Letters

Midline episiotomy and anal incontinence

Training is needed in the recognition and repair of perineal trauma

A prospective study is needed

Results should be interpreted with caution in British context

Is episiotomy ethically acceptable?

Training is needed in the recognition and repair of perineal trauma

EDITORThe finding by Signorello et al that midline episiotomy may impair anal continence is valuable and highlights the effect of perineal trauma on the anal continence mechanism.¹ The authors acknowledge the limitations of the study, which was retrospective, non-randomised, and may have included misclassifications of perineal trauma.

We investigated 161 nulliparous women in the third trimester and 12 weeks post partum. A symptom questionnaire and anorectal investigations were performed at both visits and anal endosonography was performed post partum.²

Women with an intact perineum had a mean squeeze pressure of 105.8±26.4 mmHg, those who sustained second and third degree perineal tears had a mean squeeze pressure of 92.3±30.3 mmHg (P=0.022), and those who had mediolateral episiotomies had a mean squeeze pressure of 92.2±29.7 mmHg (P=0.032).

Sphincter trauma was associated with perineal trauma at delivery: of 59 women with second or third degree tears, 41 (69%) had sphincter trauma versus 39 out of 97 women (40%) with an intact perineum (P=0.001). Sphincter trauma was also significantly more common in women who underwent vaginal delivery: 58 out of 130 (45%) women had sphincter defects in the vaginal delivery group versus 1 out of 26 women (4%) women who underwent a caesarean section (P=0.0005). However, the difference between our study and that of Signorello et al is that the patients in our study had a mediolateral and not a midline episiotomy, and it is well known that midline episiotomy is associated with a higher risk of extension to the anal sphincter.

Our study has confirmed previous reports that show that the incidence of sphincter damage increases considerably when an episiotomy occurs together with a perineal tear.³ The association of any perineal trauma, either an episiotomy or a spontaneous tear, with sphincter defects has important implications for obstetric practice as sphincter trauma has been linked directly to the development of anal incontinence.⁴ Methods to minimise perineal trauma such as the use of the ventouse rather than the forceps and the correct management of the active second stage once the head is crowning should be encouraged.

Recognition of perineal trauma is known to be poor and this may lead to inadequate repair and predispose to the development of incontinence.⁵ Doctors and midwives both need improved and focused training in the recognition and repair of sphincter trauma.

Charlotte Chaliha, specialist registrar. 
Department of Obstetrics and Gynaecology, Kingston Hospital, Kingston upon Thames, Surrey KT2 7QB

Abdul H Sultan, consultant obstetrician and gynaecologist. 
Department of Obstetrics and Gynaecology, Mayday University Hospital, Croydon, Surrey CR7 7YE

A prospective study is needed

EDITORI cannot understand why Signorello et al's study, which reached its end point after six months, was not set up prospectively.¹ Although the answers given by the study seem to be valid, the results would have been less liable to recall biases if data had been gathered using study specific clinical research forms during delivery and if questionnaires on signs and symptoms had been provided at three and six months post partum. The responses might have been higher in number, more accurate, and returned sooner, so that even the study probably would not have lasted as long.

Kees Boer, academic specialist. 
Academic Medical Centre, Department of Obstetrics and Gynaecology, University of Amsterdam, 1100 DE Amsterdam, Netherlands k.boer{at}amc.uva.nl

Results should be interpreted with caution in British context

EDITORSignorello et al raise important questions about the use of episiotomies and the detrimental effect on anal continence.¹ Unfortunately, their study may not be relevant to practice in Europe. Women in their study all had a midline episiotomy, which is the preferred procedure in the United States.

In a midline episiotomy a vertical incision is made in the direction of the anal sphincter. Third and fourth degree tears have been reported to occur in more than 20% of women having midline episiotomies. ^{2 3} In the United Kingdom and most of Europe a mediolateral episiotomy is preferred, which has a much lower risk of damaging the anal sphincter.² The incision is directed towards the ipsilateral ischial tuberosity, away from the anal sphincter. This could reduce rather than increase the risk of anal incontinence.⁴

In addition, several methodological issues are worth consideration. A greater proportion of questionnaires were completed in the episiotomy group than in the group with intact perineum (14% more; 95% confidence interval (6% to 21%)) and 11% more (3% to 18%) were completed in the group with tear than in the group with intact perineum. This could represent an important source of bias and in a worst case scenario could have a large effect on the results.

Secondly, the design of the study was to send a questionnaire at six months post partum requesting recall of symptoms at three months. It is certainly possible that recall could relate to symptoms experienced nearer to the delivery, which may account for the difference in results between the two time periods. It would seem more logical to send questionnaires at three months and follow up forms at six months.

Thirdly, the authors report that the risk of faecal incontinence at six months is tripled and that the risk of flatus incontinence at three months is doubled, with confidence intervals that include the null value. The results are consistent with no effect and to report them in this way is misleading.

In conclusion, the findings of this study, while interesting, ought to be interpreted with caution in the British context.

M S Mills, consultant obstetrician and gynaecologist. 
Deirdre J Murphy, lecturer in clinical obstetrics. 
Division of Obstetrics and Gynaecology, St Michael's Hospital, Bristol BS2 8EG D.J.Murphy{at}bristol.ac.uk

Is episiotomy ethically acceptable?

EDITORThe guiding tenet of the physician is "primum non nocere"firstly do no harm. It seems inconceivable that an operation that inflicts severe harm on women would continue to be practised wholesale, despite medical evidence of its potentially detrimental effects. Yet episiotomy is one such operation.

The recent study by Signorello and colleagues shows a considerable increase in faecal and flatus incontinence in women who have had an episiotomy.¹ These findings reinforce the overwhelming body of evidence which continues to show that episiotomy is associated with severe maternal morbidity and is rarely of any benefit. The need for immediate delivery in the face of acute fetal distress is one of the few remaining indications for episiotomy. The concept that episiotomy prevents third and fourth degree tears of the perineum or protects the pelvic floor has been repeatedly disproved.² Faecal and flatus incontinence, third and fourth degree perineal lacerations, a fear of future childbirth, severe dyspareunia, and blood loss which exceeds that at caesarean section³ are major complications associated with this unfortunately too often performed procedure.

Episiotomy seems to be totally contrary to the physician's principle of beneficence and non-maleficence. We can therefore ask whether indiscriminate performance of episiotomy is ethically acceptable or medically justifiable. Given the risks associated with the procedure, episiotomy should be considered to be a major operation, and practitioners considering performing one should carefully weigh the risks associated with the procedure against any perceived benefits. The day will come in the near future when practitioners will have to defend the complications incurred as a result of episiotomy. As medical knowledge advances, it is conceivable that episiotomy may one day join such extinct operations as blood letting, high forceps delivery, and symphysiotomy, which are now considered crude and barbaric but were once widely practised, as shown in the books of medical antiquity. As a recent reviewer aptly put it,³ "episiotomy has `been weighed in the scales and been found wanting.' "

K Olayinka Oyelese, resident. 
YinkaMD{at}aol.com

Amy Porter, chief resident. 
Clifford Wai, chief resident. 
Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, DC 20007, USA