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intentional proctoepisiotomy or bilateral mediolateral episiotomies :already discussedFrom: emilio porro (sanbonav@hotmail.com)Sun Feb 17 01:35:38 2008
We have already discussed this argument on this forum eleven years ago as below. Yours faithfully Emilio Porro M.D.ObGyn Como_Italy Re: episiotomy and shoulder dystocia was its effects on perineal body/ From: Robert J. Woolley (wooll005@gold.tc.umn.edu) Fri Apr 25 07:26:13 1997 • Messages sorted by: [ date ][ thread ][ subject ][ author ] • Next message: Jeffrey W. Clemens: "Re: midhusband/melatonin" • Previous message: Robert J. Woolley: "Re: OB-GYN-L digest 974" • Next in thread: rbraun@indyunix.iupui.edu: "Re: episiotomy and shoulder dystocia wasits effects on perineal body/" • Reply: rbraun@indyunix.iupui.edu: "Re: episiotomy and shoulder dystocia wasits effects on perineal body/"
In message <Pine.HPP.3.95.970425064904.3642B-100000@champion.iupui.edu>
writes: > How many of you feel that episiotomy is actually of any
benefit in the
> management of shoulder dystocia ? How many feel that it is not of any So far (cross my fingers) I have always managed to relieve the dystocia by other means before having to decide whether to cut. FWIW, here's the summary of the meager evidence on this question from my review: 3. Fetal distress There remains the question of whether fetal distress is an appropriate indication for episiotomy. Such use is conceded even by many authors who take an otherwise dim view of the procedure [21, 50, 81, 121, 127]. This defense obviously depends on the assumption that episiotomy will abbreviate the delivery. As discussed in the previous section, there is little scientific rationale for this assertion. That said, it must quickly be granted that the question ŇDoes episiotomy shorten the second stage of labor?Ó is not equivalent to asking ŇDoes episiotomy shorten the interval from its performance to delivery when late second stage fetal distress is diagnosed?Ó There is simply no published research on the latter query. Nor is there likely to be. Such a study would have to deal with the high incidence and low specificity of fetal heart rate ŇabnormalitiesÓ in the second stage [52-57] and the wide range of opinion as to which cardiotocogram features indicate distress needing intervention [128-129]. It is also unlikely that institutional review committees would allow or many clinicians participate in a randomized trial of episiotomy in the face of diagnosed fetal distress, given the prevalence of the assumption of its benefit. Nevertheless, we need not simply abandon the issue. An RCT could be designed so that distressed fetuses are excluded and the accoucheur learns the patientŐs allocation (episiotomy or none) only after deciding that it was time to perform one. If episiotomy truly hastens delivery by a clinically significant amount, a fairly small trial of this design should have power to demonstrate it, since, say, a two-minute decrease in the crowning-to-delivery time will be more readily apparent than a two-minute decrease in the overall second stage duration. The results in healthy fetuses should be generalizable to those in distress. 4. Shoulder dystocia Episiotomies, sometimes including intentional proctoepisiotomy or bilateral mediolateral episiotomies, are commonly described as one of the first steps that should be taken to relieve shoulder dystocia. In a recent review, Piper and McDonald were able to identify only four published commentaries that questioned this assumption, despite the lack of published research to demonstrate its benefit [130]. Without doubt, the performance of a methodologically rigorous trial of any maneuver to relieve shoulder dystocia would present formidable technical and ethical obstacles. In the absence of reliable data, the clinician must make a reasonable decision of the performance of an episiotomy in this critical moment. Considerations arguing against its use are (1) the concept of shoulder dystocia as a problem of bony disproportion, rather than a soft-tissue obstruction, and (2) the availability of apparently effective non-surgical techniques (e.g., McRoberts maneuver, maternal hands and knees position). In favor of its use are (1) wide anecdotal acceptance of its efficacy, (2) the need for expanded room in the outlet for intravaginal interventions (such as the Woods maneuver), and (3) the need to apply all available methods for a birth complication with such high fetal morbidity and mortality. I have been able to locate only one published analysis of the use of episiotomy as a prophylactic measure against shoulder dystocia; this retrospective study found that its use did not appear to reduce the risk of this emergency [131]. 127. Reynolds JL. The final fatal blow to routine episiotomy. Birth 1993; 20 (3):162-163. 128. Lotgering FK, Wallenburg HC, Schouten HJ. Interobserver and intraobserver variation in the assessment of antepartum cardiotocograms. Am J Obstet Gynecol 1982; 144:701-705. 129. Nielsen PV, Stigsby B, Nickelsen C, Nim J. Intra- and inter-observer variability in the assessment of intrapartum cardiotocograms. Acta Obstet Gynecol Scand 1987; 66:421-424. 130. Piper DM, McDonald P. Management of anticipated and actual shoulder dystocia: Interpreting the literature. J Nurse Midwifery 1994; 39 (suppl):91S-105S. 131. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol 1993; 168:1732-1739. --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- Bob Woolley -- -----------------------------------------------------------------------------
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