Updating the Thoughts on Episiotomies, More, Less, Different?

It's been an odd trend in obstetrics, the rates of episotomies have been in the opposite direction as C-sections!! In the past when obstetricians did an episiotomy they were able to avoid some of the c0-sections. Now women have been hoping to avoid. When epidemiologists want to find out what physicians are up to , they check in with the National Hospital Discharge Survey. It's a set of information tracked by the National Center for Health Statistics.In 1979 if an operative vaginal delivery occurred it was much more likely to be delivered by forceps and forceps and/or vacuums and the vacuums in those days pulled more pressure and thus were successful at helping achieve a vaginal delivery more so than they even are today. As a result there was about 85% episiotomy rate during that 70s era. If there was a spontaneous delivery, no forceps or instruments used, then about 50% of births had episiotomies. In 1989 the stakes rose and a virtually 90% of women who delivered with a vaginal birth had an episotomies. But from a low rate of about 3% of women having a c-section, by 1989 the rate had risen to between 10 and 15% and in some hospitals it was creeping higher, interestingly, episitomy had dropped in spontaneous births to 30%. By 2004 spontaneous births episiotomies were down to 25% and episiotomy with operative births was only 50%, and national C/S rates had climbed to over 20%. One of the most significant complications of episiotomy is tearing of the anus, specifically the sphincter that allows the anus to function properly.. It is not specifically known if all the tears occurred with episiotomies but rates of the tears have been higher but remain at 15% for the year 2004. Using the proper operative tools can help us have safer vaginal deliveries, but complications are possible. The alternatives up to now was to just avoid that vaginal delivery and to have a C-section.  But in a thought provoking articles from the American Journal of Obstetrics and Gynecology, they have now discovered that actually the mediolateral episiotomy, if it has to be used with forceps or a vacuum. can be very protective against rectal tears, and much more protective than the standard midline one performed. This has been the opposite of what we have been telling our patients! So if you discussed episiotomy at an appointment last spring, it may be time to hold that discussion again in light of this new information.


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