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Adv Clin Exp Med 2012, 21, 4, 545550 ISSN 18995276

Copyright by Wroclaw Medical University

Jolanta Pietras1, Bernice Folake Taiwo2

Episiotomy in Modern Obstetrics Necessity Versus Malpractice

Nacicie krocza we wspczesnym poonictwie konieczno kontra bd w sztuce
1 2

The University of Medical Sciences in Legnica, Poland Polish Health Centre, roda lska, Poland

Abstract
Episiotomy is now one of the most common procedures performed in obstetrics. At the beginning of its existence, it was performed very carefully and used in exceptional circumstances. In the second half of the twentieth century, its use became so widespread that it was almost regarded as a standard procedure in labor rooms. Authors intend to provide answers to the question as to whether it was an appropriate move in this discussion. Undoubtedly, there are reasons for which an incision is an appropriate decision, sometimes necessary, but in recent years its usefulness and relevance, in particular its routine, too widespread use are starting to be increasingly questioned and subjected to doubt, both by various womens organizations, individuals interested in the issue, stakeholders, as well as professionals. Poland is still one of the few European countries where routine episiotomy is so far regarded as an important and recognized part of patient management during almost every childbirth taking place in a hospital setting. This topic currently causes broad discussion in the media, the press and among the public. Hence, the aim of this work is to discuss key issues on episiotomy, the arguments for and against episiotomy based on literature review and available studies and reports. It is also going to present the opinion of different authors and the existing differences in their views on the above issue (Adv Clin Exp Med 2012, 21, 4, 545550). Key words: episiotomy, perineal damage, obstetric procedures.

Streszczenie
Nacicie krocza jest obecnie jednym z najczstszych zabiegw wykonywanych w poonictwie. Od pocztku byo traktowane jednak bardzo ostronie i stosowane w wyjtkowych sytuacjach, w drugiej poowie XX w. stao si powszechn, niemal standardow procedur na blokach porodowych. Odpowiedzi na pytanie, czy byo to posunicie suszne, autorzy postaraj si udzieli w niniejszych rozwaaniach. Niewtpliwie, istniej powody, dla ktrych nacicie jest decyzj waciw, niekiedy konieczn, niemniej jednak w ostatnich kilkunastu latach jego przydatno i zasadno, a w szczeglnoci jego rutynowe, zbyt powszechne stosowanie zaczyna by coraz czciej kwestionowane i podawane w wtpliwo zarwno przez rnego rodzaju organizacje kobiece, same zainteresowane, jak i profesjonalistw. Polska jest wci jednym z niewielu krajw europejskich, w ktrym rutynowe nacicie krocza jest, jak dotychczas, istotnym i uznanym elementem prowadzenia niemal kadego porodu odbywanego w warunkach szpitalnych. Temat ten wywouje obecnie szerokie dyskusje w mediach, prasie i wrd opinii publicznej, dlatego celem pracy jest omwienie najwaniejszych zagadnie dotyczcych epizjotomii, przedstawienie argumentw za i przeciw nacinaniu krocza opartych na przegldzie literatury oraz dostpnych badaniach i doniesieniach, a take zaprezentowanie opinii rnych autorw i istniejcych rnic w pogldach na omawian kwesti (Adv Clin Exp Med 2012, 21, 4, 545550). Sowa kluczowe: nacicie krocza, obraenia krocza, procedury poonicze.

Episiotomy (gr. episiotomia: episeion vulva, temno cut) is a procedure based on the incision of the perineal tissues of a parturient, with delivery scissors during the second stage of labor in order to expand the birth canal [1, 2]. The history of this

procedure goes as far back as the 17th century and was associated with the introduction of forceps into obstetrical practice [3]. Episiotomy was written and published in 1742 by Oulda [2], for the first time in modern medical literature, the next

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mention of this topic appeared at the beginning of the 19th century [3]. At first, it was not trusted and was used as a last resort, but in 1913 De Lee published his thesis that Every delivery is a pathologic process and requires surgical intervention [3, 4]. His work was repeatedly renewed as a result of which in the first half of the 20th century, routine episiotomy gradually started gaining popularity and general acceptance [3]. In 1928, Jaschke recommended performing episiotomy in every case where irreversible damage to the anal levator muscle is suspected and consequently may result in pelvic organ prolapse [2, 5]. While on the other hand, Kustner recommended episiotomy only when there was vaginal hemorrhage as evidence of the beginning of cervical rupture [2]. Earlier mentioned De Lee even proposed that women during labor should be given sedatives, perform extensive episiotomy and then bring out the fetus with the help of forceps [3]. In the 1980s, thanks to the popularisation of the idea of evidence based medicine as well as the rise of consumer movement in many countries, and the move called friendly obstetrics, routine episiotomy was allowed to undergo criticism, and the World Health Organization in 1985 in a document titled Appropriate delivery techniques recommended the restriction of episiotomy acknowledging that there is no justification for routine episiotomy [3]. The World Health Organization also acknowledged the fact that episiotomy is justified only in about 520% of childbirth (meaning about 1 in every 5 parturient) [3, 6]. Since the end of the 1970s the percentage of episiotomy done in the USA and in the majority of Western European countries has undergone a systematic and important reduction. In Poland, Greece or in South America the percentage of episiotomy during childbirth is still high and is maintained at a relatively similar level [3, 7]. It is estimated that, in our country, every second parturient had perineal incision of which almost each and every nulliparous patient underwent the procedure. Well over 50% of these women were not asked for their consent for this procedure. Meanwhile, in Great Britain and Denmark the percentage of episiotomy is 12%, in Sweden 9.7%, in New Zealand 11% and in the USA about 33% [6].

J. Pietras, B. Folake Taiwo

siotomy helps reduce the resistance of tissues [8]. Therefore, the most common reason why episiotomy is performed routinely is for perineal tissue protection [2]. Indications for episiotomy include prophylaxis of pelvic organ prolapse, manual help in extraction of the fetus, reflex position of fetal head, instrumental delivery (for instance, through the use of forceps or vacuum extractor) as well as imminent perineal rupture [2, 5, 9]. Another important part of this aspect worth mentioning is the inappropriate pelvic anatomy (high perineal wall), cervical insusceptibility, protection of the fetal head, minimization of its injuries as well as situations in which a quick end has to be put to delivery [2, 5, 8, 9]. In accordance with the recommendations of the experts team of Polish Association of Gynaecologists in 2009 concerning antenatal care and the management of labour, delay in the appearance of the presenting part and the use of episiotomy as an assisting procedure to instrumental vaginal delivery with the use of forceps and vacuum extractor were regarded as indications to episiotomy [10]. As a result of this, there are four different types of episiotomy identified: The two most often performed are the lateral and medial episiotomy, as well as mediolateral and the so called Schuchardts episiotomy. Each of these incisions has its own advantages and disadvantages. Lateral episiotomy (the most popular type) causes an increased loss of blood than the medial episiotomy and gives more pain, but one important element in accordance with information given in obstetrics text books does not constitute a threat of anal rupture and its consequences. Medial episiotomy is characterized by lesser loss of blood, lesser discomfort during the healing process, because wounds at this spot heal faster and are less painful [11], lesser blood vessels and nerval branches are damaged [8]. It lacks the possibility of extending the cut if need be and, above all, there is the danger of damaging the anus [11]. Mediolateral episiotomy has the features of both types described above. While Schuchardts episiotomy is the most extensive cut (it involves a deep incision into the vagina, perineum, and pelvic floor muscle floor) [2, 9, 11].

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

Advantages and Complications

Among the advantages (as already partly mentioned above) the following can be listed: protection of strained perineal tissues and muscles against rupture and further complications associated with pelvic organ static disorders (prolapse, fall) as well

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reduced muscular tension of pelvic floor muscle and vaginal laxity. They obtained similar results in muscle strength (there was no substantial difference) in the group of women without perineal damage during delivery and with spontaneous perineal rupture, whereas in the group that had episiotomy, muscle strength in this group of muscles was weaker [24]. According to Wooley a comparative study of the group of women with spontaneous perineal rupture and those with episiotomy showed that an increase in the performance of episiotomy procedures has no effect on reducing the number of third degree perineal tears [2, 21, 22] while the postpartum pain associated with the perineal healing was of increasing strength in the group of women with episiotomy unlike in the group with perineal tears. He obtained an ambiguous result on the complications of healing as well as on the issue of painful sexual intercourse. Edema, infection, hematomas were also often present [21, 22]. The result obtained rather showed that episiotomy reduced the risk of damaging the anterior wall of the vagina and around the urethra [22]. For the prophylaxis of the pelvic floor muscles, the author said that the effect of episiotomy on the reduction of the symptoms of urinary incontinence and the pelvic organ prolapse was not shown [21, 22]. For the prophylaxis of fetal injuries, he did not show the effect of episiotomy on the frequency of subdural bleeding neither on the state of the newborn baby after delivery according to the Apgar scale, whereas it is important to mention the fact that it reduced the time duration of the second stage of labor [2, 21, 22]. A lot of authors have also shown the psychoemotional aspect associated with episiotomy [2, 21, 22, 25] as well as rare cases of blood transmitted diseases or endometriosis in scar from perineal incision [2]. Martin et al. said that trauma (incision or rupture) thrice increases the risk of secondary and tertiary perineal rupture and that there is a direct relationship between the degree of damage in the first and subsequent deliveries [26].

as urinary incontinence. Moreover, they involve protection of the fetus during premature delivery, violent expansion as well as perineal insusceptibility of the parturient. Also, protection against tearing due to inappropriate position of presenting part especially when the fetus is large [2, 8, 9, 11] with a possibility of reducing the second stage of labor as a result of the fetal state or mother [8, 1113]. Some authors suggest that together with reconstruction of the appropriate anatomical conditions sometimes it is comparable to plastic surgery with the aim of maintaining the proper function of the vaginal vestible [8]. The other side of the issue present facts involving a lot of reports indicating possible complications resulting from this type of procedure. Thacker and Banta showed that the majority of the complications of episiotomy have a more important function in clinical practice than earlier assumed [2, 14]. As possible consequences, they further listed rupture of episiotomy, dyspareunia (painful sexual intercourse), perineal pain, long healing period, infection, as well as considerable loss of blood which makes further detailed examination necessary in the discussed scope [14]. Similar effects have also been shown by Mc Guiness et al. [15]. These authors also state that instrumental delivery favours perineal trauma. The results obtained in their opinion suggest that perineal trauma in women who never had episiotomy heals better [14, 15]. Safrati and Marechaud even stated that the amount of blood lost during episiotomy is comparable to that lost during caesarean section [16]. Ejegard et al. similarly to their predecessors showed that episiotomy very often causes increased pain during sexual intercourse and reduces wetness of the vaginal vestible for a period of about 1218 months after childbirth [17]. Buekens suggests that episiotomy does not prevent further perineal trauma but rather increases the risk [18]. Eason et al. even said that irrespective of the type, it does not reduce the risk of anal sphincter rupture [19]. Numerous reports in the last few years have shown that episiotomy, especially the medial type, as a procedure is dangerous, leading to rectal damage, gas and or stool incontinence or even the development of a rectovaginal fistula as observed by Jander and Lyrenas [20] or Wooley [21, 22], among Polish authors for example Korczyski reminds us of this fact. Similar consequences have been also reported by Haadem et al., adding to it necrosis and repeated rupture of the anal sphincter [23]. Again, Swedish authors Rockner, Jonasson and Olund, based on their own personal research, stated that episiotomy did not prevent what it was meant to do in the long run, that is, consequences such as

Controversies and Difficult Questions

In the light of the above facts the question arises: Is routine perineal incision equivalent to its protection? According to experts from Rodzi po ludzku Foundation, you cannot talk of perineal protection while at the same time causing its damage [3] while perineal incision alone, not to mention all the other possible complications, is equivalent to secondary perineal rupture [5]. Does the

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perineal incision actually prevent complications arising in the second stage of labor? As the analysis in this material have shown, advantages have only been shown mainly with respect to reducing the period of the second stage of labor and prevention of anterior vaginal wall damage as well as around the urethra [21, 22]. The issue of preventing the urogenital diaphragm damage is no longer obvious. Perineal incision is generally made after the fetus has exceeded the urogenital diaphragm and tightens the perineal tissues. In order to prevent excessive expansion of the perineal muscles, making an incision becomes a necessity, that is just before the fetal head crosses the urogenital diaphragm thus at the beginning of the second stage of labor. This kind of a procedure in Thorps view could increase the probability of third and fourth degree tears [26]. It is important to note that, nowadays, episiotomy is done at a later phase [3]. How come some medical procedures and habits are based on evidence? Does routine episiotomy actually still exist in hospitals? It is an optimistic fact that midwives in their practice are beginning to individualize these issues with respect to concrete situations and those of them that have private practices and those taking deliveries at home more often are beginning to point out the role of appropriate perineal protection. It is worth mentioning that in some countries such as Austria, it is one of the major elements of their education [3]. In Poland, over a decade ago, not much was said about this issue, perineal incision in other words episiotomy was almost a standard procedure in labor rooms, while the textbooks available cautiously and merely talked about the issue of perineal protection. Moreover, one can sometimes still read from them that perineal suture is the end of vaginal delivery [3]. Presently, there are a lot of methods used in preparing for childbirth, just as there are a number of methods of handling delivery with the aim of reducing the frequency of tissue damage and incision. Not without importance are economic issues associated with the cost of medical care. Borghi et al. carried out appropriate analysis and came to a conclusion that every low risk delivery carried out with the application of episiotomy is more costly than deliveries without incision by 1120 dollars [27]. For this reason also, the issue of performing episiotomy presently poses a lot of difficult questions and issues that need to be sorted out. In the recommendations of the team of experts of the Polish Association of Gynaecologists in 2011, the restriction of routine episiotomy reduces the risk of incurring perineal injury by 33% and reduces the risk of healing complications by 31%. The fear that failure to carry out episiotomy could result

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in uncontrolled tear of the perineal tissues and difficulties in healing do not find any reflection in the result of many research papers. It was shown rather that the number of reconstructive operation procedures and the number of stitches were less in women in which indication to episiotomy were restricted [28]. It is obvious that it will be performed in situations where it becomes very necessary, but in cases where it is used as a routine procedure (especially nulliparous women), maladjusted to concrete individual situation, conditions or possibility where it is not absolutely compulsory then it begins to raise some doubts. Practically, it is much easier to stitch perineal incision rather than perineal rupture [3, 5, 8] but based on the results of available research, it is seen that the perineum in puerperial women without episiotomy heals better [3, 14, 15] while spontaneous rupture in vaginal delivery very rarely attain third or fourth degree tears [2, 3, 21, 22]. One should be reminded again of the fact that a perineal incision is an equivalent of secondary rupture. Does this type of completed perineal trauma (rupture, tear, incision) remain without effect on the course of subsequent deliveries or do they stand as a risk factor to its rupture in subsequent deliveries? Will it not be worthwhile to pay more attention to the medical personnel and their awareness of the possibilities, principles and ways of protecting the perineum? The recommendations of the team of experts of the Polish Association of Gynaecologists in 2011 regarding prevention of intrapartum injuries to the birth canal and pelvic floor structures, more often than ever, seek to give up routine episiotomy whose result ought to be a reduction in the performance of this procedure to less than 25% of deliveries [28].

Conclusions
Episiotomy sometimes for medical reasons becomes a necessary procedure; nevertheless, it ought to be used with all prudence and sense of feeling having taken into consideration all the right indications as well as the expectations of the woman in labor. In the opinion of Korczyski, there is no evidence that episiotomy is a prophylaxis of the damaged tissues of the lower pelvis, while it could increase the risk of serious damage [2]. In the opinion of experts from the Foundation of Rodzi po ludzku, its effectiveness was not proved, while research carried out since the beginning of 1980 showed new evidence on the harmfulness of this procedure [3]. According to the recommendations of recognized organisations

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

like the World Health Organisation WHO or the National Institute for Health and Clinical Excellence NICE as well as reports from researchers, routine episiotomy is discouraged [2, 3, 29]. The decision to carry out this obstetric procedure should be individualised and in each case be determined by the wealth of information obtained

References
[1] Dudenchausen JW: Poonictwo praktyczne i operacje poonicze. PZWL, Warszawa 2010. [2] Korczyski J: Nacicie krocza we wspczesnym poonictwie. Konieczno czy przyzwyczajenie? Przegl Lek 2002, 59/2, 9597. [3] http://www.rodzicpoludzku.pl/Publikacje/Naciecie-krocza-koniecznosc-czy-rutyna.html 2011.11.23. [4] Walzer Leavitt J: Joseph B. DeLee and the practice of preventive obstetrics. Am J Public Health 1988, 78(10), 13531361. [5] Pschyrembel W: Praktyczne poonictwo. PZWL, Warszawa 1974 [6] http://www.rodzicpoludzku.pl/Porod/Naciecie-krocza-czy-mozesz-tego-uniknac.html, 2011.11.23. [7] Althobe F, Belizon JM,Bergel E: Episiotomy rates in primaparous in Latin America: hospital based restrictive study. BJM 2002, 324 (7343), 945946. [8] Brborowicz GH: Ginekologia i poonictwo, tom 1. PZWL, Warszawa 2006, 402403. [9] Martius G: Operacje poonicze. PZWL, Warszawa 1990, 227229. [10] Rekomendacje zespou ekspertw Polskiego Towarzystwa Ginekologicznego dotyczce opieki okooporodowej i prowadzenia porodu: Ginekol Pol 2009, 80, 548557. [11] Martius G: Ginekologia i poonictwo. Urban & Partner, Wrocaw 1997. [12] Wooley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I. Obstet Gynecol Surv 1995, 50, 806. [13] Wooley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II. Obstet Gynecol Surv 1995, 50, 821. [14] Thacker SB, Banta HD: Benefits and risks of episiotomy: An interpretative review of the English language literature, 18601980. Obstet Gynecol Surv 1983, 38, 322. [15] Mc Guiness, Norr K, Nacion K: Comparison between different perineal outcomes on tissues healing. J Nurse Midwifery 1991, 36, 192198. [16] Safrati R, Marechaud M, Magnin G: comparaison des deperditions sanguines lors des cesariennes et lors des accouchements par voie basse avec episiotomie. J Gynecol Obstet Biol Reprod 1999, Vol. 28, 4854. [17] Ejegard H, Ryding EL, Sjorgen B: Sexuality after delivery with episiotomy: a long-therm follow-up. Gynecol Obstet Invest 2008, 1 (66), 17. [18] Buekens et al.: Episiotomy and third degree tears. Br J Obstet Gynecol 1985, 99, 820823. [19] Eason E, Labrecque M, Wells G, Feldman P: Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000, 95(3), 464471. [20] Jander C, Lyrenas S: Third and fourth degree perineal tears. Predifictor factors in referral hospital. Acta Obstet Gynecol Scand 2001, 80, 229. [21] Woolley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I.Obstet Gynecol Surv 1995, 50, 806820. [22] Woolley RJ: Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II.Obstet Gynecol Surv 1995, 50, 821835. [23] Haadem K et al.: Anal sphincter function after delivery rupture. Obstet Gynecol 1987, 70 (1), 5356. [24] Rckner G, Jonasson A, Olund A: The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991, 70(1), 51. [25] Ciszek V et al.: Nacicie krocza uwarunkowania psychosomatyczne. Klin Perinatol Ginekol 1996, supl XIII, 6977. [26] Thorp JM, Bowes WA: Episiotomy: Can its routine use be defended? Am J Obstet 1989, 160 (5), 10271030. [27] Borghi J et al.: The cost-effectiveness of routine versus restrictive episiotomy in Argentina. Am J Obstet Gynecol 2002, 186 (2), 221228. [28] Rekomendacje zespou ekspertw Polskiego Towarzystwa Ginekologicznego dotyczce zapobiegania rdporodowym urazom kanau rodnego oraz struktur dna miednicy. Ginekol Pol 2011, 82, 390394. [29] Myers-Helfgott MG, Helfgptt A: Routine use of episiotomy in modern obstetrics. Should it be performed? Obstet Gynecol Clin North Am 1999, 26, 305.

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Address for correspondence:

Jolanta Pietras University of Medical Sciences Powstacw l. 3 59-220 Legnica Poland Tel.: +48 76 854 99 38 E-mail: dziekan@wsmlegnica.pl Conflict of interest: None declared Received: 6.12.2011 Revised: 6.02.2012 Accepted: 2.08.2012