Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
How about no episiotomy?
- Steven Ford (19 June 2000)
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Problems with episiotomy
- Martin Quinn (24 June 2000)
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Episiotomy: one of many factors impinging on the perineum
- Rachel Myr (11 July 2000)
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Cutting Episiotomy?
- Julia Fox-Rushby (16 July 2000)
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Midline versus mediolateral episiotomy
- Judith H Salaman (17 July 2000)
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Cutting episiotomy?
- Julia Fox-Rushby (17 July 2000)
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Episiotomy in context
- Sheila Kitzinger (23 July 2000)
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Volunteering for sphincter damage
- Arabinda Saha (7 August 2000)
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Steven Ford, GP Haydon Bridge
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Sir In the middle or off to one side? Much better surely to avoid episiotomy all together. It is undoubtedly desirable to define best practice but has anyone anywhere made an attempt to take steps to avoid episiotomy? It is probably an unexceptionable generalisation to say that second and subsequent vaginal deliveries are often easier, shorter and less traumatic. This seems to suggest that the changes wrought by first delivery may be instrumental in facilitating those deliveries that come after. Prophylactic, incremental, patient controlled, dilatation/distension of the perineum and vagina in the days or weeks before delivery may well yield benefits and seems an obvious candidate for trial. I have aired this proposal with an obstetric colleague and had the impression that it offended him. I sent an e.mail to a BMJ ABC author who responded with some interest. An e.mail to the American author yielded no response and I am awaiting a response from the author of this editorial. Strange how discussion of optimal episiotomy is desirable but discussion of means of avoiding it is never heard. Are there any clinical, legal or ethical issues that I am missing? Why ever not take prophylactic measures? Steven Ford |
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Martin Quinn, Locum Consultant in Ob/Gyn Truro
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Stephen Thacker takes on a very significant task in attempting to answer the questions as to whether episiotomy should be performed, and, whether it should be median or mediolateral. Some of the recent information about anal damage following episiotomy may be in doubt because of a temptation to call the normal divarication of the puborectalis as an anal sphincter defect. Despite the present number of RCT's there has been little attempt to study the impact of introital and perineal lengths at crowning on the clinical outcome. Many clinicians would tend towards a mediolateral incision in a patient with a short perineum and vice versa, based purely on a tacit awareness of the potential outcomes. In terms of long term outcomes, not only are the rates of vaginal defects leading to prolapse and incontinence, important; there may also be profound morbidity caused by prolonged maternal voluntary efforts. Magnetic resonance imaging demonstrates avulsion of the levator ani from its origin over the obturator internus in many patients with pelvic sensory symptoms that result from neurapraxis of the pelvic nerves at these sites. Presentations with pelvic pain, dyspareunia, urinary and faecal urgency, as well as may other symptoms, occur remote from the delivery and cause considerable misery. An early episiotomy may prevent a lifetime of suffering ? Considerable resolve, and resources, will be required to answer Dr Thackers' pertinent and relevant questions. |
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Rachel Myr, staff midwife, postnatal ward Vest-Agder Central Hospital, Norway
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Unfortunately, we still need reminding that the purported benefits of episiotomy, whatever the technique used, remain unproven. I wish to put forth a claim that the condition of the perineum after birth is affected by many other intrapartum factors than the 'simple' occurrence, or non- occurrence, of cutting it with a scissors and repairing it with sutures. Since Banta and Thacker's first landmark review of the risks and benefits of episiotomy, much research has been done to attempt to shed more light on the issue. As a midwife I am very grateful for that. However, I am not aware of studies investigating the effect of management style on the perineum. By management style I mean the global effects of the attitudes and behaviour of the birth attendant(s), the atmosphere created in the birth environment; whether or not there is the opportunity for the woman in labour to move about, eat, drink, have the companions she chooses; the dominant emotional tone during second stage (urgency versus calm, directive versus gently encouraging, to name examples illustrating dichotomies). That such factors make a difference can be no surprise to anyone who works on a postnatal ward, where we learn to recognize our colleagues' 'signatures' by watching mothers sit down on chairs. I am not asserting that it would be simple to study this, and I am certain it would be painful for the clinicians involved. I am saying that such study is needed if we are to understand more about the qualitative differences between giving birth in various settings and with various attendants. Differences between attendants are not along professional lines, but along very personal and specific ones. If such research is underway I would very much like to know. |
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Julia Fox-Rushby, Senior Lecturer in Health Economics London School of Hygiene and Tropical Medicine
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Sir, Thacker1 points to the uncertainty regarding which type of episiotomy technique produces the best health outcome, appropriate indications for episiotomy, and the ideal episiotomy rate for women of different parity. These issues also have important implications for the evaluation of cost borne by health providers. We have recently developed a model to predict the cost-effectiveness of changing policy from routine to restrictive episiotomy in Salta and Santa Fé provinces of Argentina2, based on results from the most recent Cochrane review3. We concluded that reducing episiotomy rates from 81% (routine practice) to 30% (restrictive practice) would reduce economic costs to the provider by between $12 and $21 per normal vaginal delivery in Salta and Santa Fé provinces respectively. Both changes were statistically significant at the 95% level and were robust to changes in assumptions. Variable costs (ie excluding overhead costs, equipment useable in other procedures and staff salaries) would fall by between $11 and $16 per delivery: a substantial saving in financial resources. Given that the probability of perineal pain, healing complications and wound dehiscence, are also significantly lower under a policy of restrictive episiotomy, a restrictive policy for current practice is recommended3. However, in order to determine the optimal rate of episiotomy, new evidence is required. The key question is what proportion of women actually ‘need’ an episiotomy? Whilst a policy of no episiotomy would reduce costs even further, such a policy may also be associated with detrimental maternal and neonatal outcomes in those cases where an episiotomy was ‘needed’ but not carried out. Without proof of clinically recognisable ‘need’, the optimal rate must be zero. If there exist a population of women for whom an episiotomy would be clinically beneficial, the next unanswered question then is how to identify them effectively and efficiently. This would allow an evidence- based investigation of the cost per true/false positive/negative and a re- assessment of the most cost-effective rate of episiotomy. It may also suggest that optimal episiotomy rates will differ by country or region depending on the prevalence of identified risk factors. Therefore we concur with Thacker’s call for further research but suggest that the need is all the more urgent as continued episiotomy may not only be ineffective, but is also consuming scarce resources which could be better used elsewhere to improve the health of mothers. References 1 Thacker SB Midline versus mediolateral episiotomy BMJ 2000; 320: 1615-1616 (17 June) 2 Borghi J, Fox-Rushby J, Bergel E, Carroli G, Abalos E, Hutton G (May 2000) Health Care to improve the outcome of labour, delivery and the post-partum period. Final report: Predicting cost-effectiveness from a Cochrane review of effectiveness, for the Global Forum for Health Research, World Health Organisation, Geneva 3 Carroli G, Belizan J Episiotomy for vaginal birth In Cochrane Collaboration, ed Cochrane Library Issue 2 Oxford: Update Software, 2000 Corresponding author
Josephine Borghi, MSc
Carroli G, MD
Bergel E, MSc
Hutton G, MSc
Abalos E
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Judith H Salaman
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Thacker is to be congratulated for his excellent editorial on midline versus mediolateral episiotomy. Whilst reference is made to pelvic floor disorders no specific mention is made of anal incontinence following episiotomy. A medline literature search from 1966 to the present day located 821 references to episiotomy, 3529 references to faecal incontinence and a cross over of 28 references between these groups. Only 2 of these specifically address anal incontinence following episiotomy and both are retrospective, the former being published in January's BMJ 1 2. Signorello 1 evaluated the relationship between midline episiotomy and anal incontinence in a retrospective cohort study. Unfortunately the follow-up in this study was only 6 months. However based on this provisional data it was concluded that, independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour midline episiotomy was not effective in protecting the perineum and sphincters and may even impair anal continence. Rageth 2 in a postal questionnaire of women who had delivered between 1 and 5 years previously found that occasional involuntary passage of faeces occurred significantly more frequently in the episiotomy versus the no episiotomy group. Nygaard et al have reported 30 year follow-up of anal continence after sphincter disruption in a retrospective cohort study. They found that frequent faecal incontinence occurred significantly more frequently in women who had undergone an episiotomy than those who had had a caesarian section 3. Although the literature on this subject is small we believe that such a debilitating and distressing consequence of an intervention performed during delivery is deserving of greater consideration. There is a clear need for randomised, controlled studies whose outcome measures include not only the degree of perineal trauma but also an accurate assessment of anal continence. (298 words) JUDITH H SALAMAN Specialist Registrar LING WONG Specialist Registrar SIMON RADLEY Senior Lecturer Academic Department of Surgery Queen Elizabeth Hospital Edgbaston Birmmingham B15 2TH 1. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 2000;320(7227):86- 90. 2. Rageth JC, Buerklen A, Hirsch HA. [Late complications of episiotomy]. Zeitschrift fur Geburtshilfe und Perinatologie 1989;193(5):233-7. 3. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstetrics & Gynecology 1997;89(6):896-901. |
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Julia Fox-Rushby
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Sir, Thacker1 points to the uncertainty regarding which type of episiotomy technique produces the best health outcome, appropriate indications for episiotomy, and the ideal episiotomy rate for women of different parity. These issues also have important implications for the evaluation of cost borne by health providers. We have recently developed a model to predict the cost-effectiveness of changing policy from routine to restrictive episiotomy in Salta and Santa Fé provinces of Argentina2, based on results from the most recent Cochrane review3. We concluded that reducing episiotomy rates from 81% (routine practice) to 30% (restrictive practice) would reduce economic costs to the provider by between $12 and $21 per normal vaginal delivery in Salta and Santa Fé provinces respectively. Both changes were statistically significant at the 95% level and were robust to changes in assumptions. Variable costs (ie excluding overhead costs, equipment useable in other procedures and staff salaries) would fall by between $11 and $16 per delivery: a substantial saving in financial resources. Given that the probability of perineal pain, healing complications and wound dehiscence, are also significantly lower under a policy of restrictive episiotomy, a restrictive policy for current practice is recommended3. However, in order to determine the optimal rate of episiotomy, new evidence is required. The key question is what proportion of women actually 'need' an episiotomy? Whilst a policy of no episiotomy would reduce costs even further, such a policy may also be associated with detrimental maternal and neonatal outcomes in those cases where an episiotomy was 'needed' but not carried out. Without proof of clinically recognisable 'need', the optimal rate must be zero. If there exist a population of women for whom an episiotomy would be clinically beneficial, the next unanswered question then is how to identify them effectively and efficiently. This would allow an evidence- based investigation of the cost per true/false positive/negative and a re- assessment of the most cost-effective rate of episiotomy. It may also suggest that optimal episiotomy rates will differ by country or region depending on the prevalence of identified risk factors. Therefore we concur with Thacker's call for further research but suggest that the need is all the more urgent as continued episiotomy may not only be ineffective, but is also consuming scarce resources which could be better used elsewhere to improve the health of mothers. Fox-Rushby J, Borghi J, Carroli G, E Bergel, Hutton G, Abalos E References 1 Thacker SB Midline versus mediolateral episiotomy BMJ 2000; 320: 1615-1616 (17 June) 2 Borghi J, Fox-Rushby J, Bergel E, Carroli G, Abalos E, Hutton G (May 2000) Health Care to improve the outcome of labour, delivery and the post-partum period. Final report: Predicting cost-effectiveness from a Cochrane review of effectiveness, for the Global Forum for Health Research, World Health Organisation, Geneva 3 Carroli G, Belizan J Episiotomy for vaginal birth In Cochrane Collaboration, ed Cochrane Library Issue 2 Oxford: Update Software, 2000 Corresponding author Julia Fox-Rushby, PhD Senior Lecturer in Health Economics Department of Public Health and Policy London School of Hygiene and Tropical Medicine Keppel Street London, WC1E 7HT UK Josephine Borghi, MSc Research Assistant, Maternal and Child Epidemiology Unit, Department of Epidemiology and Population Science London School of Hygiene and Tropical Medicine Keppel Street London, WC1E 7HT UK Carroli G, MD Director, Centro Rosarino de Estudios Perinatales (CREP), Pueyrredon 985, Rosario (2000), Santa Fe Argentina Bergel E, MSc Statistician, Centro Rosarino de Estudios Perinatales (CREP), Pueyrredon 985, Rosario (2000), Santa Fe Argentina Hutton G, MSc Research Fellow Department of Public Health and Policy London School of Hygiene and Tropical Medicine Keppel Street London, WC1E 7HT UK Abalos E Researcher Centro Rosarino de Estudios Perinatales (CREP), Pueyrredon 985, Rosario (2000), Santa Fe Argentina |
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Sheila Kitzinger, Anthropologist, Author, Hon Prof Thames Valley University Standlake Manor
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Stephen Thacker’s editorial is welcome. But it is rather like saying that there should be research into the benefits and risks of two kinds of female circumcision. Both constitute genital mutilation. He reminds readers that the first research into episiotomy followed the systematic review by Thacker and Banta in 1983, examining what was then treated as a routine minor procedure. Yet it was also women’s concern about brutal episiotomies and botched repair jobs that stimulated research. When I first asked for episiotomy rates in hospitals around the U.K. in 1978, as part of the research for my first Good Birth Guide, I was told that statistics were not kept. It was considered a normal and necessary intervention in childbirth. It was only after this that hospitals started recording episiotomy rates. Episiotomy also needs to be evaluated in terms of the conduct of the second stage: comparing commanded pushing and voluntary breath-holding with spontaneous breathing and pushing, as well as comparing relative immobility with freedom of movement . "The relationship between a woman and her physician should be based on trust." What does that mean? The woman trusts the doctor? The doctor trusts the woman? It might be better to say that she and her doctor, or midwife, should together explore the evidence available concerning different alternatives so that the woman can come to her own truly informed decision . This may be one of informed refusal. Sheila Kitzinger Social anthropologist and author Email in |
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Arabinda Saha
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Dear Sir - Thacker's editorial suggests a need for randomised controlled trials looking at the morbidity following midline as opposed to mediolateral episiotomies. I would like to ask how many women would agree to enter such a trial? He reminds us of the suggested advantages of a midline episiotomy - those of better healing and improved sexual function.1 However studies, including a recent paper by Signorello et al, clearly conclude that midline episiotomy impairs anal continence2. In addition midline episiotomies will extend to a third or fourth degree tear in more than twenty percent of women3. Elective episiotomy is required on occasions, and this should be mediolateral. There is no place for a midline approach in view of the above sequelae, and therefore no place for a randomised controlled trial. We would argue that the recognition of sphincter and/or rectal damage and its optimal repair is the most important factor in improving maternal morbidity following vaginal delivery. Tamsin Groom. Specialist Registrar. Arabinda Saha. Consultant. Department of Obstetrics & Gynaecology, Diana Princess of Wales Hospital, Grimsby. 1.Thacker SB. Midline versus mediolateral episiotomy. BMJ 2000; 320: 1615-6. 2. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 2000:320:86-90. 3. Coats PM, Chan KK, Wilkins M, Beard RJ. A Comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980; 87: 408- 12. |
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