Much Ado about a little cut

or If preventing perineal trauma is so important, why doesn’t everybody try harder to prevent it?

by Dr. Perle Feldman

In their article in this issue Eason and Labreque seek to define what we know about prevention of perineal trauma in the process of childbirth. Their answer seems to be that there is not a lot that we can be certain of. However it is clear that episiotomy is a major contributor to trauma, pain and suffering in parturient women. Yet recent generations of doctors have been taught that episiotomy benefits the mother, and expeditious delivery protects the baby. Despite increasing recent experimental data of the uselessness of episiotomy and its potential for damage it continues to be an extremely common intervention. It serves as a case in point of a cultural change in medicine, research knowledge follows disatisfaction of some practitionerswith the status quo and pressure from consumers. Research proof changes practice within large university centers, and places where the researchers are inluential. Knowledge is then spread by residents and students either as they graduate and bring their new knowlede to their new institutions or within the institution they transmit new skills from one practitioner to another. Yet there is always a conservative element people who are skeptical of change. Particularly when there are other reasons to maintain the practice.

During the Klein (1994) research trials, many of the participating obstetricians commented that while Klein’s propositions might be true that they were trivial. “Who cares about a little cut?” was the common theme. Yet by the end of the trial the use of routine episiotomy had fallen almost 50%. Two factors seemed to be responsible for this “cultural change”: first, the advantages of restricted use of episiotomy to the physicians, and second, the overwhelmingly positive response of the patients. The Obstetrical and Family medicine residents served as “vectors” infecting the “high cutters” with the skills necessary to protect the perineum once that was seen as desirable.

Leavitt, in her historical analysis of childbirth practices in North America (ref pleaseErica), underlines the importance of patients’ input and desires. She states that in each generation the concerns of women for safer, less painful, more humane childbirth have shaped research and practice. Each generation has had its particular concerns, and has built on the successes as well as problems arising from the practices of the previous generation.

Thus, the breakdown of social childbirth led to an increase in hospital births during the late 19th century. A desire for safer births led to an increase in the use of anesthesia, intravenous fluids, antibiotics, and other interventions in the 1950’s and 60’s. In the last thirty years, the natural childbirth movement reacted against the medicalization of birth and demanded a greater humanization of care. Because of the conflict between advocates of natural childbirth and some technologically oriented practitioners, there is an increasing demand for a rational evaluation of routine practices in order to bring about a balance between the desire for a woman-centered birth and necessary interventions for the safety of both mother and baby. This can only be done by analyzing what we do, so as to tease out what is useful and necessary, from the morass of tradition, custom and convenience.

What explains the excessive use of episiotomy even now? We suggest that there are potent reasons. The episiotomy allows faster delivery of the head. The conflicting demands of a busy office, OR, and emergency room can make a more expeditious approach seem desirable. The Zen of “just sitting” and waiting is a demanding discipline. For those of a more “surgical” personality watchfully waiting for the perineum to stretch and verbally guiding a mother through the end of the second stage is much more difficult than “just doing” the delivery. This can be particularly difficult while watching those disconcerting second stage variable decelerations under the omnipresent threat of malpractice. Doing episiotomy can also minimize time spent at the bedside. Those of us who work in teaching hospitals may feel comfortable leaving an experienced resident to sew up a simple episiotomy rather than a more irregular and less standardized tear. Even those of us who do not practice in a teaching hospital acquired our delivery styles in that context.

Reluctance to avoid episiotomy may also relate to inexperience, as so well expressed by Esther Floud: ‘A midwife who has learned to use episiotomy freely will have rarely observed spontaneous delivery and may therefore lack confidence in the elasticity of the perineal tissue’ {FLOUD1994}. Our own impression is that the (rare) ‘shredding’ perineal lacerations occur only with uncontrolled pushing or operative delivery, when the perineum does not have time to stretch. Operative delivery may be an indication for mediolateral episiotomy, but this has not been assessed by randomized controlled trial.

Where do we go from here?

In their article in this issue of CMAJ, Eason and Labrecque summarize the evidence on protecting the perineum, and identify areas where research is needed. Many techniques have been vigorously affirmed to prevent perineal trauma, using value-laden descriptors like ‘gentle’ and ‘natural’ but scientific evidence is lacking to support most of these claims. These techniques must be proven to work before it is justified to promote them. Listening to the voice of authority has led us down the garden paths of routine episiotomy and prophylactic forceps (not to mention fetal monitoring!) The principles of evidence-based care are nowhere more important than in the process of birth. Who cares about the care of the perineum? I suggest that those who care most are the women who give birth and the men who are their sexual partners. These are important people and I think it behooves us to try and understand what we know and to find out as much as we can.

‘the complete protection of the perineum has undoubtedly remained a weak spot in our art’

F. Ritgen, 1855 {RITGEN1855}