tissue tears, leading to more pain, more stitches and a longer recovery after childbirth. In addition, an episiotomy 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 be considered only to speed delivery when the health of the baby is at risk.

"The evidence is clear: Routine use of episiotomy is not supported by research and should stop," said Katherine E. Hartmann, director of the Center for Women's Health Research at the University of North Carolina at Chapel Hill, who led the analysis published in today's issue of the Journal of the American Medical Association. "Women need to know this information so they can talk with their care providers before they are in labor."

Other experts agreed, saying the procedure is an example of a broader problem in medicine: Many practices that became common before their effectiveness was tested have become ingrained by tradition and continue to be practiced well after their usefulness has been questioned by research.

"Routine episiotomy clearly is not necessary," said Laura Riley, director of labor and delivery at Massachusetts General Hospital in Boston who chairs the obstetrics practice committee for the American College of Obstetricians and Gynecologists. "This is a message that's been out there that's clearly taken a long time to get universally accepted and universally implemented."

The new analysis was conducted for the Agency for Healthcare Research and Quality, a federal agency that conducts influential evaluations of medical procedures, at the request of the college amid growing frustration that the procedure was still being done routinely despite strong evidence questioning its usefulness, Hartmann said.

"There was a sense that without attention being focused on this, we might be stuck with these very high rates for a very long time," she said.

An episiotomy is an incision that doctors make in the perineum -- the skin between the opening of the vagina and anus. The idea is that the incision will make delivery of a child easier and that a deliberate surgical incision will heal more quickly and with fewer complications than tears that occur spontaneously, minimizing the risk of sexual problems and other complications, such as incontinence. Because the procedure has been in widespread use since the 1930s, it has been subject to careful evaluation only fairly recently.

The number of episiotomies began to decrease in the United States in the 1980s when studies started raising questions about their value. But the procedure is still estimated to be performed in about one-third of all vaginal births -- more than 1 million of the estimated 4.2 million vaginal births that occur each year, making it more common than hysterectomies and Caesarean section deliveries. The rate varies widely around the country, but overall about 70 to 80 percent of first-time mothers undergo episiotomies.

For the study, Hartmann and colleagues scoured the medical literature for all studies on the subject between 1950 and 2004, finding 986. The researchers then identified 45 studies that provided the best data, including 26 that provided the most useful information on benefits and risks, and pooled that information for the new analysis.

Based on that data, the researchers found that women who had not undergone the procedure were no more likely to experience spontaneous tears during childbirth than those who had. In fact, those who underwent the procedure appeared somewhat more prone to tears, the researchers found.

"If you have a piece of fabric, it doesn't tear well until you get it started. The episiotomy can have that effect of actually being the starting place for a tear," Hartmann said.

As a result, women who have had episiotomies tend to need more stitches and experience more pain after childbirth, the researchers found. Women who underwent episiotomies had a 26 percent higher risk of requiring sutures.

Moreover, women who had episiotomies were no less likely to experience urinary or fecal incontinence in the three months to five years after delivery, the study found. Rather, women with episiotomies were twice as likely to suffer fecal incontinence in the first three months.

Those with episiotomies were also 53 percent more likely to suffer pain during intercourse three months after delivery.

"There's a lot of unnecessary suffering occurring to women because of the use of episiotomies," said Carol Sakala of the Maternity Center Association, a private, nonprofit group based in New York. "It's really tragic."

Sakala noted that the rate of Caesarean section deliveries has been increasing in the United States, in part because of women's fears of complications from vaginal deliveries. Unnecessary episiotomies may be a key contributing factor to those complications, she said.

"We need to send a very clear message to women and their providers," Sakala said. "The evidence clearly says that performing routine episiotomies offers none of the benefits that have been presumed in the past and in many cases offer severe harm."
 

 

  • Episiotomy Use in the United States, 1979–1997
    Anne M. Weber, Leslie Meyn    Obstetrics and Gynecology 2002;100:1177-1182.

    Although the episiotomy rate declined from 1979 to 1997, the rate in 1997 of 39 per 100 vaginal deliveries is higher than scientific evidence supports.
     

Surgical Cut in Childbirth Still Too Common-Report
(December 29, 2002)

By Jacqueline Stenson

NEW YORK (Reuters Health) - The number of women in childbirth who receive episiotomies--incisions to widen the birth canal--is declining but still too high, researchers say.  Nationwide figures estimate that episiotomies were performed in 39% of vaginal deliveries in 1997, down from 65% in 1979.  

"I expected the number to decrease, but I was hoping to see it decrease even more," said study author Dr. Anne Weber, an associate professor of obstetrics and gynecology at the University of Pittsburgh School of Medicine.

There is no consensus on what the ideal episiotomy rate should be, but current evidence indicates that "rates higher than 20% couldn't be justified," Weber told Reuters Health.

And some studies have found that even lower rates--of 10% or less--resulted in good outcomes for both mothers and babies, she noted in the study, published in the December issue of Obstetrics and Gynecology.

So why are so many episiotomies still performed? "People who were trained in an era when routine episiotomy was standard have not changed their practices," Weber said.

About two decades ago some doctors began questioning whether every woman having a vaginal delivery needed an episiotomy, but the practice really came under fire in the last decade, she noted.

"Routine episiotomy does not offer advantages to the patient and actually offers disadvantages," she said. The most severe are anal sphincter lacerations that can result in long-term fecal incontinence and the inability to control gas in as many as half of patients who experience these lacerations.

When a doctor makes the incision, that cut may continue tearing on its own and rip into anal tissue, Weber explained. Such severe, difficult-to-fix damage is much less likely when the vaginal opening tears naturally, she said.

In the study, anal sphincter lacerations occurred in 1 in 12 women who received episiotomies compared with 1 in 26 who did not. Weber said most doctors would probably agree that an episiotomy is warranted when the baby is stuck in the birth canal and at risk for respiratory distress because the head has been delivered but the chest has not. But beyond that, there are a lot of gray areas. For instance, many doctors still do episiotomies when they use forceps or vacuum devices to help deliver babies, but episiotomies for this purpose are declining and physicians do not agree on whether the practice is beneficial, she said.

The new study results were derived from the National Hospital Discharge Survey, a federal database of a sampling of US hospitals.  Findings also showed that younger women, white women and those with private insurance were among the groups most likely to receive episiotomies.

While there are no national episiotomy figures beyond 1997, the rate has probably continued to decline, Weber said, noting that some regional studies show a more recent, persistent downward trend.

 


 

  • Influence of Alternative Birth Methods on Traditional Birth Management.    Eberhard J, Geissbuhler V. Fetal Diagn Ther 2000 Oct;15(5):283-290.
    Because of popular demand for more natural childbirth, a new concept was introduced in 1991 in our clinic. It consisted of careful monitoring and birth management, restrictive use of invasive methods, and free choice of different birth methods including waterbirths and other alternative birth methods. ....The episiotomy rate has dropped from a previous rate higher than 80% to a rate lower than 15%.

  • Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals. Shorten A, Shorten B. Midwifery 2000 Sep;16(3):204-212
    Objective: to assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies....Results: after controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. 

  • Minimizing postpartum pain: a review of research pertaining to perineal care in childbearing women. Calvert S, Fleming V. J Adv Nurs 2000 Aug;32(2):407-15

  • Obstetric risk factors for stress urinary incontinence: a population-based study(1). Persson J, Wolner-Hanssen P, Rydhstroem H. Obstet Gynecol 2000 Aug 23;96(3):440-445.
    We linked three national, Swedish, population-based registries with the use of unique personal identification numbers.... All women born between 1932 and 1977 and operated on for stress urinary incontinence between 1987 and 1996 were identified from the Hospital Discharge Registry. Diabetes mellitus, body mass index (BMI), age at first delivery, parity, birth weight, and epidural analgesia were positively associated with incontinence surgery. In contrast, cesarean delivery, forceps/vacuum extraction, and episiotomy were negatively associated with incontinence surgery. 

  • Predictors of episiotomy use at first spontaneous vaginal delivery.  Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Obstet Gynecol 2000 Aug;96(2):214-8.
    We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham & Women's Hospital between December 1, 1994 and July 31, 1995....The overall rate of episiotomy was 40.6% (640 of 1576). Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%) and private providers (55.6%) (P =. 001). After controlling for confounding factors with logistic regression, private practice provider was the strongest predictor of episiotomy use (OR, 4.1; 95% CI, 3.1, 5.4) followed by faculty provider (OR, 1.7; 95% CI, 1.1, 2.5), prolonged second stage of labor (OR, 1.8; 95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6; 95% CI, 1.1, 2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8). 

  • Severe perineal lacerations during vaginal delivery: the University of Miami experience.  Angioli R, Gomez-Marin O, Cantuaria G, O'sullivan MJ. Am J Obstet Gynecol 2000 May;182(5):1083-5.
    For 50,210 women in the seven year study,  episiotomy and the type of episiotomy as well as birth weight, assisted vaginal delivery, and older maternal age were identified as independent risk factors associated with third- and fourth-degree perineal lacerations... Older patients who are being delivered of a first child are at higher risk for severe laceration. Midline episiotomy and assisted vaginal delivery should therefore be avoided in this population whenever possible, especially in the presence of a large baby.

  • Clinician-specific episiotomy rates: impact on perineal outcomes. 
    Low LK, Seng JS, Murtland TL, Oakley D. J Midwifery Womens Health 2000 Mar-Apr;45(2):87-93.
    Recent, large, randomized, controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum. Yet episiotomy remains the most common surgical procedure women undergo... Multivariate findings indicate that in the absence of episiotomy, rates of perineal integrity were highest among clinicians who usually had the lowest rate of episiotomy use. When an episiotomy was done, rates of third- and fourth-degree extensions were highest among clinicians who used episiotomy most frequently. This finding challenges the idea that clinicians who were very experienced with the use of episiotomy would avoid complications such as extensions.

  • Episiotomy for vaginal birth.  Carroli G, Belizan J.  Cochrane Database Syst Rev 2000;(2):CD000081.
    Compared six studies comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy. Compared with routine use, restrictive episiotomy involved less posterior perineal trauma, less suturing and fewer healing complications. Restrictive episiotomy was associated with more anterior perineal trauma. There was no difference in severe vaginal or perineal trauma; dyspareunia; urinary incontinence or several pain measures.  Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

  • Continuity of caregivers for care during pregnancy and childbirth. Hodnett ED. Cochrane Database Syst Rev 2000;(2):CD000062.
    Compared to usual care, women who had continuity of care from a team of midwives were less likely to be admitted to hospital antenatally and more likely to attend antenatal education programs. They were also less likely to have drugs for pain relief during labour  and their newborns were less likely to require resuscitation. No differences were detected in Apgar scores, low birthweight and stillbirths or neonatal deaths. While they were less likely to have an episiotomy, women receiving continuity of care were more likely to have either a vaginal or perineal tear. They were more likely to be pleased with their antenatal, intrapartum and postnatal care. 

  • "Cut out routine episiotomies, Canadian researchers say," Medical Post, 36(26), July 18, 2000.

  • Episiotomy: Challenging Obstetric Interventions  by Ian D. Graham

  • Carroli G, Belizan J, Stamp G. Episiotomy for vaginal birth (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software. A meta-analysis performed on the studies collected in the Cochrane Pregnancy and Childbirth Group trials register. Six studies were included. In the routine episiotomy group, 72.7% (1752/2409) of women had episiotomies, while the rate in the restrictive episiotomy group was 27.6% (673/2441). Compared with routine use, restrictive episiotomy involved less posterior perineal trauma (relative risk 0.88, 95% confidence interval 0.84 to 0.92), less suturing (relative risk 0.74, 95% confidence interval 0.71 to 0.77) and fewer healing complications (relative risk 0.69, 95% confidence interval 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (relative risk 1.79, 95% 1.55 to 2.07). There was no difference in severe vaginal or perineal trauma (relative risk 1.11, 95% confidence interval 0.83 to 1.50); dyspareunia (relative risk 1.02, 95% confidence interval 0.90 to 1.16); urinary incontinence (relative risk 0.98, 95% confidence interval 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison. Reviewers' conclusions: Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

  • "The Tragedy of Routine Episiotomy", from Henci Goer's Obstetric Myths Versus Research Realities, 1995.

  • Gentlebirth's Page on Perineal Protection / Avoiding Tears and Episiotomy

  • Episiotomies -- Medical Myth versus Reality, Cheri Van Hoover, C.N.M.

  • Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I and II. Obstet Gynecol Survey 1995; 50:806-820. Conclusion: The English-language literature published since 1980 on the benefits and risks of episiotomy can be summarized as follows: Episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.

  • Renfrew MJ. Hannah W. Albers L. Floyd E. [Mother and Infant Research Unit, University of Leeds, United Kingdom. ] Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. [Review] Birth. 25(3):143-60, 1998 Sep. BACKGROUND: Trauma to the genital tract commonly occurs at birth, and can cause short- and long-term morbidity. Clinical measures to reduce its occurrence have not been fully identified. METHODS: A systematic review of the English language literature was conducted to describe the current state of knowledge on reduction of genital tract trauma before planning a large randomized controlled trial of ways to prevent such trauma. Randomized trials and other published reports were identified from relevant databases and hand searches. Studies were reviewed and assessed using a structured format. RESULTS: A total of 77 papers and chapters were identified and placed into 5 categories after critical review: 25 randomized trials, 4 meta-analyses, 4 prospective studies, 36 retrospective studies, and 8 descriptions of practice from textbooks. The available evidence is conclusive in favor of restricted use of episiotomy. The contribution of maternal characteristics and attitudes to intact perineum has not been investigated. Several other topics warrant further study, including maternal position, style of pushing, and antenatal perineal massage. Strong opinions and sparse data exist regarding the role of hand maneuvers by the birth attendant for perineal management and birth of the baby. This became the topic of the planned randomized controlled trial, which was completed; results will be published soon. CONCLUSIONS: The case for restricting the use of episiotomy is conclusive. Several other clinical factors warrant investigation, including the role of hand maneuvers by the birth attendant in preventing birth trauma. A large randomized controlled trial will report on this topic.

  • Wood J. Amos L. Rieger N. [Department of Obstetrics and Gynaecology, Flinders Medical Centre, Adelaide, South Australia. ] Third degree anal sphincter tears: risk factors and outcome. Australian & New Zealand Journal of Obstetrics & Gynaecology. 38(4):414-7, 1998 Nov. The aim of this retrospective study was to determine the incidence, risk factors and anal symptoms related to third degree tears after vaginal delivery. There were 9,631 vaginal deliveries during the 5-year period studied, with 116 (1.2%) having a third degree tear. Statistically significant risk factors for a third degree tear were primiparity, forceps delivery, episiotomy, fetal birth-weight greater than 4,000 g and increased duration of the second stage of labour. Eighty four of the 116 women were able to be interviewed, and 21 (25%) had anal symptoms related to the tear. Only 3 women had sought help for their symptoms. Twelve women experienced anal incontinence and 2 more required delayed repair of the anal sphincter for incontinence. Third degree tears are a major cause of perinatal and postnatal morbidity. Attention needs to be directed to the prevention of such tears by awareness of the women at risk and to better follow-up and counselling of the women sustaining a tear.

  • Fatton B. Jacquetin B. [Unite d'urogynecologie Centre hospitalo-universitaire Maternite de l'Hotel-Dieu, Clermont-Ferrand. ] [Pelvic and perineal sequelae of delivery]. [Review] [French] Revue du Praticien. 49(2):160-6, 1999 Jan 15. Vaginal delivery especially with dystocia, may result in relaxation or disruption of fascial and ligamentous supports of pelvic organs. The relationship between first childbirth and obstetric trauma is strong but additional pregnancies and deliveries are aggravating factors as well as ageing and hormonal effects of the menopause. These anatomic changes are contributing to the development of stress urinary incontinence, anal incontinence and genital prolapse. Preventing obstetric trauma needs changes in current obstetric practice: reduction in the episiotomy rate, use of vacuum extractor in preference to forceps. General practitioners can help at the time of postnatal control by making a full clinical evaluation of pelvic floor damage, referring women for further investigation and asking them about postnatal sexual difficulties. Postpartum perineal physiotherapy is indicated for women at risk: pelvic floor congenital weakness instrumental delivery, postpartum urinary and/or anal incontinence.

  • Williams FL. du V. Florey C. Mires GJ. Ogston SA. [Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School. ] Episiotomy and perineal tears in low-risk UK primigravidae. Journal of Public Health Medicine. 20(4):422-7, 1998 Dec. BACKGROUND: The aim of the study was to determine the rates and to describe the risk factors for episiotomy and perineal tears in low-risk primigravidae. METHOD: A cross-sectional survey of 101 randomly selected NHS hospitals in the UK was carried out between February 1993 and January 1994. Subjects were 40 consecutive low-risk primigravidae in each hospital. The main outcome measures were number and reasons for episiotomy, and number and degree of perineal tears. RESULTS: A large proportion of women (83 per cent) experienced some form of perineal trauma. Forty per cent of the women had an episiotomy only, 6 per cent an episiotomy and perineal tear, and 37 per cent perineal or other tears without episiotomy. The main reasons for performing an episiotomy were foetal distress (27 per cent), impending tear (25 per cent) and delay of the second stage of labour (21 per cent). Fifty-nine per cent of women with a delayed second stage had a spontaneous vaginal delivery and 41 per cent required instrumental assistance. The likelihood of having an episiotomy increased with the duration of the second stage of labour, irrespective of type of delivery. Episiotomy rates varied appreciably throughout regions and hospitals in the United Kingdom, ranging from 26 to 67 per cent. There was also a large regional variation in the rates of perineal trauma; generally, high rates of one outcome were associated with low rates of the other. Compared with white women, women from the Indian sub-continent were almost twice as likely and those from the Orient almost five times as likely to have an episiotomy. CONCLUSIONS: The magnitude of the geographical variation suggests a lack of uniformity in indications for performing episiotomies and that guidelines for performing episiotomies may need to be reviewed. The rates of episiotomy in women from the Indian sub-continent and Orient were very high compared with those for white women, and this requires clarification and explanation, as they are contrary to rates experienced in these ethnic groups in other countries.

  • Bomfim-Hyppolito S. [Universidade Federal do Ceara, Fortaleza, Brazil. ] Influence of the position of the mother at delivery over some maternal and neonatal outcomes. International Journal of Gynaecology & Obstetrics. 63 Suppl 1:S67-73, 1998 Dec. OBJECTIVE: Evaluate possible advantages or disadvantages of the sitting over the horizontal position during the second stage of labor. DESIGN AND METHODS: Clinical trial randomly selecting 127 volunteers for the sitting position and 121 for the horizontal position during the second stage of labor. Duration of the second stage and of expulsion of the placenta, vulvo vaginal and perineal lacerations, blood lost and Apgar score were evaluated. RESULTS: There was a non-significant decrease of 3.4 min in the duration of the second period in the vertical position in comparison with the horizontal position. There was a similar difference in the duration of delivery of the placenta, but also non-significant. Blood loss was slightly greater among women delivering in vertical position, but the difference did not reach significance. Breastfeeding did not show any influence on blood loss and on the time for delivering the placenta. The incidence of perineal trauma was 44.1% for vertical position and 47% for horizontal position in the whole group and of 47.8% and 71.2% in the group with history of episiotomy. This last difference was statistically significant. The results of this study are in the line of other studies that suggest some advantages and possible disadvantages of the vertical position. CONCLUSIONS: Mothers should be given the choice of the posture to be assumed during parturition. The supine position should not be imposed and episiotomy should not be a routine.

  • McCandlish R. Bowler U. van Asten H. Berridge G. Winter C. Sames L. Garcia J. Renfrew M. Elbourne D. [National Perinatal Epidemiology Unit, Oxford, UK. ] A randomised controlled trial of care of the perineum during second stage of normal labour. British Journal of Obstetrics & Gynaecology. 105(12):1262-72, 1998 Dec. OBJECTIVE: To compare the effect of two methods of perineal management used during spontaneous vaginal delivery on the prevalence of perineal pain reported at 10 days after birth. DESIGN: Randomised controlled trial. SETTING: Two English maternity care units. SAMPLE: 5471 women who gave birth between December 1994 and December 1996. METHODS: At the end of the second stage of labour women were allocated to either the 'hands on' method, in which the midwife's hands put pressure on the baby's head and support ('guard') the perineum; lateral flexion is then used to facilitate delivery of the shoulders, or the 'hands poised' method, in which the midwife keeps her hands poised, not touching the head or perineum, allowing spontaneous delivery of the shoulders. MAIN OUTCOME MEASURE: Perineal pain in the previous 24 hours reported by women in self-administered questionnaire 10 days after birth. RESULTS: Questionnaires were completed by 97% of women at 10 days after birth. 910 (34.1%) women in the 'hands poised' group reported pain in the previous 24 hours compared with 823 (31.1%) in the 'hands on' group (RR 1.10, 95% CI 1.01 to 1.18: absolute difference 3%, 0.5% to 5%, P = 0.02). The rate of episiotomy was significantly lower in the 'hands poised' group (RR 0.79, 99% CI 0.65 to 0.96, P = 0.008) but the rate of manual removal of placenta was significantly higher (RR 1.69, 99% CI 1.02 to 2.78; P = 0.008). There were no other statistically significant differences detected between the two methods. CONCLUSION: The reduction in pain observed in the 'hands on' group was statistically significant and the difference detected potentially affects a substantial number of women. These results provide evidence to enable individual women and health professionals to decide which perineal management is preferable.

  • Hagymasy L. Gaal J. [Department of Obstetrics and Gynaecology, Borsod-Abauj-Zemplen County Hospital, Miskolc, Hungary. ] A comparative study of vertical and horizontal deliveries in the presence and with the assistance of the woman's partner.Journal of Psychosomatic Obstetrics & Gynecology. 19(2):98-103, 1998 Jun. The authors are the first in Hungary to have applied the method of vertical delivery with the husband's or partner's presence in the delivery room. This is part of the authors' family-centered delivery program at the Maternity Ward of Borsod-Abauj-Zemplen County Hospital, Miskolc. A comparison of 321 births was carried out, which included 158 vertical deliveries and 163 horizontal deliveries. During both vertical and horizontal deliveries, the husband or partner was present in the delivery room. The comparison included the mother's biometrics and social characteristics, as well as the circumstances of the delivery and the clinical parameters of the newborns. Certain stages of delivery in the vertical position took a shorter period of time compared to horizontal delivery, but the differences were not significant. Episiotomies were carried out in fewer cases of vertical deliveries, and significant injuries due to the lack of an episiotomy in the case of vertical deliveries were not detected. The parameters characterizing the clinical state of the newborns were the same in both groups. The answers given to questionnaires supported the favorable psychological effects of a vertical delivery. The authors hope that vertical delivery, as a possible alternative, will find its place in obstetric practice in Hungary.

  • Lorenz N. Nougtara A. Garner P. [Support Centre for International Health, Swiss Tropical Institute, Basel, Switzerland. ] Episiotomy in Burkina Faso. Tropical Doctor. 28(2):83-5, 1998 Apr. Episiotomy is a common obstetric intervention in many countries of the world, although little is known about rates in African countries. In recent years, the effectiveness of routine episiotomy to prevent severe tears and neonatal asphyxia has been questioned, and evidence shows that the procedure results in considerable maternal morbidity. This study estimates episiotomy rates in Burkina Faso. A high proportion of primigravidae (46%) received an episiotomy when trained midwives attended the delivery; a level which indicates the procedure has to be regarded as routine practice. The episiotomy rate was lower (26%) in primigravidae delivered by auxillary midwives. This proportion is closer to recommended selective approaches derived from good research summaries. The tear rate in women assisted by midwife and auxiliary staff was similar, suggesting that women tear even when the procedure is performed. These results indicate that obstetricians and midwives in Burkina Faso should critically appraise whether routine episiotomy should be abandoned. The introduction of a labour chart is a good vehicle to introduce a policy on avoiding episiotomies.

  • Cravchik S. Munoz DM. Bortman M. [Hospital Neuquen, Servicio de Obstetricia, Argentina. ] [Indications for episiotomy at public maternity clinics in Nequen, Argentina]. [Spanish] Pan American Journal of Public Health. 4(1):26-31, 1998 Jul. Indications for performing episiotomy during vaginal births are a controversial topic requiring worldwide review. In Neuquen Province, Argentina, when standards for low-risk childbirth were developed in 1995, they included the provision to limit episiotomies to cases at high risk for spontaneous laceration. The present retrospective cohort study was designed for comparing the criteria applied in 1996 as indications for episiotomy in public maternity services of Neuquen Province, as well as the effect of parity and other variables on its frequency. The Perinatal Data System yielded 7,513 medical records for review, which represented 70% of all the institutional births during the year. Of these records, 830 dealing with cesarean sections did not qualify for the study. The remaining 6,683 records were divided into eight groups according to hospital location. Episiotomy incidence rates were estimated for those eight groups and the Poisson regression was applied in order to adjust for birthweight, number of siblings, mother's age, and type of birth presentation and outcome. Taking the Neuquen Hospital data as baseline because of its higher complexity and large number of births taking place there, two hospitals had episiotomy incidence rates equal to 70% (95% CI: 62%-79%) and 67% (95% CI: 57%-78%) of the Neuquen Hospital rates. Two other hospitals had incidence rates which were higher by 28% (95% CI: 13%-45%) and 17% (95% CI: 2-35%), while the remaining hospitals showed no significant differences. Stratified regression by number of previous vaginal births showed parity to be the strongest influencing variable on indications for episiotomy. Rates for nulliparous women showed no differences by hospital, but rates for primiparous women did, with even stronger differences shown for multiparous women. The authors concluded that all institutions included in the study performed episiotomies as a virtually routine procedure on nulliparous women, that there are significant differences in their indications for primiparous women, and that those differences increase along with parity. These differences seem to show that maternity clinics in the Province of Neuquen vary widely in their criteria for episiotomy indications.

  • Kaczorowski J. Levitt C. Hanvey L. Avard D. Chance G. [Department of Family Medicine, Facultyy of Health Sciences, McMaste University, Hamilton, Ont., Canada. ] A national survey of use of obstetric procedures and technologies in Canadian hospitals: routine or based on existing evidence?. Birth. 25(1):11-8, 1998 Mar. BACKGROUND: The objective of this national survey was to describe the routine use of procedures and technologies in Canadian hospitals providing maternity care, and to determine the extent to which current use was consistent with the existing evidence and recommended guidelines for maternal and newborn care. METHODS: Representatives of 572 hospitals providing maternity care across Canada were sent questionnaires in the spring and summer of 1993; 523 (91.4%) responded. The primary outcome measures consisted of the self-reported use of obstetric procedures and technologies (perineal shaves, enemas/suppositories, intravenous infusions, initial and continuous electronic fetal heart monitoring, episiotomy rates). Hospitals were grouped according to location, size (number of live births per year), and university affiliation status. RESULTS: The hospitals in the Prairie provinces, in Quebec, and in the Atlantic provinces were significantly less likely than those in Ontario to restrict their use of perineal shaves and enemas to women on admission in labor. Small hospitals were significantly more likely than large hospitals ( 1000 live births) to restrict their use of intravenous infusions, and initial and continuous electronic fetal monitoring. The university-affiliated and nonteaching hospitals were significantly less likely than the university teaching hospitals to have episiotomy rates of less than 40 percent for primiparous women. Small hospitals were more likely than large hospitals to report episiotomy rates of less than 20 percent for multiparous women. CONCLUSIONS: Considerable variations occur in the routine use of obstetric procedures and technologies in Canadian hospitals providing maternity care, according to hospital location, size, and university affiliation status. Despite the existing evidence suggesting that the routine use of these practices and procedures is both unnecessary and potentially harmful, a significant number of Canadian hospitals continued to use them routinely in 1993.

  • Way S. [Institute of Health and Community Studies, University of Bournemouth, UK. ] Social construction of episiotomy. [Review] Journal of Clinical Nursing. 7(2):113-7, 1998 Mar. This article explores the meaning of episiotomy. A review of the literature examines the definition, procedure, perceptions and outcomes of episiotomy to create a better understanding for those using or experiencing its practice. The article highlights that episiotomy means more than just a cut in the perineum. Episiotomy means different things to different individuals and groups, the meaning being socially constructed depending on social context, professional background and personal experience. It is concluded that midwives need to understand what an episiotomy means to women, and that through research midwives need to develop their own body of knowledge of childbirth from the viewpoints of those who are actually experiencing it.

 

 

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Haadem K. [Review of the literature on advantages and disadvantages: episiotomy: only limited protection against ruptures--time for a revision?]. [Swedish] Lakartidningen. 95(40):4354-8, 1998 Sep 30. A review of the literature on the pros and cons of episiotomy suggests that it should be used restrictively. Although there is a general agreement that episiotomy is protective against anterior perineal tears, no evidence has been found to support the belief that it is protective against anal sphincter muscle tears, pelvic muscle damage or urinary incontinence in the parturient or intracranial haemorrhage or intrapartum asphyxia in the newborn. Women undergoing episiotomy are characterised by greater blood loss in conjunction with delivery, and there is a risk of improper wound healing and increased pain during the early puerperium. The prevalence of episiotomy in Sweden has been declining over the past 20 years, and is now approximately five per cent among multiparae and fifteen per cent among primiparae.

Maduma-Butshe A. Dyall A. Garner P. Routine episiotomy in developing countries. Time to change a harmful practice [editorial]. BMJ. 316(7139):1179-80, 1998 Apr 18.

Kaczorowski J. Levitt C. Hanvey L. Avard D. Chance G. A national survey of use of obstetric procedures and technologies in Canadian hospitals: routine or based on existing evidence?. Birth. 25(1):11-8, 1998 Mar. BACKGROUND: The objective of this national survey was to describe the routine use of procedures and technologies in Canadian hospitals providing maternity care, and to determine the extent to which current use was consistent with the existing evidence and recommended guidelines for maternal and newborn care. METHODS: Representatives of 572 hospitals providing maternity care across Canada were sent questionnaires in the spring and summer of 1993; 523 (91.4%) responded. The primary outcome measures consisted of the self-reported use of obstetric procedures and technologies (perineal shaves, enemas/suppositories, intravenous infusions, initial and continuous electronic fetal heart monitoring, episiotomy rates). Hospitals were grouped according to location, size (number of live births per year), and university affiliation status. RESULTS: The hospitals in the Prairie provinces, in Quebec, and in the Atlantic provinces were significantly less likely than those in Ontario to restrict their use of perineal shaves and enemas to women on admission in labor. Small hospitals were significantly more likely than large hospitals (> 1000 live births) to restrict their use of intravenous infusions, and initial and continuous electronic fetal monitoring. The university-affiliated and nonteaching hospitals were significantly less likely than the university teaching hospitals to have episiotomy rates of less than 40 percent for primiparous women. Small hospitals were more likely than large hospitals to report episiotomy rates of less than 20 percent for multiparous women. CONCLUSIONS: Considerable variations occur in the routine use of obstetric procedures and technologies in Canadian hospitals providing maternity care, according to hospital location, size, and university affiliation status. Despite the existing evidence suggesting that the routine use of these practices and procedures is both unnecessary and potentially harmful, a significant number of Canadian hospitals continued to use them routinely in 1993.

North Dakota's Genital Integrity Law, passed in 1995, prohibits the cutting of genitals of minors. If a young woman chose to take her episiotomy to court in North Dakota, she would likely win. For more information: jody@minot.com

Ciolli P, et al. "[Episiotomy: can its habitual use be defended? A study of 100 puerperae and a group of gynecologists and midwives]". Minerva Ginecol. 1997 May 1; 49(5): 187-191. Italian. The authors studied vaginal delivery with and without episiotomy, during the period 1993-1994. The aim of this study was to examine 100 puerperal women and a group of gynecologists and midwives, to evaluate the benefits and risks of routinely used medical procedures, and to understand the rational of the procedure and put in evidence the indications on which decisions were based. RESULTS: This study does not indicate that episiotomy offers a clear benefit to primipara in terms of decreased numbers of risk factors, while it is indicated in laborious vaginal delivery. The opinion of sanitary operators about this procedure is favourable especially for primiparas, but however this does not necessarily mean that more routine episiotomy can be justified.

Maier JS, et al. "Nurse advocacy for selective versus routine episiotomy. " Journal of Obstetric Gynecologic Neonatal Nursing. 1997 Mar 1; 26(2): 155-161. Although episiotomy is one of the most commonly performed surgeries, little scientific support exists for this procedure. Furthermore, the suggested advantages of routine episiotomy are challenged easily and the surgery is not without risks. Adverse effects arising from episiotomy include an increased incidence of severe lacerations, blood loss, pain, delayed healing, dyspareunia, psychologic trauma, and medical cost. Nurses can assist women in avoiding perineal trauma resulting from unnecessary episiotomy through patient education, patient advocacy, and direct care.

Handa VL, Harris TA, Ostergard DR "Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse" Obstetrics and Gynecology 1996 Sep;88(3): 470-478 . OBJECTIVES: To review the literature regarding the effects of childbirth on the muscles, nerves, and connective tissue of the pelvic floor, review the evidence to support an association between childbirth and anal incontinence, urinary incontinence, and pelvic organ prolapse; and present recommendations for the prevention of these sequelae. DATA SOURCES: Sources were identified from a MEDLINE search of English-language articles published from 1984 to 1995. Additional sources were identified from references cited in relevant research articles. METHODS OF STUDY SELECTION: We studied articles on the following topics: anatomy of the pelvic floor association of childbirth with neuromuscular injury, biomechanical and morphologic alterations in muscle function, and connective tissue structure and function; the long-term effects of childbirth on continence and pelvic organ support; and the effects of obstetric interventions on the pelvic floor. TABULATION, INTEGRATION, AND RESULTS: Articles were reviewed and summarized. An overview of the structure and function of the pelvic floor was developed to provide a context for subsequent data. Childbirth was found to be associated with a variety of muscular and neuromuscular injuries of the pelvic floor that are linked to the development of anal incontinence, urinary incontinence, and pelvic organ prolapse. Risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size. Cesarean delivery appears to be protective, especially if the patient does not labor before delivery. CONCLUSION: The pelvic floor plays an important role in continence and pelvic organ support. Obstetricians may be able to reduce pelvic floor injuries by minimizing forceps deliveries and episiotomies, by allowing passive descent in the second stage, and by selectively recommending elective cesarean delivery.

Lede RL, Belizan JM, Carroli G "Is Routine Use of Episiotomy Justified?" American Journal of Obstetrics & Gynecology. vol 174 No 5 May 1996: 1399-1402. Episiotomy, one of the most common surgical procedures, was introduced in clinical practice in the eighteenth century without having strong scientific evidence of its benefits. Its use was justified by the prevention of severe perineal tears, better future sexual function, and a reduction of urine and fecal incontinence. With regard to the first assumption, the evidence that is based on five randomized controlled trials shows a 9% reduction in severe perineal tears in the selective use of episiotomy, but this effect fluctuates between a 40% reduction and a 38% increase. In relation to long-term effects, women in whom management includes routine use of episiotomy have shown poorer future sexual function, similar pelvic floor muscle strength, and similar urinary incontinence in comparison with women in whom episiotomy is used in a selective manner. In summary, there is no reliable evidence that routine use of episiotomy has any beneficial effect; on the contrary, there is clear evidence that it may cause harm such as a greater need for surgical repair and a poorer future sexual capability. In view of the available evidence the routine use of episiotomy should be abandoned and episiotomy rates > 30% do not seem justified.

Woolley R.J. "Benefits and risks of episiotomy: a review of the English-language literature since 1980. Parts I and II." Obstet Gynecol Surv 1995 Nov;50(11):806-835. The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days. Mediolateral and, to a lesser degree, midline episiotomies substantially increase the amount of blood loss at delivery; in fact, simple avoidance of episiotomy may be the most powerful means the delivery attendant has to prevent excessive intrapartum hemorrhage. The long-term morbidity of the anal sphincter damage induced by episiotomy, particularly midline, has generally been underestimated in both its frequency and severity. Other potential fetal and maternal complications of episiotomies, although rare, are numerous and serious. The overall degree of risk that accompanies this procedure could only be justified by a clear and overriding benefit, which does not appear to exist.

Hueston, M.D. "Factors Associated With the Use of Episiotomy During Vaginal Delivery" Obstetrics & Gynecology, Vol 87 No 6 June 1996: 1001-1005. OBJECTIVE: To examine factors associated with the performance of episiotomy. METHODS: A retrospective review was performed on 8647 deliveries during 1991 and 1992 at five medical centers. Episiotomy rates were compared based on variables involving patient demographics, obstetric condition, and physician factors for the 6458 vaginal deliveries in the sample. Logistic regression modeling using variables associated in bivariate analysis was performed to examine independent effects of each variable. RESULTS: Several characteristics of the patient, her clinical status, and physician factors were all associated with episiotomy use. The strongest independent predictors of episiotomy were nulliparity (odds ratio [OR] 4.10, 95% confidence interval [CI] 3.59-4.68) and the use of forceps (OR 5.03, 95% CI 3.39-7.46) or vacuum extraction (OR 3.78, 95% CI 2.36-6.04). Provider specialty and the site of care were also associated independently with episiotomy. Episiotomy use was also associated with major perineal lacerations and an increased length of hospital stay. CONCLUSION: Although differences in episiotomy rates mainly reflect clinical circumstances, important site-to-site variations and interspecialty differences point to potential areas where physician behaviors influence the performance of episiotomy.

Mansfield CJ, Hueston WJ, Rudy M "Neonatal circumcision: associated factors and length of hospital stay" Journal of Family Practice 1995 Oct;41(4):370-376. BACKGROUND. Controversy exists regarding the efficacy of routine neonatal circumcision of male infants. Little is known about parental or provider characteristics or the use of medical resources associated with this procedure. METHODS. Records of 3703 male infants born during 1990 and 1991 at four US sites were analyzed to discern associations between circumcision and the above factors. Analyses were limited to healthy infants. RESULTS. Eighty-five percent of the infants in the study population were circumcised. White and African-American male infants were much more likely to be circumcised than those of other races (odds ratios [ORs], 7.3 and 7.1, respectively, P < .001). Compared with self-pay patients, those covered by private insurance were 2.5 times more likely to be circumcised (P < .001). Logistic regression showed that rates for obstetricians and family physicians were not significantly different. Increased odds of circumcision were found if the mother received an episiotomy (OR = 1.9, P < .001) or cesarean section (OR = 2.1, P < .001). Circumcised infants stayed in the hospital an average of one fourth of a day longer than did those who were not circumcised (mean difference, 0.26 days; 95% confidence interval, 0.16 to 0.36). CONCLUSIONS. Mother's insurance status and race as well as surgical interventions during delivery are related to circumcision. Associations with episiotomy and cesarean section suggest physician and/or parental preference for interventional approaches to health care. Generalizing the difference in hospital length of stay to the United States suggests an annual cost between $234 million and $527 million beyond charges for the procedure itself.

Argentine Episiotomy Trial Collaborative Group. 1993. "Routine vs selective episiotomy: a randomised controlled trial." Lancet 342:1517-8.
Episiotomy is a widely-done intervention in childbirth, regardless of poor scientific evidence of its benefits. This randomised controlled trial compares selective with routine use of a mediolateral episiotomy for women having first and second deliveries in 8 public maternity units in Argentina. 2606 women participated; 1555 were nulliparous (778 in the selective group and 777 in the routine group) and 1051 primiparous (520 in the selective group and 531 in the routine group). The two interventions compared were selective (limited to specified maternal or fetal indications), and routine episiotomy (following the hospital's previous policy). Episiotomy was done in 30.1% of deliveries in the selective, and 82.6% in the routine group. The main outcome measure was severe perineal trauma. Severe perineal trauma was uncommon in both groups but was slightly less frequent in the selective group (1.2% vs 1.5%). Anterior perineal trauma was more common in the selective group but posterior perineal surgical repair, perineal pain, healing complications, and dehiscence were all less frequent in the selective group. Routine episiotomy should be abandoned and episiotomy rates above 30% cannot be justified.


Borgatta, L., S. L. Piening and W. R. Cohen. 1989. "Association of episiotomy and delivery position with deep perineal laceration during spontaneous delivery in nulliparous women." American Journal of Obstetr Gynecol 160:294-7.
Spontaneous deliveries of 241 nulliparous women found that deep perineal tears occurred in 1% of the women delivered without either episiotomies or stirrups, and in 28% with both episiotomies and stirrups. Women with either episiotomies or stirrups had intermediate amounts of tears.


Combs, C. A., P. A. Robertson and R. K. Laros. 1990. "Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries." American Journal of Obstet Gynecol 163:100-4.
Among 2832 consecutive forceps and vaccum extraction deliveries, 30% suffered thrid- or fourth-degree lacerations (to the anus). In regression, the predictors of severe laceration were: midline episiotomy, nulliparity, forceps delivery (vs. vacuum extraction), local anaesthesia, and Asian race. Birth weight and gestational age were not predictors.


Doherty, P. J. and I. Cohen. 1993. "Spontaneous vaginal deliveries and perineal trauma in Lucea, Jamaica." Journal of the Louisiana State Medical Society 145:531-3.
In 1991, there were 995 uncomplicated vaginal deliveries at Noel Holmes Hospital (NHH) in Lucea, Jamaica. Seven hundred and forty-two women were discharged with intact perineums. Only 3 episiotomies were performed. These data raise a concern that episiotomy may be overused in the United States.


Farabow, W. S. et al. 1993. "A twenty-year retrospective analysis of the efficacy of epidural analgesia-anesthesia when administered and/or managed by obstetricians." American Journal of Obstetrics & Gynecology 169:270-7.
Postdate pregnancy, use of oxytocin, low forceps delivery, episiotomy, and type of anesthesia were unrelated to shoulder dystocia in newborns. This study clearly indicates that most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict. In addition, no delivery method in shoulder dystocia was superior to another with respect to injury. Thus no protocol should serve to substitute for clinical judgment.


Golay, J., S. Vedam and L. Sorger. 1993. "The squatting position for the second stage of labor: effects on labor and on maternal and fetal well-being." Birth 20:73-8.
A cohort study was designed to assess the effects of maternal squatting position for the second stage of labor on the evolution and progress of labor, and on maternal and fetal well-being. Outcomes from 200 squatting births, randomly selected from a sample of 1000, were compared with 100 semirecumbent births, randomly selected from a sample of 300. Data collection was by chart review. The two groups were similar with respect to most antepartal, intrapartal, and socioeconomic variables likely to affect labor outcomes. The mean length of the second stage of labor was 23 minutes shorter in squatting primiparas and 13 minutes shorter in squatting multiparas than in semirecumbent women. Squatting women required significantly less labor stimulation by oxytocin during second stage (P = 0.0016), and they showed a trend toward fewer mechanically assisted deliveries. Significantly fewer and less severe perineal lacerations occurred, and fewer episiotomies were performed in the squatting group (P = 0.0001). No statistically significant differences were found between groups for third-stage complications and infant complications.


Green, J. R. and S. L. Soohoo. 1989. "Factors associated with rectal injury in spontaneous deliveries." Obstet Gynecol 73:732-8.
In a study of 2706 spontaneous cephalic deliveries, midline episiotomies increased the risk of rectal injury (laceration of the rectal sphincter) by 9 times, nulliparity by 3 times, physician-assisted delivery vs. midwife by 2.5 times.


Helwig, J. T., J. M. Thorp and W. A. Bowes. 1993. "Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries?" Obstetrics & Gynecology 82:276-9.
OBJECTIVE: To explore the association between midline episiotomy and the risk of third- and fourth-degree lacerations during operative vaginal delivery with either vacuum extractor or forceps. METHODS: This retrospective cohort study analyzed all operative vaginal deliveries at a university hospital in 1989 and 1990. Univariate analysis of the relationships between perineal lacerations and obstetric variables was performed. Stratified analysis using the relevant variables was used to calculate relative risk (RR) estimates. RESULTS: Episiotomy, birth weight, and whether the index birth was the first vaginal birth were associated with third- and fourth-degree perineal lacerations. Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight. CONCLUSION: Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries.


Henriksen TB. Bek KM. Hedegaard M. Secher NJ. 1994. "[Episiotomy and perineal lesions in spontaneous vaginal delivery]. [Danish]." Ugeskrift for Laeger 156:3176-9.
The purpose of the study was to evaluate the influence of mediolateral episiotomy on the perineal state after spontaneous, singleton vaginal deliveries with the foetus in the occiput anterior position. The design was that of a population based, observational study. Two approaches were used in the analyses: Initially, we considered the parturients as quasi-randomised to one of three equally sized groups of midwives with different attitudes towards episiotomy. Secondly, we studied the effect of episiotomy on the state of the anal sphincter, controlling for birth weight, parity, and duration of second stage of labour. The subjects were 2188 pregnant women delivering consecutively, and the main outcome measures were perineal lacerations and tearing of the anal sphincter. Women allocated to the group of midwives with the lowest rate of episiotomy were more likely to have an intact perineum after delivery (OR = 1.8 (1.4-2.2)), had a slight tendency towards more perineal lacerations (OR = 1.3 (1.0-1.5)), but no increased risk of tearing of the anal sphincter, compared with the women allocated to the two groups of midwives with higher frequencies of episiotomy. The second approach showed that episiotomy was related to an increased risk of tearing of the anal sphincter (OR = 2.3 (1.2-4.6)). However, this relation was not found among the group of parturients delivered by the midwives with the lowest rate of episiotomy (22%). Our results encourage a conservative approach to the use of mediolateral episiotomy, and in the light of previous findings, it seems reasonable to suggest that episiotomy should ideally be used in about one in five spontaneous vaginal deliveries.


Henriksen, T. B. et al. 1992. "Episiotomy and perineal lesions in spontaneous vaginal deliveries." Br Journal of Obstetr Gynaecol 99:950-4.
British midwives were classified as high, moderate or low users of episiotomies (EP). A total of 2188 of the women they had delivered were retrosepctively studied. Women with the low EP midwives were the most likely to have an intact perineum after delivery, with a slightly higher risk of a laceration, but no increased risk of a tear to the anus. Among the moderate and high EP midwives however, episiotomies were found to increase the risk of a tear to the anus. "Our findings encourage a conservative approach to the use of mediolateral episiotomy...".


Hueston, W. J. and M. Rudy. 1993. "A comparison of labor and delivery management between nurse midwives and family physicians." Journal of Fam Pract 37:449-54.
BACKGROUND. Practice associations between family physicians and nurse midwives have been suggested as a means to increase the availability of obstetric care in rural areas. No evidence exists, however, that family physicians and midwives have comparable practice styles or achieve similar outcomes in obstetric patients. METHODS. The study examines patients cared for by a co-practice of nurse midwives and family physicians at a rural hospital. Data were collected through a retrospective chart audit for all patients whose prenatal care, labor, or delivery was managed by members of the practice in 1990 and 1991. RESULTS. Few differences were noted between nurse midwives and family physicians in the management of labor or delivery. The only consistent finding was that family physicians were more likely than midwives to use an episiotomy for delivery (40% vs 30% in primiparous women, P = .02; and 20% vs 10% in multiparous women, P = .007). Despite seemingly similar management styles, primiparous women managed by family physicians were more likely to undergo cesarean section (14% vs 8%, P = .05) resulting from the diagnosis of dystocia. When practice specialty was included in a logistic regression model with parity and the number of preexisting risk factors, the effect of specialty on cesarean sections remained significant with a relative risk of 2.79 for cesarean section if patients had their labor managed by a family physician (P .001). CONCLUSIONS. Family physicians and nurse midwives managed patients in labor similarly, but nurse midwives were more likely to achieve a vaginal delivery in primiparous women and do so without an episiotomy. Although the differences found would not interfere with a collaborative practice, subtle differences in patient management do exist. Further exploration of these differences may be helpful in understanding the impact of these differences on mixed-specialty practices. Author-abstract.


Klein MC. Gauthier RJ. Robbins JM. Kaczorowski J. Jorgensen SH. Franco ED. Johnson B. Waghorn K. Gelfand MM. Guralnick MS. et al. 1994. "Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation." American Journal of Obstetrics & Gynecology 171:591-8.
OBJECTIVE: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. CONCLUSION: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.


Larsson, P. G. et al. 1991. "Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration." Gynecol Obster Invest 31:213-6.
In a prospective investigation of 2144 deliveries comparing women with episiotomies and those with spontaneous lacerations, women with episiotomies were found to have a sig higher infection rate and longer healing times. Morbidity was higher for the episiotomy group immediately and at the 3-month follow-up.


McGuinneess, M., K. Norr and K. Nacion. 1991. "Comparison between different perineal outcomes on tissue healing." Journal of Nurse Midwifery 36:192-8.
Perineal healing was compared between 181 women with episiotomies and 186 women without at one to two weeks after delivery. All subjects were medically indigent low-risk women at a tertiary care hospital. Maternal age, race, parity, and birth weight were not correlated to perineal healing. Length of the second stage of labor was correlated. Of the EP group, 8% experienced delayed perineal healing, while only 2% had delayed healing in the no-episiotomy group.


Piper DM. McDonald P. 1994. "Management of anticipated and actual shoulder dystocia. Interpreting the literature." Journal of Nurse-Midwifery 39:91S-105S.
Shoulder dystocia is a rare but serious obstetric complication that can result in significant neonatal and maternal morbidity and in costly litigation. Conflict exists in the literature regarding definition, incidence, predictability and preventability, relationship to neonatal injury, and appropriate management models. Anticipatory clinical interventions for potential shoulder dystocia have included ultrasound assessment of macrosomia; elective induction of labor; elective caesarean section; altered place of birth; and generous episiotomy/episioproctotomy. The authors note that these interventions often conflict with client desires and nurse-midwifery philosophy of birth, generate significant risks and costs in themselves, and do not address the poor predictability of shoulder dystocia. In recent literature, the safety and efficacy of maternal position change maneuvers (such as McRoberts maneuver, hands-knees position, and squatting) have been presented as methods to resolve most cases of shoulder dystocia. Despite the success of these more benign, external maneuvers, the episiotomy mandate remains in nearly all obstetric and midwifery texts and handbooks (1-8) and journal references (9-19). A literature review of related professional disciplines was undertaken to study these conflicts and to identify support for applying a philosophy of minimal, appropriate intervention to the complex issue of shoulder dystocia. [References: 75].


Rockner, G. and A. Olund , A Jonasson. 1991. "The effect of mediolateral epsiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones." Acta Obstet Gynecol Scand 70:51-4.
In a prospective study, pelvic floor muscle was studied pre- and post-partum in 71 primiparous women with uncomplicated pregnancies delivered vaginally. Pelvic floor muscle was significantly weakened in the group with episiotomies, while the muscle strength was the same in those who had spontaneous lacerations and those with intact perineums.


Ruderman, J. et al. 1993. "Are physicians changing the way they practise obstetrics?" Canadian Medical Association Journal 148:409-15.
OBJECTIVE: To examine trends in obstetric interventions in women at low risk over approximately 3 years. It was postulated that there would be a general reduction in most intervention rates. DESIGN: Retrospective review of hospital records. SETTING: Three downtown hospitals of the University of Toronto, in which academic and nonacademic family physicians and obstetricians practised. PATIENTS: A total of 2365 women in phase 1 (April 1985 to March 1986) and 1277 in phase 2 (May to September 1988) met the inclusion criteria for grade A (pregnancy at no predictable risk) of the Ontario Antenatal Record at the time of admission to hospital. OUTCOME MEASURES: Rates of artificial rupture of the membranes, induction, augmentation, epidural anesthesia, continuous electronic fetal monitoring (EFM), instrumental delivery, episiotomy and cesarean section. RESULTS: The family physicians and the obstetricians had significant decreases (p 0.01) over time in the rates of episiotomy, especially mediolateral, and low forceps delivery. The rate of epidural anesthesia decreased significantly in the obstetrician group. The rates of artificial rupture of the membranes, induction and continuous EFM increased in the two physician groups; the increased rate of EFM was significant in the obstetrician group (p 0.01). There was no significant change in the rates of augmentation, midforceps delivery, vacuum extraction or cesarean section. All of the trends were found to hold when the intervention rates were analysed according to the women's parity. CONCLUSIONS: Some of the findings reflect recommendations and trends reported in the literature, whereas others are not supported by clear medical evidence. The unpredictable nature of the trends suggests that further study is warranted of the reasons for obstetric trends and for the changes in physicians' practice patterns.


Shiono, P., M. A. Klebanoff and J. C. Carey. 1990. "Midline episiotomies: more harm than good?" Obstet Gynecol 75:765-70.
Episiotomy and severe perineal lacerations were studied in 24,114 women. Overall 8% of primiparous women and 1.5% of multiparous women had sever lacerations. Women with midline episiotomies were 50 times more likely and women with mediolateral episiotomies were more than eight times more likely to suffer a sever laceration than women without episiotomies. Severe lacerations, and episiotomies, were also correlated with forceps delivery, larger babies, breech and transverse presentations, and smaller women. After adjusting for these risk factors, midline episiotomy was still still associated with 4 (nulliparas) to 12 (multiparas) times as many severe lacerations, and mediolateral episiotomy was still associated with a 2.5 times greater risk of severe laceration.


Smith, M. A., M. T. Ruffin and L. A. Green. 1993. "The rational management of labor." American Family Physician 47:1471-81.
Some practices and procedures that are common during the management of childbirth lack proof of efficacy, and some have adverse effects. The practice of withholding food and liquids and using intravenous fluids during labor may pose risks such as fluid overload, and maternal and fetal hyperglycemia. Enemas should be reserved for women with painful constipation. Evidence does not support the value of shaving the perineal area. Nonpharmacologic measures to control pain during labor are safe and moderately effective. Pharmacologic methods of analgesia and anesthesia provide good pain relief but pose significant risks. Continuous electronic fetal monitoring should be considered a diagnostic procedure, not a screening procedure. Amniotomy may shorten labor but can result in abnormally high uterine forces, infection, umbilical cord prolapse and fetal laceration. Position changes and alternative birth positions promote greater comfort and efficiency during labor. Finally, episiotomy has not been shown to reduce severe lacerations or prevent pelvic relaxation, and use of this procedure should be limited.


Stones, R. W. et al. 1993. "Risk factors for major obstetric haemorrhage." European Journal of Obstetrics, Gynecology, & Reproductive Biology 48:15-8.
Induced labour, caesarean delivery and episiotomy significantly increased the risk of potentially life threatening haemorrhage.


Sultan AH. Kamm MA. Hudson CN. Bartram CI. 1994. "Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair." BMJ 308:887-91.
OBJECTIVES--To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. DESIGN--(i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. SETTING--Antenatal clinic in teaching hospital in inner London. SUBJECTS--(i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. MAIN OUTCOME MEASURES--Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. RESULTS--(i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. CONCLUSIONS--Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.


Thorp, J. M. and W. A. Bowes. 1989. "Episiotomy: can its routine use be defended?" American Journal of Obstet Gynecol 160:1027-30.
A careful review finds little evidence to support the claim that episiotomy reduces perineal trauma or pelvic floor weakening, and in fact the evidence shows that it increases the risks of severe lacerations.


Walker, M. P., D. Farine, S. H. Rolbin and J. W. Ritchie. 1991. "Epidural anaesthesia, episiotomy, and obstetric laceration." Obstetr Gynecol 77:668-71.
Uncomplicated vertex deliveries with spontaneous onset and normal course (N= 9493) were retrospectively studied. Epidural anaesthesia was not associated with increased risk of birth canal trauma, but episiotomy was associated with an increased risk of perineal trauma, and with a four-fold increased risk of major trauma.


Wilcox, L. S. et al. 1989. "Episiotomy and its role in the incidence of perineal lacerations in a maternity center and tertiary hospital obstetric service." American Journal of Obstet Gynecol 160: 732-8.
A retrospective study of the records of 1262 women who delivered at a maternity center staffed by midwives and a teaching hospital staffed with physicians found that, controlling for several factors, women at the teaching hospital were twice as likely to have episiotomies. In turn, episiotomies were associated with a four-fold increase in the incidence of severe perineal lacerations.

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British National Health Service, Health Evidence Bulletin on "Episotomy/ Perineal Trauma"
based on Enkin et al. above. Conclusion: "routine use (of episiotomy) in spontaneous delivery should be strongly discouraged."

Birth Chairs, Midwives and Medicine
by Amanda Carson Banks