I am frequently asked by clients my opinion on their birth decisions. Generally speaking my reaction is to introduce them to information from experts and then suggest that they make their decisions based on what they have gleaned from the literature along with their own intuition. Rarely do I insert my personal philosophy into these discussions because I don’t always see the decisions as black and white.
Episiotomy is one of the few topics that to me IS black and white. It may sound radical but my personal philosophy on routine (or prophylactic) episiotomy is that is is genital mutilation and I don’t feel it has a place in normal labor and delivery.
I know…“Come on Tracie, don’t tiptoe…tell us how you really feel.” I am speaking bluntly about this topic because I have seen the needless suffering it causes and I got tired of feeling helpless when hearing women’s heartbreaking stories of physical and emotional pain.
The turning point for me was when a close friend was telling me that over a year after her son’s birth she was still unable to have intercourse without intense pain at her repair site. When it came out in the conversation that she could have refused the episiotomy she said to me, “Tracie! Why didn’t you tell me this BEFORE I had one.”
Of course the reason I didn’t was that I figured it wasn’t my business and I didn’t want to be perceived as opinionated. (Can you imagine someone thinking that I am opinionated? Shocking!) After this incident I realized that I felt far more regret over my friend’s pain that I would have about possibly having an awkward moment if I were told to mind my business. I vowed to myself that I would never again let my concern for how I am perceived interfere with opportunities to educate women about protecting their bodies. So with that said, here is my take on episiotomy---take it or leave it.
One of the most common fears I hear from women is that they’ll have a big baby or at least a baby with a big head. Often that fear is heightened by practitioners who threaten that they will likely experience severe tearing if they don’t submit to an episiotomy. This is supported by well meaning friends and family who in their own experience believe this fallacy for one reason or another.
The presumption is that a) All women will need one because “there is no way something that big can fit through an opening that small” b) Episiotomy will protect the perineum from tearing.
These two presumptions are absurd on so many levels but let’s talk about why they are fallacies.
Fallacy #1: Actually has two components; “...there isn’t room for the baby to come out without an episiotomy” and “...if I don’t get one I will tear.” Allow me to interject a personal experience here. While I realize that this is anecdotal only, sometimes things make the most sense to me when I hear a real story instead of a statistic.
My first baby only weighed 7lbs. 5oz. but his head was nearly 15 in. I was told prior to delivery that I was likely carrying a baby well over 9 lbs. based on the size of his noggin. While I admit it was no picnic pushing him out, the point is, I did---and I did it without an episiotomy and without perineal tearing. (I did have a very small hymenal tear that I never felt or noticed, and lets face it--I haven’t needed that old hymen in years.) Was I able to do this because of my maternal super powers? No. I am about as average as women come. The point of the anecdote is simply that a big head does not mean a traumatic delivery. But there is more to the story.
I had discussed my passionate objection to episiotomy with my OB prior to the birth. Although for the most part he agreed that they are “usually unnecessary” he also made clear that he felt they had their place in delivery and that if it appeared that I might tear he would want to perform one. I told him I’d rather roll the dice and take my chances with tearing. We agreed to disagree and his attitude was pretty much, “Hey lady, it’s your funeral.”
Skip ahead to birth day: At the point that my son was crowning my doctor noticed "blanching” (which is where the skin is stretched so tight it appears white from lack of blood flow to that area---blanching often precedes tearing). He looked up at me and said, “I think you are going to tear. Are you sure you don’t want an episiotomy?” I politely declined. (After I told him what he could do with his @%&* scissors, I am pretty sure I offered to give him an episiotomy. I confess; I am not always my sweet self when I am in transition).
On the next contraction I gave one more push and my son practically fell out of me. After the birth; when my perineum was still intact; the doctor very sweetly said, “Good call on not getting that episiotomy.” I thought it took some humility for him to admit that.
I tell this story to illustrate how modern obstetrics is primed to believe that women can’t give birth without intervention and how that belief is passed onto the consumer because we believe that doctors always know better than us. I like to think that the conclusion of this experience was that I became empowered and my doctor learned something about women’s abilities.
Fallacy #2: An episiotomy will protect you from tearing. This is completely unreasonable. “You might tear, so lets cut you just to be safe.” This is just about as ridiculous as saying, “You might get hit by a car today, so just in case, go lay down in the driveway and I’ll run you over.”
Interestingly in obstetrical lingo a tear is called a laceration and an episiotomy is also called a laceration so what exactly does performing a laceration do to prevent a laceration. Do you see the circular logic? Let’s put it this way, if you refuse an episiotomy then the worst thing that could happen is that you might have a laceration. If you get an episiotomy then you will definitely have a laceration.
It should be noted that most women will not tear at all and of the few tears that DO occur, the majority are so insignificant as to not require suturing. When they do need suturing it is a few stitches instead of the extensive repair of several layers of fascia which is required with all episiotomies.
Here is a visual. Hold up your index finger and thumb and look at the U shaped tissue that connects the two. Imagine that is the perineum. Now with your other hand make a pair of scissors and snip the tissue there. Notice that you are not just incising the front side of that, you are also cutting the back side. This means that a 1 in. cut is really a 2 in. cut. Now imagine that you are also cutting into the muscle that is beneath that tissue.
This is how an episiotomy is performed. Unlike a tear which only occurs at the point that is stretched tightest, the episiotomy takes in all layers of skin that come in contact with the surgical scissors. This is the reason that severe tearing such as fourth degree tearing occurs almost exclusively after an episiotomy has been performed. It is extremely rare for severe tearing of any kind to occur when there has been no episiotomy.
If you have concerns about tearing even a little bit, then start researching ways to avoid it. There is really no reason to tear if certain precautions are taken. Here are a few prevention tips:
1) Completely avoid the lythotomy position. (Lying on your back with your legs in the air.) Not only is it very uncomfortable and inhibits the natural use of gravity, but the pressure on the perineum is unnatural and frequently causes tearing.
2) Talk to your doctor/midwife about providing perineal support and (if necessary) manipulation (pushing the skin back and easing the baby’s head through--kind of like putting on a tight turtle neck). If they are unwilling or unable to assist you---CHANGE PROVIDERS.
3)Absolutely do not submit to an episiotomy. There is a MUCH greater risk of 4th degree tearing when one has been performed. (Think about trying to tear a piece of fabric without cutting it and then think about how if you give it a “little snip” it can be easily torn.)
4) Learn all you can about controlled crowning through breathing and holding back for a contraction just at the point of crowning to allow that little bit of stretch that takes place right then.
5) Avoid meds especially epidural because the more in control of your muscles that you are the more able to push effectively and to hold back when needed. You are also able to adopt appropriate positions for pushing such as squatting, hands and knees, c position, etc. and your instinct will tell you what is best for you at the time. (Be open to whatever your instincts tell you)
Where did we lose sight of the fact that for thousands of years women gave birth without being rescued by a surgeon? (And that is in fact what episiotomy is---surgery.) Why is it that we believe ourselves to be so different than our predecessors when it comes to the fundamental ability to give birth?
Women’s bodies were made to give birth---that’s why we get hormones that relax our bones (relaxin), and why we get hormones to open our cervix (oxytocin) and why the uterus begins the process of expelling the baby. Babies’ bodies were made to be born---that’s why they have bones in their heads that overlap and mold to the smallest point possible, and why their shoulders pop under their shoulder blades, and why they squirm and turn instinctively in the direction opposite to where they are encountering resistance from bone (the pelvis). Have faith in the process and forget the rhetoric you may hear from negative people...it’s not worth listening to if it contradicts the facts and science of human anatomy.
Wednesday, July 30, 2008
Episiotomy
The following is excerpted from Obstetric Myths vs. Research Realities by Henci Goer
Myth: A nice clean cut is better than a jagged tear.
Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989
Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it.
In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it "protects the perineum from injury," a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have gotten around to looking, every study has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.
By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual disatisfaction after childbirth (the concern was the male partner, of course, hence, the once-popular "husband's knot," an extra tightening during suturing that made many women's sex lives a permanent misery), urinary incontinence, and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies. In any case, episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended. Nor has anyone ever explained how cutting a muscle and stitching it back together preserves its strength.
Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986; The 1990, both abstracted below).
Meanwhile, episiotomy, like any other surgical procedure, carries the risk of blood loss, poor wound healing, and infection. Infections are painful. Sutures must be removed to drain the wound, and later the perineum must be restitched.
Obviously an infection could start in a repaired tear, but substantial numbers of women who do not have episiotomies have intact perineums…It bears repeating that women with no episiotomy hardly ever suffer deep tears.
Despite two decades of evidence to the contrary, most doctors and some midwives still cling to the liberal use of episiotomy. The Canadian multicenter randomized controlled trial (Klein et al. 1992, ) could not get doctors to abandon it. Episiotomy rates were reduced by only one-third in the so-called restricted arm of the study. More than half of primiparas (first time mothers) in the restricted group (57%) still had episiotomies, as did nearly one-third of multiparas (women who have given birth previously) (31%). "The intensity with which physicians adhere to the belief that episiotomy benefits women is well illustrated by the behavior of many of the participating physicians in this trial. Many were unwilling or unable to reduce their episiotomy rate according to protocol."
If episiotomy lacks scientific rationale, what drives its use? As Robbie Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits underlying cultural beliefs about women and childbirth. It reinforces beliefs about the inherent defectiveness and untrustworthiness of the female body and the dangers this poses to women and babies. So DeLee (1920), imbued with these beliefs, writes:
Labor has been called, and still is believed by many, to be a normal function. . . . Yet it is a decidedly pathologic process. . . . If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic--abnormal, but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby's head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal.
Having invented the problem, he proffers a solution: as soon as the head passes through the dilated cervix, anesthetize the woman with ether, cut a large mediolateral episiotomy, pull the baby out with forceps, and manually remove the placenta, then give the woman scopolamine and morphine for the lengthy repair work and to "prolong narcosis for many hours postpartum and to abolish the memory of labor." Repair involves pulling down the cervix with forceps to examine it and stitch any tears and laboriously reconstructing the vagina to restore "virginal conditions." While few modern obstetricians are willing to go as far as DeLee, these beliefs about women still pervade obstetrics, and they fuel episotomy.
Episiotomy serves another purpose. Davis-Floyd observes that surgery holds the highest value in the hierarchy of Western medicine, and obstetrics is a surgical specialty. Episiotomy transforms normal childbirth--even natural childbirth in a birthing suite--into a surgical procedure.
Davis-Floyd also points out that episiotomy, the destruction and reconstruction of women's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." This is what lurks behind DeLee's emphasis on surgically restoring "virginal conditions." It also partially explains why most trials of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada, where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. Klein et al. attribute the greater success of a British "restricted" versus "liberal" use of episiotomy trial in achieving fewer episiotomies and more intact perineums to "the increased comfort of British midwives in attending births with the intention of preserving an intact perineum."
In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs.
Summary of Significant Points
Episiotomies do not prevent tears into or through the anal sphincter or vaginal tears. In fact, deep tears almost never occur in the absence of an episiotomy. (Abstracts 1-12, 16, 19-20, 23-28)
Even when properly repaired, tears of the anal sphincter may cause chronic problems with coital pain and gas or fecal incontinence later in life. In addition, anal injury predisposes to rectovaginal fistulas. (Abstracts 11, 15, 21-22)
If a woman does not have an episiotomy, she is likely to have a small tear, but with rare exceptions the tear will be, at worst, no worse than an episiotomy. (Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)
Episiotomies do not prevent relaxation of the pelvic floor musculature. Therefore, they do not prevent urinary incontinence or improve sexual satisfaction. (Abstracts 1-4, 7, 12-16)
Episiotomies are not easier to repair than tears. (Abstracts 1, 3, 9)
Episiotomies do not heal better than tears. (Abstracts 1, 5-6, 12-15, 21)
Episiotomies are not less painful than tears. They may cause prolonged problems with pain, especially pain during intercourse. (Abstracts 1, 2, 7, 12, 14-15, 19-20)
Episiotomies do not prevent birth injuries or fetal brain damage. (Abstracts 1, 3, 5-7, 12, 14, 17-18, 27)
Episiotomies increase blood loss. (Abstracts 1, 12, 19)
As with any other surgical procedure, episiotomies may lead to infection, including fatal infections. (Abstracts 1, 12, 19, 22)
Epidurals increase the need for episiotomy. They also increase the probability of instrumental delivery. Instrumental delivery increases both the odds of episiotomy and deep tears. (Abstracts 5, 11-12, 21, 25-26)
The lithotomy position increases the need for episiotomy, probably because the perineum is tightly stretched. (Abstracts 10, 25, 27)
The birth attendant's philosophy, technique, skill, and experience are the major determinants of perineal outcome. (Abstracts 2, 5-7, 9-10, 25-27)
Some techniques for reducing perineal trauma that have been evaluated and found effective are: prenatal perineal massage, slow delivery of the head, supporting the perineum, keeping the head flexed, delivering the shoulders one at a time, and doing instrumental deliveries without episiotomy. (Others, such as perineal massage during labor or hot compresses have yet to be studied.) (Abstracts 23-24, 28)
Independent of specifically contracting the pelvic floor muscles (Kegels), a regular exercise program strengthens the pelvic floor. (Abstract 13)
References
Cunningham FG, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 18th ed. Norwalk, CT: Appleton and Lange, 1989.
Davis-Floyd RE. Birth as an American rite of passage. Berkeley: University of California Press, 1992.
DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:34-44.
Ewing TL, Smale LE, and Elliott FA. Maternal deaths associated with postpartum vulvar edema. Am J Obstet Gynecol 1979;134:173-179.
Golde S and Ledger WJ. Necrotizing fasciitis in postpartum patients: a report of four cases. Obstet Gynecol 1977;50(6):670-673.
Oxorn-Foote H. Human labor and birth. 5th ed. Norwalk, CT: Appleton-Century-Crofts, 1986.
Pritchard JA, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 17th Edition. Norwalk: Appleton, Century, Crofts, 1985.
Shy KK and Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Obstet Gynecol 1979;54(3):292-298.
Sleep J, Roberts J, and Chalmers I. The second stage of labour. In A guide to effective care in pregnancy and childbirth. Enkin M, Keirse MJNC, and Chalmers I, eds. Oxford: Oxford University Press, 1989.
Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 1986;68(3 Suppl):26S-28S.
Sutton GP et al. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66(5):733-736.
Myth: A nice clean cut is better than a jagged tear.
Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989
Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it.
In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it "protects the perineum from injury," a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have gotten around to looking, every study has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.
By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual disatisfaction after childbirth (the concern was the male partner, of course, hence, the once-popular "husband's knot," an extra tightening during suturing that made many women's sex lives a permanent misery), urinary incontinence, and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies. In any case, episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended. Nor has anyone ever explained how cutting a muscle and stitching it back together preserves its strength.
Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986; The 1990, both abstracted below).
Meanwhile, episiotomy, like any other surgical procedure, carries the risk of blood loss, poor wound healing, and infection. Infections are painful. Sutures must be removed to drain the wound, and later the perineum must be restitched.
Obviously an infection could start in a repaired tear, but substantial numbers of women who do not have episiotomies have intact perineums…It bears repeating that women with no episiotomy hardly ever suffer deep tears.
Despite two decades of evidence to the contrary, most doctors and some midwives still cling to the liberal use of episiotomy. The Canadian multicenter randomized controlled trial (Klein et al. 1992, ) could not get doctors to abandon it. Episiotomy rates were reduced by only one-third in the so-called restricted arm of the study. More than half of primiparas (first time mothers) in the restricted group (57%) still had episiotomies, as did nearly one-third of multiparas (women who have given birth previously) (31%). "The intensity with which physicians adhere to the belief that episiotomy benefits women is well illustrated by the behavior of many of the participating physicians in this trial. Many were unwilling or unable to reduce their episiotomy rate according to protocol."
If episiotomy lacks scientific rationale, what drives its use? As Robbie Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits underlying cultural beliefs about women and childbirth. It reinforces beliefs about the inherent defectiveness and untrustworthiness of the female body and the dangers this poses to women and babies. So DeLee (1920), imbued with these beliefs, writes:
Labor has been called, and still is believed by many, to be a normal function. . . . Yet it is a decidedly pathologic process. . . . If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic--abnormal, but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby's head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal.
Having invented the problem, he proffers a solution: as soon as the head passes through the dilated cervix, anesthetize the woman with ether, cut a large mediolateral episiotomy, pull the baby out with forceps, and manually remove the placenta, then give the woman scopolamine and morphine for the lengthy repair work and to "prolong narcosis for many hours postpartum and to abolish the memory of labor." Repair involves pulling down the cervix with forceps to examine it and stitch any tears and laboriously reconstructing the vagina to restore "virginal conditions." While few modern obstetricians are willing to go as far as DeLee, these beliefs about women still pervade obstetrics, and they fuel episotomy.
Episiotomy serves another purpose. Davis-Floyd observes that surgery holds the highest value in the hierarchy of Western medicine, and obstetrics is a surgical specialty. Episiotomy transforms normal childbirth--even natural childbirth in a birthing suite--into a surgical procedure.
Davis-Floyd also points out that episiotomy, the destruction and reconstruction of women's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." This is what lurks behind DeLee's emphasis on surgically restoring "virginal conditions." It also partially explains why most trials of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada, where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. Klein et al. attribute the greater success of a British "restricted" versus "liberal" use of episiotomy trial in achieving fewer episiotomies and more intact perineums to "the increased comfort of British midwives in attending births with the intention of preserving an intact perineum."
In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs.
Summary of Significant Points
Episiotomies do not prevent tears into or through the anal sphincter or vaginal tears. In fact, deep tears almost never occur in the absence of an episiotomy. (Abstracts 1-12, 16, 19-20, 23-28)
Even when properly repaired, tears of the anal sphincter may cause chronic problems with coital pain and gas or fecal incontinence later in life. In addition, anal injury predisposes to rectovaginal fistulas. (Abstracts 11, 15, 21-22)
If a woman does not have an episiotomy, she is likely to have a small tear, but with rare exceptions the tear will be, at worst, no worse than an episiotomy. (Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)
Episiotomies do not prevent relaxation of the pelvic floor musculature. Therefore, they do not prevent urinary incontinence or improve sexual satisfaction. (Abstracts 1-4, 7, 12-16)
Episiotomies are not easier to repair than tears. (Abstracts 1, 3, 9)
Episiotomies do not heal better than tears. (Abstracts 1, 5-6, 12-15, 21)
Episiotomies are not less painful than tears. They may cause prolonged problems with pain, especially pain during intercourse. (Abstracts 1, 2, 7, 12, 14-15, 19-20)
Episiotomies do not prevent birth injuries or fetal brain damage. (Abstracts 1, 3, 5-7, 12, 14, 17-18, 27)
Episiotomies increase blood loss. (Abstracts 1, 12, 19)
As with any other surgical procedure, episiotomies may lead to infection, including fatal infections. (Abstracts 1, 12, 19, 22)
Epidurals increase the need for episiotomy. They also increase the probability of instrumental delivery. Instrumental delivery increases both the odds of episiotomy and deep tears. (Abstracts 5, 11-12, 21, 25-26)
The lithotomy position increases the need for episiotomy, probably because the perineum is tightly stretched. (Abstracts 10, 25, 27)
The birth attendant's philosophy, technique, skill, and experience are the major determinants of perineal outcome. (Abstracts 2, 5-7, 9-10, 25-27)
Some techniques for reducing perineal trauma that have been evaluated and found effective are: prenatal perineal massage, slow delivery of the head, supporting the perineum, keeping the head flexed, delivering the shoulders one at a time, and doing instrumental deliveries without episiotomy. (Others, such as perineal massage during labor or hot compresses have yet to be studied.) (Abstracts 23-24, 28)
Independent of specifically contracting the pelvic floor muscles (Kegels), a regular exercise program strengthens the pelvic floor. (Abstract 13)
References
Cunningham FG, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 18th ed. Norwalk, CT: Appleton and Lange, 1989.
Davis-Floyd RE. Birth as an American rite of passage. Berkeley: University of California Press, 1992.
DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:34-44.
Ewing TL, Smale LE, and Elliott FA. Maternal deaths associated with postpartum vulvar edema. Am J Obstet Gynecol 1979;134:173-179.
Golde S and Ledger WJ. Necrotizing fasciitis in postpartum patients: a report of four cases. Obstet Gynecol 1977;50(6):670-673.
Oxorn-Foote H. Human labor and birth. 5th ed. Norwalk, CT: Appleton-Century-Crofts, 1986.
Pritchard JA, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 17th Edition. Norwalk: Appleton, Century, Crofts, 1985.
Shy KK and Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Obstet Gynecol 1979;54(3):292-298.
Sleep J, Roberts J, and Chalmers I. The second stage of labour. In A guide to effective care in pregnancy and childbirth. Enkin M, Keirse MJNC, and Chalmers I, eds. Oxford: Oxford University Press, 1989.
Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 1986;68(3 Suppl):26S-28S.
Sutton GP et al. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66(5):733-736.
Tuesday, July 29, 2008
Due Date
The concept of a due date is based on a gestational length established by fiat in the early 1800s. Franz Carl Naegele officially declared that pregnancy lasted 10 lunar months (10 x 28 days), counting from the first day of the last menstrual period). However, when Mittendorf et al. measured the median duration of pregnancy, they found that healthy, white, private care, primiparous women with well-established due dates averaged 288 days and multiparas averaged 283 days, values significantly differnet from both Naegele's rule and each other.
Others have found similar results. Mittendorf et al. also cited other studies showing racial differences in gestational length. For example, one showed that black women averaged 8.5 days fewer than white women of similar socioeconomic status.
Moreover, ultrasound-determined due dates are not accurate. One study used the date extablished by ultrasound at 16 to 18 weeks to test the validity of dating by the last normal menstrual period (LNMP). It found that as gestational age went past term positive predictive values for the LNMP declined from 95% to 12%. The authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound date is the problem. Even first trimester measurements have an error bar of +/-5 days in the second trimester and +/-22 days in the third.
Few practitioners appreciate the limitaions of ultrasound or clinical data. Otto and Platt say the due date should not be changed unless the discrepancy is more than two weeks, yet they see doctors changing a due date by a few days, no trivial alteration if a woman will be induced when she exceeds a certain date.
Some risk does accrue in healthy postdate pregnancies (notably meconium passage and big babies) but it does not follow that we should induce all women. Studies have found that as gestational age goes from 37 to 44 weeks, perinatal mortality and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate pregnancies on grounds of increased complications, should we not equally logically try to delay labor onset in the early term group?
-Henci Goer Obstetric Myths vs. Research Realities, Bergin & Garvey 1994
Others have found similar results. Mittendorf et al. also cited other studies showing racial differences in gestational length. For example, one showed that black women averaged 8.5 days fewer than white women of similar socioeconomic status.
Moreover, ultrasound-determined due dates are not accurate. One study used the date extablished by ultrasound at 16 to 18 weeks to test the validity of dating by the last normal menstrual period (LNMP). It found that as gestational age went past term positive predictive values for the LNMP declined from 95% to 12%. The authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound date is the problem. Even first trimester measurements have an error bar of +/-5 days in the second trimester and +/-22 days in the third.
Few practitioners appreciate the limitaions of ultrasound or clinical data. Otto and Platt say the due date should not be changed unless the discrepancy is more than two weeks, yet they see doctors changing a due date by a few days, no trivial alteration if a woman will be induced when she exceeds a certain date.
Some risk does accrue in healthy postdate pregnancies (notably meconium passage and big babies) but it does not follow that we should induce all women. Studies have found that as gestational age goes from 37 to 44 weeks, perinatal mortality and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate pregnancies on grounds of increased complications, should we not equally logically try to delay labor onset in the early term group?
-Henci Goer Obstetric Myths vs. Research Realities, Bergin & Garvey 1994
Fluids in Labor
Conference ReportHighlights of the 35th Annual Meeting of the Society for Obstetric Anesthesia and PerinatologyMay 14-17, 2003; Phoenix, Arizonafrom Medscape Ob/Gyn & Women's HealthPosted 06/05/2003
"Can I please have something to drink?" Preoperative Intake of Clear Liquids Work presented by Cynthia Wong, MD, and colleagues from Northwestern University in Chicago, Illinois, found that gastric emptying of water was normal in term, obese patients. This is an important finding that supports the recent trend toward liberalization of preoperative intake of clear liquids as well as the allowance of oral clear liquid intake during labor.
Liberalization of previously held strict NPO ("nothing by mouth") policies appears safe and will result in improved patient comfort and satisfaction. The topic of oral intake during labor was also the subject of a Pro-Con debate between Geraldine O'Sullivan, MD, from St. Thomas' Hospital in London, and Samuel Hughes, MD, of the University of San Francisco, California.
Dr. O'Sullivan opined that the stomach of pregnant women is almost always "full" regardless of fasting times, that parturients seldom wish to eat large amounts of solid food in labor anyway, and that gastric emptying appears to be normal in pregnancy and labor, contrary to previously held beliefs.
Thus, she argued that limited amounts of liquids and even soft solids be allowed during labor, as a means of providing comfort and improving metabolic markers related to prolonged food deprivation. Moreover, she argued that maternal deaths related to anesthesia are usually the result of failed attempts to secure the airway, rather than pulmonary aspiration of gastric contents.
By contrast, Dr. Hughes argued that maternal mortality due to all causes, including anesthetic causes, has markedly declined over the past several decades and that clinicians should continue to do everything possible to continue this trend, in the interest of patient safety. He stated that hydration can be achieved with intravenous fluids, and that limitation of oral intake during labor is a small price to pay for improved safety.
Interestingly, a vote of the audience members both before and after the debate indicated a sizable number of converts to the opinion of Dr. O'Sullivan.
"Can I please have something to drink?" Preoperative Intake of Clear Liquids Work presented by Cynthia Wong, MD, and colleagues from Northwestern University in Chicago, Illinois, found that gastric emptying of water was normal in term, obese patients. This is an important finding that supports the recent trend toward liberalization of preoperative intake of clear liquids as well as the allowance of oral clear liquid intake during labor.
Liberalization of previously held strict NPO ("nothing by mouth") policies appears safe and will result in improved patient comfort and satisfaction. The topic of oral intake during labor was also the subject of a Pro-Con debate between Geraldine O'Sullivan, MD, from St. Thomas' Hospital in London, and Samuel Hughes, MD, of the University of San Francisco, California.
Dr. O'Sullivan opined that the stomach of pregnant women is almost always "full" regardless of fasting times, that parturients seldom wish to eat large amounts of solid food in labor anyway, and that gastric emptying appears to be normal in pregnancy and labor, contrary to previously held beliefs.
Thus, she argued that limited amounts of liquids and even soft solids be allowed during labor, as a means of providing comfort and improving metabolic markers related to prolonged food deprivation. Moreover, she argued that maternal deaths related to anesthesia are usually the result of failed attempts to secure the airway, rather than pulmonary aspiration of gastric contents.
By contrast, Dr. Hughes argued that maternal mortality due to all causes, including anesthetic causes, has markedly declined over the past several decades and that clinicians should continue to do everything possible to continue this trend, in the interest of patient safety. He stated that hydration can be achieved with intravenous fluids, and that limitation of oral intake during labor is a small price to pay for improved safety.
Interestingly, a vote of the audience members both before and after the debate indicated a sizable number of converts to the opinion of Dr. O'Sullivan.
Sleeping With Your Baby
Cosleeping with a baby is common in many parts of the world. But it’s controversial in North America, where some medical organizations warn that it can cause suffocation.
Here is another perspective from James J. McKenna, Ph.D., author of a new book on the subject called Sleeping With Your Baby: A Parent’s Guide to Cosleeping (Platypus Media, LLC, 2007). Dr. McKenna directs the Mother-Baby Sleep Laboratory at the University of Notre Dame. He has been studying cosleeping for over 25 years.
Q: Does cosleeping benefit babies?
A: Benefits are, of course, always relevant to whom is cosleeping, what it means to them, and how they practice it. Cosleeping makes babies happy. From a scientific point of view, cosleeping babies cry less and sleep more. Babies lying next to their mothers can breastfeed easily without having to cry in order to make their needs known. Mothers get more sleep, too (though it is more light sleep.) Here in the U.S., we are the most unsatisfied, unhappy and exhausted parents in the world because we place babies at odds with their biology.
Q: Isn’t cosleeping dangerous?
A: Sleeping alone is not biologically correct. Human infants are born more neurologically immature than any other species (excluding marsupials.) Our central nervous systems depend on a microenvironment that is like the in-utero environment, full of sensory stimulation. Babies need the warmth, stimulation and monitoring that comes with sleeping next to a caregiver.
Almost all, fully 95 percent, of the world sleeps with their baby, and there are only very few cultures in the world for which babies sleeping alone is even thought to be acceptable or desirable. In many Asian cultures where cosleeping is the norm, including China, Vietnam, Cambodia and Thailand, Sudden Infant Death Syndrome (SIDS) is either unheard of or rare. In Hong Kong and Japan, which have almost universal cosleeping, SIDS rates are among the lowest in the world. The vast majority of scientific studies on infant behavior and development conducted in diverse fields during the last 100 years suggests that the question placed before us should not be “Is it safe to sleep with my baby?” but rather, “Is it safe not to do so?” My book includes information on how to bedshare safely and when it should be avoided, information parents need to make sound choices.
Q: Why do parents always get told that they should never sleep with their babies?
A: Parents are receiving dangerous advice from medical authorities that mislead them into assuming that all pediatricians and all SIDS researchers recommend against bedsharing. This is just not true. The American Academy of Pediatrics Task Force on SIDS claims bedsharing is always hazardous. This is flat out wrong! Done correctly, whether this means cosleeping, bedsharing or room sharing, infants sleeping with their parents are more likely to survive! The U.S. Consumer Products Safety Commission says never sleep with your baby; the only safe place for an infant to sleep is in a crib that meets current safety standards.
It is sad that a small group of “experts” have the parents in western countries bamboozled into believing that the entire history of civilization was wrong, that parents and babies have been doing it all wrong since the dawn of humanity!
Q: Should parents rely on doctors for infant sleep advice?
A: One of the most important things I am hoping to do is remind parents that while professional evaluation is important for sick children, issues of childcare, especially regarding where babies sleep and the relationship this reflects, are decisions best made by information-armed parents, not by external authorities who neither know the parents, nor the infant, nor how sleeping arrangements might work in any given family. At this point in time, medical authorities seem overly willing to use selected and simplistic medical findings to infer their own conclusions about where babies should sleep. Many employ, in my mind inappropriately, a one-size-must-fit-all strategy for sleeping arrangements. Indeed, cosleeping is being misrepresented – often by people who think they know something about it but choose to dismiss any scientific evidence that disagrees with their own negative position. Many of these authorities only know about catastrophic failures associated with dangerous forms of cosleeping and use these failures to draw simplistic conclusions about a very complex practice.
Q: Won’t my child be emotionally dependent if we cosleep?
A: Absolutely not! Independence and autonomy have nothing to do with forcing babies to learn
how to sleep by themselves. Parents are often under the mistaken impression that if they don’t train their babies to sleep alone every night, somehow some developmental or social skill later in life will be kept from them, or that their babies will never exhibit good sleep patterns later in life. Yet research has consistently shown us that children who routinely sleep with their parents or are not “sleep-trained,” actually become more independent socially and psychologically, are able to be alone better by themselves, and have greater abilities to interrelate and be empathetic.
Q: Do you believe that all parents should cosleep with their babies?
A: No, I believe parents should do what they feel is best for their families. I think it is important to empower parents and let them know that every child born in the world is unique as is each family. Since no child is the same, no solution to what children need is necessarily the same. Parents know their own babies better than anyone. Pediatricians are not trained in human development, childcare strategies or psychology. They know how to fix sick babies. We have to be very careful to not medicalize behaviors that are not appropriately medicalized: where babies sleep, what is a proper sleeping arrangement and how parents decide to respond to their baby’s nutritional needs. I do believe that parents should be well-informed so that they are able to make the best decisions for their families, and so that if they do choose to do something like share a bed with their baby, they can do it as safely as possible.
Here is another perspective from James J. McKenna, Ph.D., author of a new book on the subject called Sleeping With Your Baby: A Parent’s Guide to Cosleeping (Platypus Media, LLC, 2007). Dr. McKenna directs the Mother-Baby Sleep Laboratory at the University of Notre Dame. He has been studying cosleeping for over 25 years.
Q: Does cosleeping benefit babies?
A: Benefits are, of course, always relevant to whom is cosleeping, what it means to them, and how they practice it. Cosleeping makes babies happy. From a scientific point of view, cosleeping babies cry less and sleep more. Babies lying next to their mothers can breastfeed easily without having to cry in order to make their needs known. Mothers get more sleep, too (though it is more light sleep.) Here in the U.S., we are the most unsatisfied, unhappy and exhausted parents in the world because we place babies at odds with their biology.
Q: Isn’t cosleeping dangerous?
A: Sleeping alone is not biologically correct. Human infants are born more neurologically immature than any other species (excluding marsupials.) Our central nervous systems depend on a microenvironment that is like the in-utero environment, full of sensory stimulation. Babies need the warmth, stimulation and monitoring that comes with sleeping next to a caregiver.
Almost all, fully 95 percent, of the world sleeps with their baby, and there are only very few cultures in the world for which babies sleeping alone is even thought to be acceptable or desirable. In many Asian cultures where cosleeping is the norm, including China, Vietnam, Cambodia and Thailand, Sudden Infant Death Syndrome (SIDS) is either unheard of or rare. In Hong Kong and Japan, which have almost universal cosleeping, SIDS rates are among the lowest in the world. The vast majority of scientific studies on infant behavior and development conducted in diverse fields during the last 100 years suggests that the question placed before us should not be “Is it safe to sleep with my baby?” but rather, “Is it safe not to do so?” My book includes information on how to bedshare safely and when it should be avoided, information parents need to make sound choices.
Q: Why do parents always get told that they should never sleep with their babies?
A: Parents are receiving dangerous advice from medical authorities that mislead them into assuming that all pediatricians and all SIDS researchers recommend against bedsharing. This is just not true. The American Academy of Pediatrics Task Force on SIDS claims bedsharing is always hazardous. This is flat out wrong! Done correctly, whether this means cosleeping, bedsharing or room sharing, infants sleeping with their parents are more likely to survive! The U.S. Consumer Products Safety Commission says never sleep with your baby; the only safe place for an infant to sleep is in a crib that meets current safety standards.
It is sad that a small group of “experts” have the parents in western countries bamboozled into believing that the entire history of civilization was wrong, that parents and babies have been doing it all wrong since the dawn of humanity!
Q: Should parents rely on doctors for infant sleep advice?
A: One of the most important things I am hoping to do is remind parents that while professional evaluation is important for sick children, issues of childcare, especially regarding where babies sleep and the relationship this reflects, are decisions best made by information-armed parents, not by external authorities who neither know the parents, nor the infant, nor how sleeping arrangements might work in any given family. At this point in time, medical authorities seem overly willing to use selected and simplistic medical findings to infer their own conclusions about where babies should sleep. Many employ, in my mind inappropriately, a one-size-must-fit-all strategy for sleeping arrangements. Indeed, cosleeping is being misrepresented – often by people who think they know something about it but choose to dismiss any scientific evidence that disagrees with their own negative position. Many of these authorities only know about catastrophic failures associated with dangerous forms of cosleeping and use these failures to draw simplistic conclusions about a very complex practice.
Q: Won’t my child be emotionally dependent if we cosleep?
A: Absolutely not! Independence and autonomy have nothing to do with forcing babies to learn
how to sleep by themselves. Parents are often under the mistaken impression that if they don’t train their babies to sleep alone every night, somehow some developmental or social skill later in life will be kept from them, or that their babies will never exhibit good sleep patterns later in life. Yet research has consistently shown us that children who routinely sleep with their parents or are not “sleep-trained,” actually become more independent socially and psychologically, are able to be alone better by themselves, and have greater abilities to interrelate and be empathetic.
Q: Do you believe that all parents should cosleep with their babies?
A: No, I believe parents should do what they feel is best for their families. I think it is important to empower parents and let them know that every child born in the world is unique as is each family. Since no child is the same, no solution to what children need is necessarily the same. Parents know their own babies better than anyone. Pediatricians are not trained in human development, childcare strategies or psychology. They know how to fix sick babies. We have to be very careful to not medicalize behaviors that are not appropriately medicalized: where babies sleep, what is a proper sleeping arrangement and how parents decide to respond to their baby’s nutritional needs. I do believe that parents should be well-informed so that they are able to make the best decisions for their families, and so that if they do choose to do something like share a bed with their baby, they can do it as safely as possible.
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