This is from Pat Pully (CNMPAT) 1. Klein et al Relation of episiotomy to perineal trauma and morbidity, sexual dysfunction and pelvic floor relaxation. Am J Obstet and Gynecol 1994;171:591-8 2. Klein et al Physicians Beliefs and behaviour during a randomized controlled trial of episiotomy:consequences for women under their care. Can Med Assoc J. 1995; 153 (6) Sept 15th. 769-79.
The latter two studies show the clear causal relationship between episiotomy and 3rd/4th degree tears. Women who were intact or had spontaneous tears had best outcomes, episiotomy the worst with respect to perineal pain, sexual and pelvic floor functioning. 52 of 53 3rd/4th degree tears occurred in presence of episiotomy (extensions). The CMAJ article shows that physicians with strong pro-episiotomy beliefs of course do more episiotomies BUT they also do more induction, augmentation, forceps and cesareans too. And they diagnose fetal distress when its not there many times more often and perineums "that won't distend"--AND their pateints have more pain and are less satisfied.
It shows lots more about the paradigm of birth used by those who cling tenaciously to routine episiotomy via a vis the way they view birth i.e. an accident waiting to happen, normal only in retrospect, every woman an unexploded bomb needing defusing, unreliable incubators who babies need rescuing etc etc. Please recognize that these latter descriptors are my interpretations of the data deliberately drawn in exaggerated form to add spice to your life.
The bad news is that about 1/4 of the docs could be so described. The good news is that 1/4 of docs had a style of practice more like midwifery in attitude and practice. Moreover, half of this 1/4 were FPs and half obstetricians. It did not matter your speciality, what mattered was between your ears. If your head was straight you got good results, if not your patients suffered.
Dear folks:
The author of the recent post citing Gainey appears to be in a direct
historical line with Joseph B. DeLee, (3) who is credited with
introducing both episiotomy and associated outlet forceps to modern
obstetrics. DeLee provided no evidence for this approach other than
his unsubstantiaed opinion.
Gainey is also in that tradition. He is often cited by those attached to routine episiotomy to support this view. Gainey (4,6) was a meticulous observer who studied 1000 women in the 1930s (6) in a teaching clinic where neither episiotomy nor outlet forceps was employed. Gainey then compared 1000 women attended in the 1940s and 50s in a private clinic where Dr. Gainey personally supervised the routine use of both procedures, (4) and concluded that with episiotomy was better than without. Gainey's two populations were not only separated in time and place but were uncontrolled for social, obstetrical or demographic factors--as well as the skill of the operator, and in the second report timing of observations was not standardized, and ranged from a few months to years.
DeLee and Gainey, practising in another era and regularly seeing severe trauma, can be forgiven for not using epidemiological methods to control for confounders and for being seduced by physiological and anatomical plausibility. We cannot. We should now understand that retrospective, historical data cannot be used for this purpose. Several randomized controlled trials (RCTs) have shown the inability of episiotomy to prevent perineal trauma, (7-11 and 14-16), while one RCT (7) and one observational study (12) have demonstrated failure of episiotomy to prevent pelvic floor relaxation. Allen et al have shown episiotomy to be unrelated to the frequent abnormalities found in both nerve conduction and electromyographic perineometry, the long term clinical significance of which remains to be established. (13) But Allen et al reported significant denervation effects only for very large babies or very long second stages; hence, neither the speculation based on physiological plausibility but going beyond their data by Allen should be used to recommend the use of routine or earlier episiotomy.
Its time for the tenacious adherents of routine episiotomy as a preventive strategy for pelvic floor protection to conduct a proper trial specifically addressing this issue and to stop using historical opinion based on exhortation and uncontrolled personal experience to promote their beliefs. As well, it is an interesting observation that those who hand on to routine episiotomy in the face of overwhelming evidence to the contrary are often using many other procedures to excess as well (14-16).
As a an exasperated colleague recently said: "If you think episiotomy is so wonderful, you can always do it after the baby is born."
Michael Klein, MD, CCFP, ABFP,
FAAP (Neonatal-Perinatal)
Professor Family Practice and Pediatrics
University of British Columbia
Head Family Practice
Grace (Maternity) Hospital,
Vancouver, British Columbia
References:
3. DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:34-44.
4. Gainey HL. Postpartum observation of pelvic tissue damage:further studies. Am J Obstet Gynecol 1953;70:800-7.
6. Gainey HL. Post-partum observation of pelvic tissue damage. Am J Obstet Gynecol 1943;45:457-66.
7. Klein MC, Gauthier RC, Jorgensen SH, Robbins, JM, Kaczorowski J, Johnson B, Corriveau M, Westreich R, Waghorn K, Gelfand MM, Guralnick M, Luskey G, Joshi AK. Does episiotomy prevent perineal trauma and pelvic floor relaxation? On-Line J Curr Clin Trials. 1992; July 1 1992 (Doc 10).
8. Harrison RF, Brennan M. Is routine episiotomy necessary? Br Med J 1984;288:1971-5.
9. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J 1984;289:587-90.
10. Sleep J, Grant. West Berkshire perineal management trial: three year followup. Br Med J 1987;295:749-51.
11. Argentine episiotomy trial collaborative group. Lancet 1993;342:1517-18.
12. Rockner G Jonasson A, Anders O. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991;70:51-4.
13. Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97:770-9.
14. Klein MC et al Relation of episiotomy to perineal trauma and morbidity, sexual dysfunction and pelvic floor relaxation. Am J Obs and Gynecol 1994;171:591-8
15. Klein MC et al Physician's beliefs and behaviour during a randomized controlled trial of episitomy:consequences for women in their care. Can Med Assoc J. 1995;153(6). 769-79
16. Klein MC. Studying episiotomy: when beliefs conflict with science. J Fam Pract. 1995;41:483-8.