Episiotomy: Barbaric Practice?

source:www.wholelifehealth.ca

I just completed a paper on Episiotomy and specifically its routine use however with a topic like this it’s easy to get lost down the rabbit hole. I found out all kinds of interesting things and I know if I don’t share them right this minute, I never will. So here I want to share some of my findings as well as my entire paper below, it’s not the cleanest thing (specifically in the intro to the discussion) but if you would like to see my analysis of the studies, it’s all there.

Here, in point form:

  • An episiotomy is an incision made into the vagina to widen it during childbirth
  • This procedure was invited (by a man, surprise surprise) 300 years ago for “difficult births” whereby it served to speed up 2nd stage of labour
  • Normally, during second stage of labour, some time is required to allow the vagina to dilate and the tissues of the perineum to stretch to accomodate the head. This requires TIME. Thus if you just cut the vagina to be larger instead, less TIME is required.
  • Women who push too hard too fast and don’t allow for the TIME for the vagina to dilate (the cervix dilates first, then the vagina) end up with spontaneous tears to the vagina
  • The key variable here is TIME. Hope I established that so far.
  • Spontaneous (natural) tears are often 1st or 2nd degree, and rarely 3rd or 4th degree. One study found 3rd degree natural tears to occur at a rate of 2.5%, and 4th degree natural tears at a rate of 0%
  • Here is what the grading scale entails:

Natural tearing is classified on a 4-degree scale (Carroli & Mignini 2009):

  • First degree involves the fourchette, perineal skin and vaginal mucus membrane
  • Second degree involves the perineal muscles and skin
  • Third degree involves injury to the anal sphincter complex. Hudelist et al note that these tears result in major complications and are often the result of operative vaginal delivery (2008).
  • And fourth degree involves injury to the perineum involving the anal sphincter complex and anal epithelium
  • Episiotomies were brought into widespread use in the early 1900s despite having no scientific validation at the time (nor now, for the record)
  • Originally a mediolateral incision was made, going toward the ischial tuberosity, however a newer technique called midline was introduced in 1965 which involves cutting directly (halfway) to the anus, through the vagina. This specifically results in a lot more 3rd and 4th degree tears because (surprise surprise) the episiotomy stretches and lengthens. One study found that midline episiotomy increased 4th degree rates from 1% to 17%
  • Episiotomy rates in the US are claimed to be 35-62% as per the studies I looked at
  • They are as low as 9.2% in Sweden
  • A task force states they should be no higher than 30%, and another paper states 15% is within reach, beyond which maternal outcomes are not benefitted by the procedure
  • If a physician views episiotomy favourably, they are (surprise surprise) more likely to utilize them. they are also more likely to augment labour with oxytocin, prescribe epidurals, and perform c-sections on their patients. They are also more likely to be male, and marginally older, and claim there to be fetal distress in normal labours (fetal distress was their reasoning for using the episiotomy)
  • Here are the proposed reasons for an episiotomy, and what the papers I looked at found – in very, very short summary. (Take a look at the paper, the numbers are fascinating)!
Claim:
Reduction in the likelihood of third degree tears (severe trauma)
  • Carroli – Did not reduce
  • Hudelist – VOD* + midline increased severe trauma; mediolateral + VOD decreased severe trauma
  • Shahraki – increased severe trauma (25% in episiotomy vs. 2.5% spontaneous tears are 3rd degree, 0% as 4th degree)
  • Klein – no decline, similar rates of trauma in both, groups, thus episiotomy not effective at reducing severe trauma
  • Cleary-Goldman – no difference in severe trauma
Preventing relaxation of the muscles of the pelvic floor and perineum, purportedly leading to improved sexual functioning postpartum
  • Hartmann – no benefit
Reduced risk of fecal and urinary incontinence
  • Cleary-Goldman – no impact on incontinence
Easier to repair and heals better than a laceration due to being a straight cut
  • Cleary-Goldman – “There is no objective data from review of the literature that episiotomies are easier to repair than spontaneous lacerations.”
Shortens second stage labour. Prolonged second stage of labour (>120 minutes) possibly due to having to wait for vaginal tissues to stretch could theoretically result in fetal asphyxia, cranial trauma, cerebral hemorrhage and mental retardation
  • Shahraki – no difference in Apgar scores
  • Other theories not investigated nor noted in any of the studies I found, more research needed
Suggested that it may be necessary to make more room for rotation maneuvers in the case of shoulder dystocia
  • Cleary-Goldman – it may be indicated for shoulder dystocia, more research needed

*VOD = Vaginal Operative Delivery (Vacuum or Forceps use)

The possible adverse effects of routine episiotomy include:

  • Extension of the episiotomy by cutting the anal sphincter or rectum either on purpose or unavoidable extension of the incision
  • Unsatisfactory anatomic results including skin tags
  • Assymmetry or excessive narrowing of the introitus
  • Vaginal prolapse
  • Recto-vaginal and anal fistulas
  • Increased blood loss and hematoma
  • Pain and edema in the episiotomy region
  • Infection
  • Sexual dysfunction – and if women have an episiotomy they are more likely to delay resuming sex after childbirth (OR 3.43, 95% CI 1.9-6.2) (McDonald & Brown 2013).
  • Costs of routine use and additional resources to sustain a policy of routine episiotomy

I conclude:

  • Episiotomies do not reduce the likelihood of 3rd and 4th degree tears in Spontaneous Vaginal Births and may in fact increase severe trauma
  • Specifically the mediolateral technique may reduce trauma in births where forceps or vacuum is used, but midline makes things WAY worse when used with forceps or vacuum
  • Episiotomies do not prevent pelvic floor relaxation, incontinence, or Apgar scores in infants, nor do they impact sex life (frequency) aside from having sex later (postpartum) and having more pain during sex
  • There is no data to show that episiotomies are easier to repair than lacerations
  • Some studies show more favourable outcomes with natural spontaneous tearing than with episiotomies
  • Since not all women tear, if routine episiotomies are given, it means even the women who wouldn’t have incurred tears now have trauma from a surgical incision
  • Money and resources are saved if we avoid routine use
  • Restrictive use means restricting episiotomy for shoulder dystocia, genuine fetal distress, and vaginal operative deliveries, though more research is still needed on all of these things
  • Episiotomy does shorten second-stage labour, and that’s not necessarily a good thing from my personal point of view. The body is technically not yet ready to pass that baby through.
  • The vagina is capable of “stretching” and delivering 10-lb babies intact, according to my midwife :) and when I say intact, I’m referring to the vagina, not the baby!
  • Perineal massage for the month prior to giving birth may reduce the risk of tearing in first-time moms, and the use of the Epi-No device may reduce the risk of needing episiotomy. I personally did neither of these things and did not tear, save for two small (lesions? lacerations? okay maybe they were tears but they were tiny like papercuts).
  • Without episiotomy, women are more likely to incur anterior tears on the labia or anterior vagina but these are very low morbidity (low effects on your life)

So, do with it what you will. But unless you’re having an operative delivery (forceps / vacuum), or the baby has shoulder dystocia or fetal distress, I wouldn’t go for it *personally*, this is my opinion on myself, not medical advice whatsoever. Also, there is a lot that can be done naturopathically-speaking and movement-wise to reduce your risk of operative delivery / shoulder dystocia / fetal distress (induction often causes it so go into labour naturally to avoid it, and if you aren’t going into labour well then naturopathy can help you there too). So really, you have the power within you to at least some degree, to avoid this purposeful vaginal trauma.

The authors of the studies I looked at conclude that routine episiotmy use should be abandoned in favour of restrictive use for the reasons I mentioned here (dystocia + distress + VOD).

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