By Andrea L. Hall
Monday, May 14, 2007
Two years after a landmark study called for an end to routine episiotomies, the procedure is still performed in about one-quarter of vaginal births. Health providers say women themselves can help change the trend.
(WOMENSENEWS)--Ann Eberhart's first episiotomy became infected and she says she "literally couldn't sit for three months."
Eberhart, a stay-at-home mother of three young children from Alexandria, Va., had so much discomfort from her second episiotomy that she visited four doctors hoping one would surgically remove the scar tissue and re-stitch her.
By the time she reached the fifth doctor, three years after the birth of her second child, "I was finally comfortable down there," she says. With the birth of her third child in 2005, she tore naturally and healed quickly. "I now realize I wasn't as educated as I needed to be," she says.
Two years after a landmark study concluded that routine use of episiotomy--a surgical incision made between the vagina and rectum during childbirth--was unnecessary, approximately one-quarter of U.S. women who give birth vaginally still undergo the procedure, often without their consent.
The federally funded study, published in May 2005 in the Journal of the American Medical Association, was a systematic review of the best available evidence on episiotomy published between 1950 and 2004. The researchers from the University of North Carolina at Chapel Hill and the Research Triangle Institute in Research Triangle Park, N.C., screened 986 articles on the subject and chose 26, based on their relevant data, for the study. They then concluded that five decades of medical literature fail to support routine use of the procedure.
The authors also found that episiotomy rates of less than 15 percent "should be immediately within reach." Although the number of episiotomies has consistently declined over the past two decades, researchers concluded the pace is not fast enough.
Doctors may be slow to stop performing this routine procedure, keeping the episiotomy rate too high. But pregnant women themselves should do more to take maternal care into their own hands to help hasten the decline, some health providers argue.
"Doctors didn't suggest that fathers come into the delivery room; patients did," says Dr. Iffath Hoskins, senior vice president, chair and residency director of the Department of Obstetrics and Gynecology at Lutheran Medical Center in New York. "Doctors didn't suggest that fathers be with the mothers for C-sections; patients did," she says. "Patients have transformed medical practice into what it is today."
There is little debate that episiotomies should be employed in certain emergencies, such as cases of fetal distress when speeding the delivery is crucial. This is known as restrictive, or selective, episiotomy.
The controversy, however, surrounds routine or liberal cutting in what was long believed to be an effort to reduce the risks of significant tearing, pain, urinary incontinence, fecal incontinence and pelvic floor defects.
The JAMA researchers found that the benefits traditionally attributed to routine episiotomy do not exist. They also found that episiotomy actually increases the risk of severe tearing, pain with intercourse, incontinence and other pelvic problems following delivery.
Based on these findings, the researchers called for an end to the procedure, except when the health of the fetus is at risk.
Dr. John R. Scott, a Spartanburg, S.C., obstetrician-gynecologist who advocates against routine episiotomy, thinks it's hard to retrain older doctors.
"You can read and understand the literature, which shows that you should let nature take its course, but it's so ingrained in you to cut a small episiotomy," Scott said in an interview.
A study published last year in the Journal of Reproductive Medicine showed that physicians in practice 15 years or more perform episiotomies 50 percent more often than those in practice less than 15 years. "I can't wait for the doctors who do routine episiotomies to fall out by attrition," says Hoskins. "That's too long to wait."
Scott says current medical residents are less likely to be trained to use routine episiotomy than in the past. The JAMA article found that although episiotomy rates have consistently declined over the past 20 years, wide variation in practice indicates that its use is driven by local professional norms, training and practitioner preference rather than the needs of individual women at the time of birth. A study conducted by researchers at the University of Ottawa, Ontario, published in the April 2000 issue of Obstetrics and Gynecology, also found factors such as time pressures, malpractice concerns and lack of experience with clinical alternatives to episiotomy.
In comparison to medical doctors, midwives are more likely to be trained to stretch the perineum--the muscle and tissue between the vagina and rectum--rather than cut, says Mairi Breen Rothman, certified nurse-midwife and professional services consultant for the Silver Spring, Md.-based American College of Nurse-Midwives. "I've been a nurse-midwife for 11 years and have cut four episiotomies," she says, adding that such a low rate is common among midwives.
Episiotomy rates do vary by practitioner type. Private-practice physicians are up to four times more likely to cut an episiotomy than ob-gyn residents or hospital faculty physicians. Faculty physicians use episiotomy up to three times more often than midwives. But although midwives, on average, perform far fewer episiotomies than physicians, there is wide variation in episiotomy rates among both midwives and physicians.
Studies have shown that when birth attendants are given specific instructions restricting episiotomies to deliveries in which there is fetal distress, episiotomies are performed in as few as 8 percent to 10 percent of spontaneous births and a high proportion of births occur with an intact perineum.
Although most pregnant women know what an episiotomy is, many do not realize that it's often unnecessary. And although they swap pregnancy and birth stories, many women don't discuss episiotomy with each other. Most of the women interviewed for this article said that although they'd talked about pregnancy and childbirth with their friends or relatives, they did not discuss episiotomy.
"It seems like the dirty secret that nobody wants to talk about," says Meghan Armistead of Baltimore, Md., who hopes to become pregnant and has discussed maternity issues with many of her friends.
She added that it is sometimes difficult to raise the issue with doctors. "I think of myself as a pretty assertive person, but it's not something that's easy to talk about," Armistead says.
Women will ask about epidurals and IVs, but tend not to talk about episiotomies, Hoskins, the ob-gyn, says. "That's not a good thing."
In Listening to Mothers II, a national survey of more than 1,500 women who gave birth in 2005 conducted by Childbirth Connection, a New York-based nonprofit working to improve maternity care, 73 percent of those who had an episiotomy stated that it was done without their prior consent.
Patient advocacy is always important, says Hoskins. "It means that the patient has a right to have a say in her own medical care."
Breen Rothman says that women should feel free to ask their birth attendants lots of questions and understand that "they don't have to blindly accept what their providers want to do."
Andrea L. Hall is a freelance writer, attorney and stay-at-home mother in Rockville, Md.
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Journal of American Medical Association
"Outcomes of Routine Episiotomy: A Systematic Review":
http://jama.ama-assn.org/cgi/content/full/293/17/2141 (registration required)
Agency for Healthcare Research and Quality
"The Use of Episiotomy in Obstetrical Care: A Systematic Review"
(evidence report that accompanied the JAMA article)
[Adobe PDF format]: http://www.ahrq.gov/downloads/pub/evidence/pdf/episiotomy/episob.pdf
"Listening to Mothers II: Report of the Second National U.S. Survey of Women's Chilbearing Experiences":