Relevant

Clinical Inquiry Assignment

Erica L. Robinson #1010232 March 4, 2013 Submitted to Dr. Heidi Fritz

Erica L. Robinson RCIA Assignment 2013 Relevant Clinical Inquiry Assignment: The Inquiry: Is routine episiotomy an effective labour-management technique for the prophylaxis of vaginal tears? I believe this is a clinically relevant topic for myself as I intend to practice as a naturopathic doula and an ND who counsels pregnant women and helps them in designing their birth plans. Knowing that OB/GYNs have at least a 12% increased use of interventions in low-risk women (such as episiotomies) when compared with midwives, I think it is important that our patients have truly informed choice. Having the knowledge of the efficacy of routine episiotomy for prophylactic purposes will aid in my educating patients so that they have truly informed choice, particularly if the patient is being co-managed by an OB/GYN (their primary care provider for the pregnancy). For these reasons, this information will be relevant to all NDs who work with pregnant patients. Research Strategy: I utilized PubMed for my searching My first term was simply Episiotomy I wanted to see what was out there. It returned a whopping 2035 articles. I then searched Routine Episiotomy which returned 171 articles. From one article, I found several more linked to it, on similar topics, surrounding is routine episiotomy necessary in modern obstetrics? (Found several reviews) The next search was episiotomy and vaginal tear which returned 324 articles and was not as fruitful in finding articles specific to my question, but did return articles on the negative effects of episiotomy on maternal morbidity. This is indirectly related to my question because it provides impetus with which to show there are certain downfalls to the use of episiotomy. I then searched episiotomy and pelvic floor, returning 134 articles, many of which I will be using. The use of episiotomy appears to have been postulated as a method of protecting the pelvic floor from relaxation when it actually delivers the opposite results. Next I searched episiotomy to prevent vaginal tears which only brought back 16 articles, some of which I will be using I then searched episiotomy reduce perineal trauma returning 44 articles including some free articles which I will be using here. For the abstracts that fit my search but I was unable to access, I had a friend at U of T get the articles for me.

Discussion: Vaginal tears can occur during childbirth as the babys head passes through the vaginal opening and particularly if it descends quickly. These tears can involve perineal skin or extend to the muscles and anal sphincter and anus, which can be difficult to repair. Some primary care providers (midwoves, OBs) surgically cut the 1

Erica L. Robinson RCIA Assignment 2013 perineum (known as an episiotomy) in an effort to avoid tears and then suture the cut, proposing that this method incurs less damage given it is a straight line and easier to repair though as we will see below, this idea lacks scientific validation. Some childbirth facilities have or had a policy of routine episiotomy (Carroli & Mignini 2009). This routine use (instead of restrictive) is particularly what I shought to investigate. The papers I have looked at seek to find if routine episiotomy is indeed favourable and results in less damage to the perineum than restrictive episiotomy use (where only performed if actually needed versus routine / liberal use) and natural tearing. When discussing tearing to the vagina, anterior tearing refers to the structures including the labia, urethra, clitoris, and anterior vagina and is associated with little morbidity, while posterior refers to the posterior vaginal wall, perineal muscles and anal sphincter (Carroli & Mignini 2009). 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 Tearing is often the result of the babys head descending too quickly and not allowing the vagina enough time to dilate and allow appropriate tissue stretching (Carroli & Mignini 2009) however Hudelist et al state that specifically third degree tears are more related to a vaginal operative delivery (VOD) (with VOD being an independent risk factor for severe perineal trauma) and that while the external anal sphincter can be repaired immediately following childbirth with good outcomes in the research, it is the long-term complications noted in the research that have raised cause for alarm and the suggested use of episiotomy in VOD to avoid third degree tears, including: urinary incontinence, anal / fecal incontinence in 29-57% of patients, pelvic floor defects, dysparuneia, increased need for analgesics, sexual dysfunction, and depression. Carroli & Mignini note that while episiotomy is one of the most routine surgeries in use today, its widescale was introduced in the 1900s (having been around now for a total of 300 years) without strong scientific evidence for its effectiveness. Rates are 62.5% in the US, as high as 100% in Taiwan, and as low as 9.7% in Sweden and an average of 30% in Europe according to these authors. Suggested benefits of episiotomy include: Reduction in the likelihood of third degree tears 2

Erica L. Robinson RCIA Assignment 2013 Preventing relaxation of the muscles of the pelvic floor and perineum, purportedly leading to improved sexual functioning postpartum Reduced risk of fecal and urinary incontinence Easier to repair and heals better than a laceration due to being a straight cut 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 Suggested that it may be necessary to make more room for rotation maneuvers in the case of shoulder dystocia

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

Midline versus mediolateral episiotomy are hypothesized to differ in that: midline may have better sexual functioning in future and better healing with less scar, whereas mediolateral may result in less extension of the incision and decreased risk of severe perineal trauma, though these claims remain unknown according to Carroli & Mignini while Hudelist cites several large-scale studies demonstrating a higher risk for severe perineal damage with midline episitomy (2009). The Argentine Episiotomy Trial Collaborative Group reported that episiotomy rates above 30% in multiparous and 40% in primiparous women cannot be justified (Shahraki et el, 2011). Indeed one set of authors for an article examined below state that a 15% rate should be within reach (Hartmann et al 2005). While episiotomies have been around for three centuries and were initially reserved for difficult births, their routine use as a prevention of tears to the perineum became widespread at the beginning of the nineteenth century (Cleary-Goldman & Robinson, 2003). While the mediolateral technique was the first used, it was replaced in 1965 by the widespread use of the midline or median technique, despite the fact that it was

Erica L. Robinson RCIA Assignment 2013 known to increase 3rd and 4th degree tears (via extension of the midline episiotomy) and these 3rd and 4th degree tears were documented as going from <1% in 1965 to >17% (Cleary-Goldman & Robinson) after the introduction of the midline episiotomy. Knowing the risks involved with episiotomy, I continued to look into whether or not its routine use was valid. Here are the studies I found: Title of Article Reference Design Episiotomy for Vaginal Birth (Review) Carroli & Mignini 2009 Review of RCTs comparing routine episiotomy use with restrictive episiotomy use, RCTs comparing routine midline episiotomy with restrictive midline episiotomy, RCTs comparing restrictive mediolateral episiotomy with routine mediolateral episiotomy, and RCTs comparing midline vs mediolateral episiotomy Included eight studies of 5541 women. In the routine episiotomy group, 75.15% of women had episiotomy versus the restrictive group in which 28.40% had episiotomy. Compared with routine use, restrictive episiotomy resulted in: Less severe perineal trauma (RR 0.67, 95% CI 0.49-0.81) Less suturing (RR 0.71, 95% CI 0.49-0.91) Fewer healing complications (RR 0.69, 95% CI 0.56-0.85) But restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61-2.10) No difference in: Severe vaginal / perineal trauma (RR 0.92, 95% CI 0.72-1.18) Dysparuenia (RR 1.02, 95% CI 0.90-1.16) Urinary incontinence (RR 0.98, 95% CI 0.79-1.02) Severe pain measures Results for (restrictive vs. routine) (mediolateral vs. midline) were similar to the overall comparison Restrictive episiotomy use appears to have benefits when compared to routine episiotomy use, including less posterior perineal trauma, less suturing and fewer complications, however with more anterior trauma. The authors state that there is little evidence to support routine episiotomy. They also state that there is not enough evidence (only three trials at the time) to differentiate between a midline versus mediolateral episiotomy. They suggest in terms of clinical application that until further research becomes available and in the context of restrictive episiotomy, the caregiver should perform the episiotomy technique with which they are most familiar. They state that further research should look into the indications for restrictive episiotomy in the case of

Number and Detail of Studies Reviewed Summary of Results

Conclusions

Erica L. Robinson RCIA Assignment 2013 instrumental delivery, breech birth, macrosomia, preterm delivery and presumed imminent tears. They also note that a cost-effective analysis study in Argentina demonstrated that a restrictive episiotomy policy is less costly and more effective. Title of Article Reference Design Number and Detail of Studies Reviewed Summary of Results

The role of episiotomy in instrumental delivery: Is it preventative for severe perineal injury?
Hudelist et al 2008 A review of the data on the role of routine episitomy use in Vaginal Operative Delivery (VOD). The authors do not directly state the number of studies reviewed but include many studies on vaginal operative delivery in conjunction with midline episiotomy and VOD in conjunction with mediolateral episiotomy. One study observed included 33,842 primiparous and multiparous VODs with midline episiotomy (versus no episitomy) and found: When combining midline episiotomy with forceps delivery, higher risk for severe perineal trauma of 41.8% in primiparous (OR 21.1, 95% CI 16.7-25.5) and 22.2% in multiparous women (OR 77.1, 95% CI 49.7-104.5) In comparison to VOD alone (without episiotomy): 23.2% of primiparous experienced severe perineal trauma (OR 6.8, 95% CI 49.7-104.5) 8.5% in multiparous (OR 26.3, 95% CI 18,1-34.5) To recap, that is 41.8% severe trauma in the episiotomy group versus 23.2% trauma in the non episiotomy group in primiparous, and 22.2% vs 8.5% in multiparous; in either primip or multip more damage occurred with midline episiotomy With ventouse vacuum extraction method: 34.7% of primiparous women with midline episiotomy (OR 13.7, 95% CI 10.1-17.3) experienced severe perineal trauma versus 9.4% of primiparas who had ventouse alone ()R 3.1, 95% CI 1.9- 4.3) 30.3% of multiparous women with midline episiotomy (OR 123.5, 95% CI 71.1-175.9) experienced severe perineal trauma versus 0.5% of multiparas who had ventouse alone (OR 1.2, 95% CI 0.1-2.3) Another study reviewed indicated a significantly increased risk for sphincter trauma when combining VOD + midline episiotomy (RR 2.4, 95% CI 1.7-3.5) Yet another study examining VOD (forceps or ventouse) found that mediolateral episiotomy versus no incision resulted in a 5

Erica L. Robinson RCIA Assignment 2013 statistically increased risk of major trauma (7.5% verus 2.5%, 2.92 OR, 95% CI 1.27-6.72) They conclude that the majority of observational studies demonstrate that the use of midline episiotomy with VOD is more dangerous to the perineum than mediolateral episiotomy and thus midline should not be combined with VOD. They also conclude that mediolateral episiotomy when having a VOD is protective in reducing the incidence of severe perineal trauma when using instruments.

Conclusions

Title of Article

A comparison between early maternal and neonatal complications of restrictive episiotomy and routine episiotomy in primiparous vaginal delivery
Shahraki et all 2011 Cross-sectional study (n=80) looking at the short-term implications only, of routine versus restrictive episiotomy One cross-sectional study presented on a total of 80 women with normal vaginal delivery, in two groups of forty women: one a routine episiotomy group and the other restrictive episiotomy use. The two groups were compared at 24 and 48 hours in terms of perineal laceration size, neonatal apgar score and post-delivery pain. Episiotomy was performed in 7.5% of the restrictive group vs. 100% in the routine episiotomy group Indicated episiotomy in the restrictive group was due to irregular heartbeat during delivery as detected by the physician An intact perineum or a 1st degree tear was seen in 80% of the women in the restrictive group vs. 35% in the routine group: (restrictive group had 35% intact, 45% grade 1 tear) 2nd degree tears were seen in 75% of the routine group, 17.5% of the restrictive group 3rd degree tears in 15% of the routine group, 2.5% of the restrictive group 4th degree tears in 10% of the routine group and 0% of the restrictive group This demonstrates how rare spontaneous 3rd and 4th degree tears are, yet more likely to occur with episiotomy (despite prevention of tears being one of its claims of use) There was no significant difference in Apgar scores in the neonates There was less reported pain (via the Visual Analog Scale) at 24 and 48 hours postpartum in the restrictive group vs. the routine: Immediately after delivery average pain on VAS was 10 in restrictive group and 9 in routine; 24 hours later it was 6 in the restrictive group vs. 8 in the routine group; 48 hours later it was 5 in the restrictive group versus 6 in the routine group

Reference Design Number and Detail of Studies Reviewed

Summary of Results

Erica L. Robinson RCIA Assignment 2013 Conclusions The authors conclude that in restrictive episiotomy, the rate of indicated episiotomy was low. Also the rate of short-term maternal complications such as pain and perineal laceration was lower in the restrictive group, which goes against the hypothesis noted in my discussion above suggesting that routine episiotomy would prevent tears. They note that severe perineal trauma was not high overall but was lower in the restrictive group.

Title of Article Reference Design Number and Detail of Studies Reviewed Physicians beliefs and behaviour during a randomized control trial of episiotomy: consequences for women in their care Klein et al 1995 RCT of 447 women (226 primiparous and 221 multiparous) attended by 43 physicians The study initially involved 703 comparable women at low risk of medical or obstetric problems who were followed for 3 months postpartum. There were two arms of the study: restrictive use and liberal (but not routine) use of episiotomy The women in the study were eligible if they were between 18 and 40 yoa, 30-34 weeks pregnant at the starting time of the study, and giving birth at one of two university hospitals in Montreal with a parity of 0-2, pregnant with a single fetus. Physicians were given a 7-point scale to fill out, whereby if they attained a high score they were likely to view episiotomy and its consequences negatively. Similar rates of overall perineal trauma in primiparous both groups (restrictive vs. routine episiotomy) with more trauma caused by epiosotomy in the routine group, and more trauma from tears in the restricted group Multiparous women in the restrictive use group gave birth with an intact perineum more often than the routine group 53 of the 54 4th degree tears in this study were the result of a mediolateral episiotomy The authors did not see significant difference in postpartum perineal pain, perineal muscle strength, urinary or pelvic-floor symptoms or sexual functioning Women with an intact perineum had less perineal pain postpartum, required less medication, had stronger pelvic floor muscles at 3 months postpartum, resumed sexual relations earlier, had less pain during intercourse and were more sexually satisfied Episiotomy was strongly associated with extension to 3rd and 4th degree tears 1/3rd of physicians in the study did not change their use of 7

Summary of Results

Erica L. Robinson RCIA Assignment 2013 episiotomy as per the study protocol, performing episiotomy in 90% of the women in both the restrictive and liberal use group These physicians were also more likely to use oxytocin induction or augmentation of labour, epidural and c-section (which these women were then removed from the study) The authors then went on to study the phsycians beliefs, and then rearrange the data in accordance to the consequences of their beliefs on the perineums of the involved women The physicians likely to have a favourable view of episiotomy were more likely to be male and marginally older The physicians who viewed episiotomy favourably also had the highest rates of lithotomy position Women cared for by doctors that viewed episiotomy favourably were less likely to have an intact perineum (OR 0.45, p <0.05) Spontaneous tears appear preferable to episiotomy Physicians who viewed episitomy very unfavourably used the procedure less often and their patients had less severe perineal trauma (3rd and 4th degree lacerations) less perineal pain and higher satisfaction with the birth experience The authors conclude that episiotomy use is a system beginning with physician beliefs, linking them to clinical actions and resulting in their consequences Physicians who viewed episiotomy very unfavorably were more likely to allow labour to progress without interference, and women under their care had longer first stages of labour and received fewer oxytocin augmentations and c-sections Physicians who viewed episiotomy more favourably more often diagnosed fetal distress in apparently normal labours and more often thought the perineum was unable to distend or about to tear severely Information on the relation of attitudes and beliefs to care and outcome is only beginning to accumulate. So while this study initially demonstrated similar rates of perineal trauma (thus somewhat nullifying the protective effect of episiotomy against perineal trauma) which is connected to my original inquiry, it went on to provide additional information which I feel is also clinically relevant, particularly for NDs counseling pregnant women on care providers in their pregnancy, and the kinds of questions we might suggest they ask their care provider surrounding their beliefs on episiotomy.

Conclusions

Erica L. Robinson RCIA Assignment 2013 Title of Article Reference Design Number and Detail of Studies Reviewed The role of episiotomy in current obstetric practice Cleary-Goldman & Robinson 2003 A review of 7 studies (RCTs, Obersvational, Case-Control, Prospective, Retrospective) Examined 7 studies between 1984-2002 with a total of 111,106 participants, examining mediolateral episiotomy and severe perineal trauma Studies included were an RCT, an observational, 3 retrospective, 1 prospective, and 1 case-control in both primiparous and multiparous patients Also reviewed 6 studies comparing mediolateral and median (midline) episiotomy on a total of 437,291 women between 1980 and 2001 Furthermore reviewed 4 studies on 5588 women examining episiotomy and severe perineal trauma at VOD One of the studies mentioned analyzed approximately 5,000 deliveries grouping women into restrictive and routine mediolateral episiotomy use. The restrictive group experienced less perineal trauma (RR 0.88), less suturing (RR 0.74), and fewer healing complications (RR 0.69). There was no difference in severe perineal trauma (3rd and 4th degree lacerations), urinary incontinence, or dysparuenia. Anterior perineal trauma was more common in the restrictive group (RR 1.79) though noted of low morbidity. Median and mediolateral episiotomies are associated with more blood loss than no episiotomy at vaginal delivery with more blood loss from the mediolateral technique, with postpartum hemorrhage RR of 2.06 in one study and 4.67 in another The authors state that the association between post-partum pain and episiotomy is conflicting. Three studies examined demonstrated that both median and mediolateral episiotomy caused more pain than spontaneous tears, whereas one study found there was no relationship between pain and episiotomy type or lack thereof Severe perineal trauma (3rd and 4th degree lacerations) was associated with median episiotomy in rates of 9.7 26.9% of women receiving this type of episiotomy The data on episiotomy (none, midline, or mediolateral) at VOD was conflicting, with two studies showing that midline episiotomy was associated with increased severe perineal trauma, in one of the studies with a RR of 2.4. A third study found no significant difference in 3rd degree lacerations in those with and without midline episiotomy at VOD. The fourth study found 14.9% of the midline group to have severe trauma, 5.1% of the no episiotomy group, and 0.7% of the mediolateral group.

Summary of Results

Erica L. Robinson RCIA Assignment 2013 Conclusions There is no objective data from review of the literature that episiotomies are easier to repair than spontaneous lacerations. The literature supports a restricted role of episiotomy in current practice. The authors note that current indications for episiotomy are non-reassuring fetal status, possibly VOD, and shoulder dystocia. It remains unclear the role of episotomy at VOD, with three options: midline, mediolatera, or none. While the VOD itself is correlated with increased perineal damage, it remains unknown what role episiotomy plays here and the authors claim we dont know whether to choose midline or mediolateral, though the study above (Hudelist et al 2008) notes that mediolateral is preferred and midline associated with more perineal trauma.

Title of Article Reference Design Number and Detail of Studies Reviewed Summary of Results Outcomes of episiotomy: A systematic review Hartmann et al, 2005 Systematic Review 26 RCTs on routine episiotomy or type of episiotomy that assessed outcomes in the first 3 months postpartum, along with trials and prospective studies that assessed longer-term outcomes. Found fair to good evidence from clinical trials indicating severity of perineal laceration, pain, and pain medication use are no better in routine versus restrictive episiotomy groups Evidence regarding long-term outcomes is poor, particularly incontinence and pelvic floor dysfunction because no studies have yet to follow women to the age at which they are more likely to experience these outcomes Studies also show no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation No evidence demonstrated that episiotomy impaired sexual functioning but pain with intercourse was more common in women with episiotomy (RR 1.53, 95% CI 0.93-2.51) In pain outcomes examining postpartum pain at 10 days divided into mild, moderate, or severe, the routine use group had rates of 14.6%, 7.8% and 0.2% respectively, while the restrictive use group had rates of 14.1%, 7.5%, and 0.9%, and both groups being comparable at 3 months. Thus there was no significant difference and severity was virtually identical Outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision. They caution against the shift to an unfamiliar episiotomy technique and suggest that a more restrictive use will avert larger numbers of all types of perineal injuries than change in technique. They also state that in the absence of benefit and with a potential for harm, any procedure should be abandoned and claim that rates of 10

Conclusions

Erica L. Robinson RCIA Assignment 2013 episiotomy of less than 15% should be easily within reach, but that it is clinicians who are slow to change, but they should realign the evidence with episiotomy use (much like tonsil removal in children has decreased due to ongoing research). They note that the clinicians are the primary agents to exercise choice regarding episiotomy rather than the patient, but to me this shows that as NDs counseling patients, we can provide them with more information to start this kind of a conversation with their pregnancy primary care provider. The authors conclude that clinicians have the opportunity to avoid 1 million episiotomies per year that are not improving maternal outcomes. To quickly revisit the purported benefits of episiotomy and what the above studies showed: 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 Hartmann no benefit

Preventing relaxation of the muscles of the pelvic floor and perineum, purportedly leading to improved sexual functioning postpartum Reduced risk of fecal and urinary incontinence Easier to repair and heals better than a laceration due to being a straight cut 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

Cleary-Goldman no impact on incontinence Cleary-Goldman There is no objective data from review of the literature that episiotomies are easier to repair than spontaneous lacerations. Shahraki no difference in Apgar scores Other theories not investigated nor noted in any of the studies I found, more research needed

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Erica L. Robinson RCIA Assignment 2013 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

My question regarding the routine use of episiotomy has been resolved: there is no place for routine episiotomy use in modern obstetrics or midwifery, and rates over 15-30% show no further benefit to the mother or neonate and in fact could likely be brought as low as 10% as seen in several studies restrictive-use groups and country-wide in Sweden. The possible indications for episiotomy include shoulder dystocia, vaginal operative delivery, and non-reassuring fetal status, as a widening of the introtius allows for turning of the fetus in dystocia, and easier access with instrumentation, with a shorter stage two labour. In regards to VOD and episiotomy, while earlier research was unclear, it appears that midline episiotomies are more detrimental than mediolateral thus mediolateral episiotomies are preferred (Kudelish et al 2006, Hudelist et al 2008) I also learned more than I went searching for. It appears there are some preliminary associations in episiotomy rate, and favourable views of episiotomy in physicians (Klein et al 1995). Interestingly in another study, episotomy rates were 59.6% among OBs, 57.6% among family physicians, and 30.2% among Certified Nurse- Midwives (Rosenblatt et al, 1997). Hartmann et al note that there is currently a 35% episiotomy rate in the US but that it can differ between institutions, and in comparing Philadelphia alone with an overall rate of 42% (above the national average), some institutions have a 20% rate versus others with a 73% rate. Despite the fact that the routine use of episiotomy has not been supported by research for several years now and suggested to be abandoned, (de Tayrac et al 2006, Hartmann et al 2005), we can see that it is clinicians who are choosing to continue to practice more liberal episiotomy use rather than aligning their practice with current research. However on the positive side, use has been declining over the past two decades (Hartmann et al 2005). My findings modify my role in the management of perinatal women in that I believe a discussion surrounding episiotomy is a warranted component of prenatal visits. It may be of benefit to ascertain their primary care providers stance on episiotomy, and to illuminate the research for them so that they may take on a more active role in their own care and asking that their clinician stay up-to-date with research. Furthermore, I quickly investigated other perineum management techniques in order to provide future patients with further information to help manage the possible prevention of episiotomies. In a review by Eason et al, perineal massage during second stage labour, birthing position, infant head position, and minimizing of pushing suggested no difference in tear prevention, whereas an RCT on waterbirth did find less spontaneous trauma / tearing. A review by Beckmann & Garett concluded that controlled digital perineal massage was associated with an 12

Erica L. Robinson RCIA Assignment 2013 overall reduction in incidence of trauma requiring suturing in primiparous but not multiparous women and that women practicing perineal massage for the last month of pregnancy were less likely to require an episiotomy (2006). Lastly, the Epi-No inflatable device has several studies on its use from week 37 onwards. One pilot study showed a nonsignificant lower incidence of pelvic floor muscle injury (Shek et al 2011), another RCT found lower episiotomy rates in the treatment group (41.9% vs 50.5%; P = 0.11)(Ruckhberle et al 2009) and a further pilot study (abstract only available) shows a highly significantly improved outcome for the perineum in primiparous women compared to controls, with no actual numerical data available (Kovacs et al, 2004). While none of these options are conventional standards of care aside from perineal massage provided by midwives in second stage labour, they do represent alternatives that patients may utilize. Particularly the perineal massage for one month prior to birth, and potentially the Epi-No trainer. These two items may be recommended to patients to potentially lower episiotomy rate and are considered safe and cost-effective. The findings to my inquiry would affect my treatment strategy partially by recommending self-perineal massage in the final month of pregnancy, but also and more so by educating patients on this research so that they know its routine use is no longer warranted and can have an educated conversation about it with their primary care provider for the pregnancy. Limitations / Selection Process: The limitations of this paper were firstly that many of the articles were not available through CCNM subscriptions and backdoor methods of obtaining them had to be utilized for many articles, whereas a few were abstract-only. Luckily however I included all full-text articles in my discussion as I was able to access these through one means or another. Other limitations are that different institutions diagnose third degree (anal sphincter damage) tears differently according to Hudelist et al (2009), with 87% missed by midwives and 24% missed by doctors. This suggests they are misdiagnosed and repaired incorrectly according to Hudelist et al, potentially leading to unfavourable short and long-term outcomes. As well I believe this alters the evidence found, particularly if there is any correlation between midwife- attended birth and lower episiotomy (which there is) in which case data may state that 3rd degree tears are more common with episiotomy use but this may be incorrect simply due to misdiagnosis of existing 3rd degree tears in cases where no episiotomy was used, and knowing that midwives are a) more likely to misdiagnose and b) less likely to give episiotomy thus confounding the evidence. With respect to the quality of the research and levels of evidence, all of the evidence used fell into some of the top categories: RCTs, cohort studies and case-controlled studies.

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Erica L. Robinson RCIA Assignment 2013 Overall the articles I selected were mostly systematic reviews looking at several RCTs, cohort studies and case-controlled studies because this gives a better understanding of the research when we can combine many studies at once. I also chose to include studies looking at not only spontaneous vaginal birth but also vaginal operative delivery because VOD is an indication for episiotomy and I wanted to know if its routine use was justified in this respect to which the answer remains unclear (all we know is that mediolateral is preferable to midline episiotomy.) In conclusion I now have the research to support the abandonment of routine episiotomy use in favour of restrictive use and am better able to counsel patients on types of episiotomy and when they are warranted, as well as several potential methods of decreasing the chance of needing an episiotomy. References: Aasheim, V., Nilsen, A., Lukasse, M., & Reinar, L. (2011). Perineal techniques during the second stage of labour for reducing perineal trauma.. Cochrane Database Syst Rev., 7(12). Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/22161407 Beckmann, M., & Garrett, A. (2006). Antenatal perineal massage for reducing perineal trauma.. Cochrane Database Syst Rev., 25(1). Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/16437520 Carroli, G., & Mignini, L. (2009). Episiotomy for vaginal birth (review). Cochrane Database Syst Rev., 1. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/19160176 Cleary-Goldman, J., & Robinson, J. (2003). The role of episiotomy in current obstetric practice.. Semin Perinatol., 27(1), 3-12. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/12641298 Eason, E., Labrecque, M., Wells, G., & Feldman, P. (2000). Preventing perineal trauma during childbirth: a systematic review.. Obstet Gynecol., 95(3), 464-71. Retrieved March 2, 2013, from

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Erica L. Robinson RCIA Assignment 2013

http://ezproxy.ccnm.edu:2077/pubmed/10711565 Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. (2005). Outcomes of routine episiotomy: a systematic review.. JAMA, 293(17), 2141-8. Hudelist, G., Mastoroudes, H., & Gorti, M. (2008). The role of episiotomy in instrumental delivery: Is it preventative for severe perineal injury?. J Obstet Gynaecol., 28(5), 469-73. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/18850416 Klein, M., Gauthier, R., Jorgensen, S., Robbins, J., Kaczorowski, J., Johnson, B., et al. (1992). Does episiotomy prevent perineal trauma and pelvic floor relaxation?. Online J Curr Clin Trials., 10. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/1343606 Klein, M., Kaczorowski, J., Robbins, J., Gauthier, R., Jorgensen, S., & Joshi, A. (1995). Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.. CMAJ, 153(6), 769-79. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/7664230 Kok, J., Tan, K., Koh, S., Cheng, P., Lim, W., Yew, M., et al. (2004). Antenatal use of a novel vaginal birth training device by term primiparous women in Singapore.. Singapore Med J., 45(7), 318-23. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/?term=Antenatal+use+of+a+novel +vaginal+birth+training+device+by+term+primiparous+women+in+Singap ore

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Erica L. Robinson RCIA Assignment 2013

Kovacs, G., Heath, P., & Heather, C. (2009). First Australian trial of the birth-training device Epi-No: a highly significantly increased chance of an intact perineum.. Aust N Z J Obstet Gynaecol. , 44(4), 347-8. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/15282009 Kudish, B., Blackwell, S., Mcneely, S., Bujold, E., Kruger, M., Hendrix, S., et al. (2006). Operative vaginal delivery and midline episiotomy: a bad combination for the perineum.. Am J Obstet Gynecol., 195(3), 749-54. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/16949408 McDonald, E., & Brown, S. (2013). Does method of birth make a difference to when women resume sex after childbirth?. British Journal of Obstetrics and Gynaecology, 120(4). Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/23442053 Rosenblatt, R., Dobie, S., Hart, L., Schneeweiss, R., Gould, D., Raine, T., et al. (1997). Interspecialty differences in the obstetric care of low-risk women.. Am J Public Health., 87(3), 344-51. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/9096532 Ruckhberle, E., Jundt, K., Buerle, M., Brisch, K., Ulm, K., Dannecker, C., et al. (2009). Prospective randomised multicentre trial with the birth trainer EPI- NO for the prevention of perineal trauma.. Aust N Z J Obstet Gynaecol. , 49(5), 478-83. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/19780729 Shahraki, A., Aram, S., Pourkabirian, S., Khodaee, S., & Choupannejad, S. (2011). A comparison between early maternal and neonatal complications of

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Erica L. Robinson RCIA Assignment 2013

restrictive episiotomy and routine episiotomy in primiparous vaginal delivery.. J Res Med Sci. , 16(12), 1583-9. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/?term=PMC3434900 Shek, K., Chantarasorn, V., Langer, S., Phipps, H., & Dietz, H. (2011). Does the Epi-No Birth Trainer reduce levator trauma? A randomised controlled trial.. Int. Urogynecol. Journal, 22(12), 1521-8. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/21809156 http://ezproxy.ccnm.edu:2077/pubmed/23204687 Tayrac, R. d., Panel, L., Masson, G., & Mares, P. (2006). [Episiotomy and prevention of perineal and pelvic floor injuries].. J Gynecol Obstet Biol Reprod (Paris)., 35(1), 1S24-1S31. Retrieved March 2, 2013, from http://ezproxy.ccnm.edu:2077/pubmed/16495824

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