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Jolanta Pietras

1

, Bernice Folake Taiwo

2

Episiotomy in Modern Obstetrics

– Necessity Versus Malpractice

Nacięcie krocza we współczesnym położnictwie

– konieczność kontra błąd w sztuce

1 The University of Medical Sciences in Legnica, Poland 2 Polish Health Centre, Środa Śląska, Poland

Abstract

Episiotomy is now one of the most common procedures performed in obstetrics. At the beginning of its existence, it was performed very carefully and used in exceptional circumstances. In the second half of the twentieth century, its use became so widespread that it was almost regarded as a standard procedure in labor rooms. Authors intend to provide answers to the question as to whether it was an appropriate move in this discussion. Undoubtedly, there are reasons for which an incision is an appropriate decision, sometimes necessary, but in recent years its useful-ness and relevance, in particular its routine, too widespread use are starting to be increasingly questioned and subjected to doubt, both by various women’s organizations, individuals interested in the issue, stakeholders, as well as professionals. Poland is still one of the few European countries where routine episiotomy is so far regarded as an important and recognized part of patient management during almost every childbirth taking place in a hospital setting. This topic currently causes broad discussion in the media, the press and among the public. Hence, the aim of this work is to discuss key issues on episiotomy, the arguments for and against episiotomy based on literature review and available studies and reports. It is also going to present the opinion of different authors and the existing differences in their views on the above issue (Adv Clin Exp Med 2012, 21, 4, 545–550).

Key words: episiotomy, perineal damage, obstetric procedures.

Streszczenie

Nacięcie krocza jest obecnie jednym z najczęstszych zabiegów wykonywanych w położnictwie. Od początku było traktowane jednak bardzo ostrożnie i stosowane w wyjątkowych sytuacjach, w drugiej połowie XX w. stało się powszechną, niemal standardową procedurą na blokach porodowych. Odpowiedzi na pytanie, czy było to posunię-cie słuszne, autorzy postarają się udzielić w niniejszych rozważaniach. Niewątpliwie, istnieją powody, dla których nacięcie jest decyzją właściwą, niekiedy konieczną, niemniej jednak w ostatnich kilkunastu latach jego przydatność i zasadność, a w szczególności jego rutynowe, zbyt powszechne stosowanie zaczyna być coraz częściej kwestiono-wane i podakwestiono-wane w wątpliwość – zarówno przez różnego rodzaju organizacje kobiece, same zainteresokwestiono-wane, jak i profesjonalistów. Polska jest wciąż jednym z niewielu krajów europejskich, w którym rutynowe nacięcie krocza jest, jak dotychczas, istotnym i uznanym elementem prowadzenia niemal każdego porodu odbywanego w warunkach szpitalnych. Temat ten wywołuje obecnie szerokie dyskusje w mediach, prasie i wśród opinii publicznej, dlatego celem pracy jest omówienie najważniejszych zagadnień dotyczących epizjotomii, przedstawienie argumentów za i przeciw nacinaniu krocza opartych na przeglądzie literatury oraz dostępnych badaniach i doniesieniach, a także zaprezentowanie opinii różnych autorów i istniejących różnic w poglądach na omawianą kwestię (Adv Clin Exp

Med 2012, 21, 4, 545–550).

Słowa kluczowe: nacięcie krocza, obrażenia krocza, procedury położnicze.

Adv Clin Exp Med 2012, 21, 4, 545–550 ISSN 1899–5276

rEvIEwS

© Copyright by wroclaw Medical University

Episiotomy (gr. episiotomia: episeion – vulva,

temno – cut) is a procedure based on the incision

of the perineal tissues of a parturient, with delivery scissors during the second stage of labor in order to expand the birth canal [1, 2]. The history of this

procedure goes as far back as the 17th century and

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mention of this topic appeared at the beginning of the 19th century [3]. At first, it was not trusted

and was used as a last resort, but in 1913 De Lee published his thesis that “Every delivery is a patho-logic process and requires surgical intervention” [3, 4]. His work was repeatedly renewed as a result of which in the first half of the 20th century,

rou-tine episiotomy gradually started gaining popular-ity and general acceptance [3]. In 1928, Jaschke recommended performing episiotomy in every case where irreversible damage to the anal levator muscle is suspected and consequently may result in pelvic organ prolapse [2, 5]. while on the oth-er hand, Kustnoth-er recommended episiotomy only when there was vaginal hemorrhage as evidence of the beginning of cervical rupture [2]. Earlier men-tioned De Lee even proposed that women during labor should be given sedatives, perform extensive episiotomy and then bring out the fetus with the help of forceps [3]. In the 1980’s, thanks to the popularisation of the idea of evidence based medi-cine as well as the rise of consumer movement in many countries, and the move called “friendly obstetrics”, routine episiotomy was allowed to un-dergo criticism, and the world Health Organiza-tion in 1985 in a document titled “Appropriate delivery techniques” recommended the restriction of episiotomy acknowledging that „there is no jus-tification for routine episiotomy” [3]. The world Health Organization also acknowledged the fact that episiotomy is justified only in about 5–20% of childbirth (meaning about 1 in every 5 parturient) [3, 6]. Since the end of the 1970’s the percentage of episiotomy done in the USA and in the major-ity of western European countries has undergone a systematic and important reduction. In Poland, Greece or in South America the percentage of episiotomy during childbirth is still high and is maintained at a relatively similar level [3, 7]. It is estimated that, in our country, every second par-turient had perineal incision of which almost each and every nulliparous patient underwent the pro-cedure. well over 50% of these women were not asked for their consent for this procedure. Mean-while, in Great Britain and Denmark the percent-age of episiotomy is 12%, in Sweden 9.7%, in New Zealand 11% and in the USA about 33% [6].

Indications

The second stage of labor (true stage of child-birth) is the most traumatic stage for the lower pelvic tissues; that is why this period can result in situations which are the cause of different distant complications, such as damage of muscle, connec-tive tissues, or nerves associated with it [2].

Epi-siotomy helps reduce the resistance of tissues [8]. Therefore, the most common reason why epi-siotomy is performed routinely is for perineal tis-sue protection [2].

Indications for episiotomy include prophy-laxis of pelvic organ prolapse, manual help in ex-traction of the fetus, reflex position of fetal head, instrumental delivery (for instance, through the use of forceps or vacuum extractor) as well as im-minent perineal rupture [2, 5, 9]. Another impor-tant part of this aspect worth mentioning is the inappropriate pelvic anatomy (high perineal wall), cervical insusceptibility, protection of the fetal head, minimization of its injuries as well as situa-tions in which a quick end has to be put to delivery [2, 5, 8, 9].

In accordance with the recommendations of the experts team of Polish Association of Gynaecol-ogists in 2009 concerning antenatal care and the management of labour, delay in the appearance of the presenting part and the use of episiotomy as an assisting procedure to instrumental vaginal deliv-ery with the use of forceps and vacuum extractor were regarded as indications to episiotomy [10].

As a result of this, there are four different types of episiotomy identified: The two most often per-formed are the lateral and medial episiotomy, as well as mediolateral and the so called Schuchardt’s episiotomy. Each of these incisions has its own advantages and disadvantages. Lateral episiotomy (the most popular type) causes an increased loss of blood than the medial episiotomy and gives more pain, but – one important element in accordance with information given in obstetrics text books – does not constitute a threat of anal rupture and its consequences. Medial episiotomy is characterized by lesser loss of blood, lesser discomfort during the healing process, because wounds at this spot heal faster and are less painful [11], lesser blood ves-sels and nerval branches are damaged [8]. It lacks the possibility of extending the cut if need be and, above all, there is the danger of damaging the anus [11]. Mediolateral episiotomy has the features of both types described above. while Schuchardt’s episiotomy is the most extensive cut (it involves a deep incision into the vagina, perineum, and pel-vic floor muscle floor) [2, 9, 11].

Advantages

and Complications

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as urinary incontinence. Moreover, they involve protection of the fetus during premature delivery, violent expansion as well as perineal insuscepti-bility of the parturient. Also, protection against tearing due to inappropriate position of present-ing part especially when the fetus is large [2, 8, 9, 11] with a possibility of reducing the second stage of labor as a result of the fetal state or mother [8, 11–13]. Some authors suggest that together with reconstruction of the appropriate anatomical con-ditions sometimes it is comparable to plastic sur-gery with the aim of maintaining the proper func-tion of the vaginal vestible [8].

The other side of the issue present facts in-volving a lot of reports indicating possible com-plications resulting from this type of procedure. Thacker and Banta showed that the majority of the complications of episiotomy have a more im-portant function in clinical practice than earlier assumed [2, 14]. As possible consequences, they further listed rupture of episiotomy, dyspareunia (painful sexual intercourse), perineal pain, long healing period, infection, as well as considerable loss of blood which makes further detailed exami-nation necessary in the discussed scope [14]. Simi-lar effects have also been shown by Mc Guiness et al. [15]. These authors also state that instrumen-tal delivery favours perineal trauma. The results obtained in their opinion suggest that perineal trauma in women who never had episiotomy heals better [14, 15]. Safrati and Marechaud even stated that the amount of blood lost during epi-siotomy is comparable to that lost during caesar-ean section [16]. Ejegard et al. similarly to their predecessors showed that episiotomy very often causes increased pain during sexual intercourse and reduces wetness of the vaginal vestible for a period of about 12–18 months after childbirth [17]. Buekens suggests that episiotomy does not prevent further perineal trauma but rather in-creases the risk [18]. Eason et al. even said that irrespective of the type, it does not reduce the risk of anal sphincter rupture [19]. Numerous reports in the last few years have shown that episiotomy, especially the medial type, as a procedure is dan-gerous, leading to rectal damage, gas and or stool incontinence or even the development of a recto-vaginal fistula as observed by Jander and Lyrenas [20] or wooley [21, 22], among Polish authors for example Korczyński reminds us of this fact. Similar consequences have been also reported by Haadem et al., adding to it necrosis and re-peated rupture of the anal sphincter [23]. Again, Swedish authors – rockner, Jonasson and Olund, based on their own personal research, stated that episiotomy did not prevent what it was meant to do in the long run, that is, consequences such as

reduced muscular tension of pelvic floor muscle and vaginal laxity. They obtained similar results in muscle strength (there was no substantial dif-ference) in the group of women without perineal damage during delivery and with spontaneous perineal rupture, whereas in the group that had episiotomy, muscle strength in this group of muscles was weaker [24].

According to wooley a comparative study of the group of women with spontaneous perineal rupture and those with episiotomy showed that an increase in the performance of episiotomy procedures has no effect on reducing the num-ber of third degree perineal tears [2, 21, 22] while the postpartum pain associated with the perineal healing was of increasing strength in the group of women with episiotomy unlike in the group with perineal tears. He obtained an ambiguous result on the complications of healing as well as on the issue of painful sexual intercourse. Edema, infec-tion, hematomas were also often present [21, 22]. The result obtained rather showed that episioto-my reduced the risk of damaging the anterior wall of the vagina and around the urethra [22]. For the prophylaxis of the pelvic floor muscles, the author said that the effect of episiotomy on the reduction of the symptoms of urinary incon-tinence and the pelvic organ prolapse was not shown [21, 22]. For the prophylaxis of fetal inju-ries, he did not show the effect of episiotomy on the frequency of subdural bleeding neither on the state of the newborn baby after delivery accord-ing to the Apgar scale, whereas it is important to mention the fact that it reduced the time duration of the second stage of labor [2, 21, 22]. A lot of authors have also shown the psychoemotional as-pect associated with episiotomy [2, 21, 22, 25] as well as rare cases of blood transmitted diseases or endometriosis in scar from perineal incision [2]. Martin et al. said that trauma (incision or rup-ture) thrice increases the risk of secondary and tertiary perineal rupture and that there is a direct relationship between the degree of damage in the first and subsequent deliveries [26].

Controversies and Difficult

Questions

In the light of the above facts the question arises: Is routine perineal incision equivalent to its protection? According to experts from „Rodzić po

ludzku” Foundation, you cannot talk of perineal

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perineal incision actually prevent complications arising in the second stage of labor? As the analy-sis in this material have shown, advantages have only been shown mainly with respect to reducing the period of the second stage of labor and pre-vention of anterior vaginal wall damage as well as around the urethra [21, 22]. The issue of prevent-ing the urogenital diaphragm damage is no longer obvious. Perineal incision is generally made after the fetus has exceeded the urogenital diaphragm and tightens the perineal tissues. In order to pre-vent excessive expansion of the perineal muscles, making an incision becomes a necessity, that is just before the fetal head crosses the urogenital diaphragm thus at the beginning of the second stage of labor. This kind of a procedure in Thorp’s view could increase the probability of third and fourth degree tears [26]. It is important to note that, nowadays, episiotomy is done at a later phase [3]. How come some medical procedures and habits are based on evidence? Does routine episiotomy actually still exist in hospitals? It is an optimistic fact that midwives in their practice are beginning to individualize these issues with respect to concrete situations and those of them that have private practices and those taking deliv-eries at home more often are beginning to point out the role of appropriate perineal protection. It is worth mentioning that in some countries such as Austria, it is one of the major elements of their education [3]. In Poland, over a decade ago, not much was said about this issue, perineal incision in other words episiotomy was almost a standard procedure in labor rooms, while the textbooks available cautiously and merely talked about the issue of perineal protection. Moreover, one can sometimes still read from them that “perineal su-ture is the end of vaginal delivery” [3]. Presently, there are a lot of methods used in preparing for childbirth, just as there are a number of meth-ods of handling delivery with the aim of reducing the frequency of tissue damage and incision. Not without importance are economic issues associat-ed with the cost of massociat-edical care. Borghi et al. car-ried out appropriate analysis and came to a con-clusion that every low risk delivery carried out with the application of episiotomy is more costly than deliveries without incision by 11–20 dollars [27]. For this reason also, the issue of performing episiotomy presently poses a lot of difficult ques-tions and issues that need to be sorted out. In the recommendations of the team of experts of the Polish Association of Gynaecologists in 2011, the restriction of routine episiotomy reduces the risk of incurring perineal injury by 33% and reduces the risk of healing complications by 31%. The fear that failure to carry out episiotomy could result

in uncontrolled tear of the perineal tissues and difficulties in healing do not find any reflection in the result of many research papers. It was shown rather that the number of reconstructive opera-tion procedures and the number of stitches were less in women in which indication to episiotomy were restricted [28].

It is obvious that it will be performed in situa-tions where it becomes very necessary, but in cases where it is used as a routine procedure (especially nulliparous women), maladjusted to concrete indi-vidual situation, conditions or possibility – where it is not absolutely compulsory – then it begins to raise some doubts. Practically, it is much easier to stitch perineal incision rather than perineal rup-ture [3, 5, 8] but based on the results of available research, it is seen that the perineum in puerpe-rial women without episiotomy heals better [3, 14, 15] while spontaneous rupture in vaginal delivery very rarely attain third or fourth degree tears [2, 3, 21, 22]. One should be reminded again of the fact that a perineal incision is an equivalent of second-ary rupture. Does this type of completed perineal trauma (rupture, tear, incision) remain without ef-fect on the course of subsequent deliveries or do they stand as a risk factor to its rupture in subse-quent deliveries? will it not be worthwhile to pay more attention to the medical personnel and their awareness of the possibilities, principles and ways of protecting the perineum?

The recommendations of the team of experts of the Polish Association of Gynaecologists in 2011 regarding prevention of intrapartum injuries to the birth canal and pelvic floor structures, more often than ever, seek to give up routine episiotomy whose result ought to be a reduction in the perfor-mance of this procedure to less than 25% of deliv-eries [28].

Conclusions

Episiotomy sometimes for medical reasons be-comes a necessary procedure; nevertheless, it ought to be used with all prudence and sense of feeling having taken into consideration all the right indi-cations as well as the expectations of the woman in labor. In the opinion of Korczyński, there is no evidence that episiotomy is a prophylaxis of the damaged tissues of the lower pelvis, while it could increase the risk of serious damage [2].

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like the world Health Organisation – wHO or the National Institute for Health and Clinical Ex-cellence – NICE as well as reports from research-ers, routine episiotomy is discouraged [2, 3, 29]. The decision to carry out this obstetric procedure should be individualised and in each case be de-termined by the wealth of information obtained

on the advantages and disadvantages of the proce-dure [2, 29]. The authors handling this issue very often highlight the fact that from the ethical and medical point of view the research on performing episiotomy ought to be continued in the area of its usefulness and benefits in modern obstetrics [2, 21, 22].

References

[1] Dudenchausen JW: Położnictwo praktyczne i operacje położnicze. PZwL, warszawa 2010.

[2] Korczyński J: Nacięcie krocza we współczesnym położnictwie. Konieczność czy przyzwyczajenie? Przegl Lek 2002,

59/2, 95–97.

[3] http://www.rodzicpoludzku.pl/Publikacje/Naciecie-krocza-koniecznosc-czy-rutyna.html 2011.11.23.

[4] Walzer Leavitt J: Joseph B. DeLee and the practice of preventive obstetrics. Am J Public Health 1988, 78(10),

1353–1361.

[5] Pschyrembel W: Praktyczne położnictwo. PZwL, warszawa 1974

[6] http://www.rodzicpoludzku.pl/Porod/Naciecie-krocza-czy-mozesz-tego-uniknac.html, 2011.11.23.

[7] Althobe F, Belizon JM,Bergel E: Episiotomy rates in primaparous in Latin America: hospital based restrictive

study. BJM 2002, 324 (7343), 945–946.

[8] Bręborowicz GH: Ginekologia i położnictwo, tom 1. PZwL, warszawa 2006, 402–403. [9] Martius G: Operacje położnicze. PZwL, warszawa 1990, 227–229.

[10] rekomendacje zespołu ekspertów Polskiego Towarzystwa Ginekologicznego dotyczące opieki okołoporodowej

i prowadzenia porodu: Ginekol Pol 2009, 80, 548–557.

[11] Martius G: Ginekologia i położnictwo. Urban & Partner, wrocław 1997.

[12] Wooley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I. Obstet

Gynecol Surv 1995, 50, 806.

[13] Wooley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II. Obstet

Gynecol Surv 1995, 50, 821.

[14] Thacker SB, Banta HD: Benefits and risks of episiotomy: An interpretative review of the English language

litera-ture, 1860–1980. Obstet Gynecol Surv 1983, 38, 322.

[15] Mc Guiness, Norr K, Nacion K: Comparison between different perineal outcomes on tissues healing. J Nurse

Midwifery 1991, 36, 192–198.

[16] Safrati R, Marechaud M, Magnin G: comparaison des deperditions sanguines lors des cesariennes et lors des

accouchements par voie basse avec episiotomie. J Gynecol Obstet Biol reprod 1999, vol. 28, 48–54.

[17] Ejegard H, Ryding EL, Sjorgen B: Sexuality after delivery with episiotomy: a long-therm follow-up. Gynecol

Obstet Invest 2008, 1 (66), 1–7.

[18] Buekens et al.: Episiotomy and third degree tears. Br J Obstet Gynecol 1985, 99, 820–823.

[19] Eason E, Labrecque M, Wells G, Feldman P:Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000, 95(3), 464–471.

[20] Jander C, Lyrenas S: Third and fourth degree perineal tears. Predifictor factors in referral hospital. Acta Obstet

Gynecol Scand 2001, 80, 229.

[21] Woolley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I. Obstet

Gynecol Surv 1995, 50, 806–820.

[22] Woolley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II. Obstet

Gynecol Surv 1995, 50, 821–835.

[23] Haadem K et al.: Anal sphincter function after delivery rupture. Obstet Gynecol 1987, 70 (1), 53–56.

[24] Röckner G, Jonasson A, Olund A: The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength

evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991, 70(1), 51.

[25] Ciszek V et al.: Nacięcie krocza – uwarunkowania psychosomatyczne. Klin Perinatol Ginekol 1996, supl XIII,

69–77.

[26] Thorp JM, Bowes WA: Episiotomy: Can its routine use be defended? Am J Obstet 1989, 160 (5), 1027–1030. [27] Borghi J et al.: The cost-effectiveness of routine versus restrictive episiotomy in Argentina. Am J Obstet Gynecol

2002, 186 (2), 221–228.

[28] rekomendacje zespołu ekspertów Polskiego Towarzystwa Ginekologicznego dotyczące zapobiegania

śródporodowym urazom kanału rodnego oraz struktur dna miednicy. Ginekol Pol 2011, 82, 390–394.

[29] Myers-Helfgott MG, Helfgptt A: routine use of episiotomy in modern obstetrics. Should it be performed? Obstet

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Address for correspondence:

Jolanta Pietras

University of Medical Sciences Powstańców Śl. 3

59-220 Legnica Poland

Tel.: +48 76 854 99 38

E-mail: dziekan@wsmlegnica.pl

Conflict of interest: None declared

References

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