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Re: Informed consentFrom: Barbara Nicol (blnicol@ix.netcom.com)Wed Jun 7 11:12:53 2006
I've cut, I think, 3 in the past 4 years. I've had the interesting experience of trying to argue patients out of having one - some patients request them in their birth plan. (Yeah, I know the CNMs have likely never experienced this; such patients don't go to CNMs. They wouldn't (probably) come to me if episiotomy stats got published.) I also have had the experience of seeing a buttonhole into the rectum with an intact external perineum. A friend tells a story of watching a hand come out of the anus and having to cut a 4th in order to deliver the elbow, as the head was coming out simultaneously in a more conventional manner. Bummer, so to speak. Sutter keeps records on episiotomy and 3rd/4th degree lacs and I must agree that it's highly regional. Our hospital got interviewed by the stats keepers because of our low rate of both. It was kind of a surreal experience because we really couldn't say much that was useful about our technique of perineal management other than not cutting. Some of us are hands-off, some of us do massage and support and the whole perineal rain-dance. Positions for pushing vary. None of that makes a difference in overall lacs, 3rds and 4ths - at least in our statistics - but not reaching for the scissors really does. (As has already been shown numerous times.) I also have to admit that on the rare occasions when I do cut, they are way easier to repair. This is not to excuse those who cut a lot, but just to admit the truth. However, I choose to regard the lacs as a challenge to my plastics skills, and the much increased chance that I won't have to do a repair at all goes a long way to make up for the occasional convuluted "now where did this bit go?" stellate lac. There is the occasional patient with distress in late second stage in whom the choice is epis or vacuum. In that case, episiotomy is a useful adjunct. - Barb Nicol, M.D. St Luke's, San Francisco
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