Friday
Sep162011
Captain Obvious on Episiotomies and Cesareans?
Friday, September 16, 2011 at 11:30AM
By Jill Arnold
I think I am the last person on whom it dawned that maybe one of the reasons there are fewer episiotomies performed today than a decade or so ago is that there are fewer opportunities to do so as a result of the increase in the number of cesareans. I always assumed the downward trend could primarily be attributed to the reason given in the notes:
Episiotomies are performed to assist or speed delivery and/or prevent trauma to the mother. They were performed fairly routinely, but lack of clinical evidence of benefits and some indication of increased injury from the procedure has led to decline in the use of the procedure.
If you have fewer vaginas on which to perform episiotomies, you will probably perform fewer episiotomies. And probably perform more suprapubic episiotomies. Or maybe you’re just performing more repairs on obstetric lacerations as noted and fewer episiotomies.
Thoughts?
Source: http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/FF_report_2007.pdf
Reader Comments (11)
Why....how interesting! No coincidence here, quite obvious indeed. The chart does not lie.Thanks for the share. Episiotomy was definitely an fear as a first time mom, but what I feared the most.....I got. The unnecessary cesarean. I wised up the second time around, found a Midwife and had my baby at home. No cutting of anything.
I've wondered the same thing about forceps delivery. According to the CDC's final birth data for 2008 (Table D), the forceps delivery rate looks like this:
1990 - 5.1%
1995 - 3.5%
2000 - 2.1%
2005 - 0.9%
2007 - 0.8%
2008 - 0.7%
I'm hypothesizing that the "dystocia" cases are now all being sectioned.
From the chart, it doesn't look like perineal tears are replacing the episiotomies. Of course, many women who got episiotomies in the past would not have torn anyway.
The increase in the repair of obstetric lacerations is probably due more in part to the rise in inductions than the decrease in episiotomies.
KK - probably not fair to discuss the drop in forceps rates without looking at the vacuum extraction rates concurrently.
I don't have the table in front of me at the moment (posting from phone), but the vacuum extraction rate had a smaller decrease, from something like 3.9% in 1990 to 3.2% in 2008. Which is interesting in itself (why a big drop in forceps use and a big overall drop in assisted deliveries but not a huge drop in the vacuum component?).
This is really pretty simple. Studies over the past few decades have shown no benefit to routine episiotomies as was once thought and this has been passed on to trainees. Now, episiotomy is usually reserved for situations where the baby needs to be delivered urgently due to distress and reduces the time it would take for the perineum to stretch. I probably perform about 1-2/year, or less than 1%, for babies that need to come out "now".
Hope this helps.
My observation is that There are less forceps than vacuums because forceps requires more skill than vacuum, and vacuum can only be done when baby is close enough to out that a cs is pretty hard to justify. That said, having seen all types, I think I would choose a cs over a forceps, give the associated trauma, personally! Also, as less are now done, the skills are being lost, as new docs are not seeing them to learn them. Forceps saved lives before babies were routinely born in hospital, but are quite out of vogue these days.
I wish more people (care providers) would catch on to what Dr. Dorn so nicely expressed. Even a certain blogging former doctor declared that them to be going out of style. But my experience as a doula has been that their popularity must vary widely by region. In my neck of the woods they are still used routinely and taught as necessary (judging from my current experience in nursing school in a major university). To put it bluntly, every (in-hospital) vaginal birth I have witnessed, save ONE, has included a routine episiotomy. I dream of a world where that procedure is viewed as such a drastic, last-resort tool that any time it is used the attendant must face a review board afterward to justify the decision. Maybe then more doctors/midwives would be able to stand along side of Dr. Dorn and rightly boast of knowing they only need to perform maybe 1-2 a year.
My sister escaped an episiotomy with her delivery, but instead the doctor had his hands down there and was stretching/pulling her vaginal opening. She told him to stop because it hurt worse than the baby descending, but instead he just numbed her up with some Lidocaine and kept on. She had a 3rd-degree laceration when it was all said and done.
This is a really interesting question, and I don't know the answer. I've heard anecdotal evidence one way or the other, but that's hardly representative of the real state of affairs.
What I do know for sure, however, is that I'm very glad that I had midwives. I was fortunate not to tear with either of my vaginal deliveries, and so if I'd had an episiotomy, it would have been for nothing.