Methods to prevent perineal trauma during childbirth include avoiding episiotomy and forceps delivery and slowing delivery of the head to allow the perineum time to stretch. Each intervention can lengthen the second s...
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Methods to prevent perineal trauma during childbirth include avoiding episiotomy and forceps delivery and slowing delivery of the head to allow the perineum time to stretch. Each intervention can lengthen the second stage of labor and change the biophysical stresses on infants and the pelvic floor. Available evidence supports the belief that the interventions are safe for infants and do not lead to significant short- or long-term maternal morbidity. We should abandon the conventional teaching that a longer second stage and perineal stretching are harmful. Routine episiotomy is no longer advisable. Forces that might inhibit physicians from practicing evidence-based techniques of obstetric delivery include time pressures, malpractice concerns, lack of experience with slow perineal stretching, and an interventionist practice pattern. Changes in practice can be effectively introduced through consumer pressures, opinion leaders, and in teaching institutions, by house staff. (C) 2000 by The American College of Obstetricians and Gynecologists.
Recent, large, randomized, controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum. Yet episiotomy remains the mo...
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Recent, large, randomized, controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum. Yet episiotomy remains the most common surgical procedure women undergo. This article examines if clinician experience, rather than scientific evidence, forms the basis for continuing this practice. Perineal outcome data are analyzed for 865 low-risk women who were attended at birth by the staff nurse-midwives or faculty obstetricians at a university-based, tertiary-care hospital. Data were collected under routine, non-experimental conditions such that the circumstances of the labor and the clinician's preferences were allowed to determine management decisions regarding the use of episiotomy or other techniques of perineal management. Multivariate findings indicate that in the absence of episiotomy, rates of perineal integrity were highest among clinicians who usually had the lowest rate of episiotomy use. When an episiotomy was done, rates of third- and fourth-degree extensions were highest among clinicians who used episiotomy most frequently. This finding challenges the idea that clinicians who were very experienced with the use of episiotomy would avoid complications such as extensions. Future research should explore the use of nonsurgical techniques such as those employed by midwives to promote perineal integrity. Then interdisciplinary research and evidence-based education regarding these techniques can occur to improve perineal outcomes for all women. (C) 2000 by the American College of Nurse-Midwives.
Objective: To identify factors associated with the use of episiotomy at spontaneous vaginal delivery. Methods: We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham &...
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Objective: To identify factors associated with the use of episiotomy at spontaneous vaginal delivery. Methods: We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham & Women's Hospital between December 1, 1994 and July 31, 1995. The association of demographic variables and obstetric factors with the rate of episiotomy use were examined. Adjusted odds ratios (OR) and confidence intervals (CI) were estimated from multiple logistic regression analysis. Results: The overall rate of episiotomy was 40.6% (640 of 1576). Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%) and private providers (55.6%) (P = .001). After controlling for confounding factors with logistic regression, private practice provider was the strongest predictor of episiotomy use (OR, 4.1;95% CI, 3.1, 5.4) followed by faculty provider (OR, 1.7;95% CI, 1.1, 2.5), prolonged second stage of labor (OR, 1.8;95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6;95% CI, 1.1, 2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8). Conclusion: The strongest factor associated with episiotomy at delivery was the category of obstetric provider. Obstetric and demographic factors evaluated did not readily explain this association. (C) 2000 by The American College of Obstetricians and Gynecologists.
Objective: To test the null hypothesis that there are no differences in incidence of perineal and vaginal lacerations in primiparous black and white women. Methods: We reviewed University of Michigan Hospital delivery...
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Objective: To test the null hypothesis that there are no differences in incidence of perineal and vaginal lacerations in primiparous black and white women. Methods: We reviewed University of Michigan Hospital delivery records, from July 1996 to December 1998, of black and white women 18 years and older and at least 35 weeks' gestation who had their first vaginal delivery. Birth weight, episiotomy, gestational age, laceration, length of second stage, oxytocin use, epidural use, and operative vaginal delivery were analyzed by univariable and multivariable tests. Results: We analyzed 176 black women (mean age a standard deviation 23.7 +/- 4.7 years;range 18-41 years) and 1633 white women (27.8 +/- 5.4 years;18-49 years;P <.001). Black women were less likely to have second, third, or fourth degree lacerations (43% compared with 59%;P <.001). The mean length of second stage of labor was shorter in the black women (73 +/- 69 minutes;range 3-494 minutes compared with 106 +/- 78 minutes;range 2-642 minutes;P <.001). infants of black women weighed less (3292 +/- 490 g;1990-5190 g compared with 3429 +/- 470 g;1860-4953 g;P <.001). Multivariable analysis showed that black women were twice as likely to deliver with intact perineums than white women (P <.001). Conclusion: Black primiparas were less likely to deliver with second-degree or greater lacerations and more likely to deliver with their perineums intact. (Obstet Gynecol 2000;96:622-4. (C) 2000 by The American College of Obstetricians and Gynecologists.).
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