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Re: episiotomy and shoulder dystocia wasits effects on perineal body/From: Robert J. Woolley (wooll005@gold.tc.umn.edu)Sun Apr 27 21:59:33 1997
In message <01BC5355.54B98060@lp13-37.redrose.net> writes: > Of interest I know of a case where there was a lawsuit and the case > rested on the OB decision NOT to do an epis. You couldn't believe how > many of our low life colleagues were willing to testify under oath (and > for a hefty fee) that it is malpractice not to do an epis. That OB lost > the case. The main points that came up were 1. ACOG tech bull #196 > states "Some have advocated performing a generous episiotomy to increase > space for manipulations" 2. the same is said in Williams and is repeated > in the new 20th ed (on page 452). The lawyer twisted this statement to > indicate if your procedures don't go well to release the SD an epis is > needed. I don't know if you can argue with that. Are you arguing that we should perform episiotomies not for the benefit of the patient, but as self-defense? Just to really get > you going I was just served on a case where a midwife delivered the baby > and I was the backup. The baby did well -- no SD but she cut an epis. > Patient is suing because she states she didn't want an epis and it (the > epis) caused her a rectocele and now sex is painful. Sounds ridiculous > right. Well they have an expert opinion by a FACOG that this is the > case. Sounds like a hard case to win, if nothing was decided between CNM and patient. However, if the midwife agreed not to do it (unconditionally), then did, it's not malpractice, it's criminal assault. The case may come down to what discussion they had about whether it would be done or not. FWIW, here's what the literature says about long-term pain and dyspareunia caused by spontaneous tear vs. episiotomy. c. Long-term pain Six studies have addressed the issue of long-term pain caused by perineal damage. At 8 to 12 weeks postpartum, no patient contacted by Larsson et al was experiencing any perineal pain, regardless of the type of birth injury [12]. Although Weijmar Schultz et al found that more average pain was reported at six weeks than at six months, there was no statistically significant difference between those with episiotomy, first- or second-degree tears, and intact perinea [68]. The RCT of House et al reported Òno differences [in pain or tenderness] between the management groups at 6 weeks and 3 months. There were no patients with more than minimal perineal discomfort at 3 monthsÓ [48]. In their RCT, Sleep et al observed, at three months postpartum, comparable frequencies of Òmild,Ó Òmoderate,Ó and ÒsevereÓ pain between the liberal and restrictive use of episiotomy allocation groups [47]. Since the publication of Thacker and BantaÕs review [1], only two papers have found a difference in long-term perineal pain between episiotomies and spontaneous tears. At three weeks, Ršckner et alÕs patients with mediolateral episiotomy had more pain during sitting, walking, defecation, and micturition than those with second-degree tears, though the difference was not statistically significant in the last two categories [64]. At three months, the groups differed in reported pain only while sitting, again in favor of those with spontaneous lacerations. In their original paper, Klein et al did not report on long-term pain [50]. In the re-analysis, these data were presnted, although not by the original random allocation groups [23]. Similar percentages of women who experienced a spontaneous laceration and who had a non-extended midline episiotomy reported some degree of pain at three months. However, of those with any pain, the former group had less frequent and less severe pain. d. Dyspareunia Five observational studies and three of the RCTs collected data on postpartum dyspareunia, time to resumption of sexual intercourse, or both. In South Africa, Bex and Hofmeyr surveyed women who had delivered their first child at Johannesburg Hospital 12 to 24 months previously [69]. Current rates of dyspareunia were, counterintuitively, 38% after mediolateral episiotomy, 0% after second-degree tear, and 17% with an intact perineum. Current frequency of intercourse paralleled this distribution. At three months postpartum, the intact group had had less dyspareunia than the others, which were comparable. The very low rate of survey return (22%), the small numbers included (49 patients with vaginal deliveries), and the retrospective nature of some of the questions (asking women whether they had experienced dyspareunia on a specific date up to 21 months in the past, for example) render the data essentially useless. Ršckner et al reported no difference in time to resumption of intercourse or in dyspareunia at three months between women with mediolateral episiotomy and those with spontaneous second-degree or third-degree tears [64]. Conversely, a survey of London women five to seven weeks after delivery found that the presence or absence of episiotomy had no effect on the likelihood of a woman having resumed intercourse by the time of the interview, while a spontaneous laceration did delay such resumption, proportionate to its degree [70]. Neither outcome increased the frequency of dyspareunia at first postpartum coitus. In still different findings, 16% of the patients queried by Larsson et al had dyspareunia 8 to 12 weeks after an episiotomy versus 11% after spontaneous laceration (all degrees combined), a significant difference [12]. When Weijmar Schultz et al [68] compared their patients with a first- or second-degree tear to those with a mediolateral episiotomy, they discovered that the former group resumed sexual activity sooner but, paradoxically, had more dyspareunia at six months. Their results are confounded by a difference between the groups, in favor of the episiotomy subjects, in suture technique known to affect the degree of postpartum pain [71-72]. In the RCTs, Sleep et al noted earlier return to intercourse among the patients with the lower episiotomy rate, but no difference in dyspareunia up to three months postpartum [47]. Further follow-up at three years still revealed no difference [73]. House et al noted a slightly longer time to resumption of intercourse in the liberal use group (6.5 weeks) than in the restrictive group (5.5 weeks) [48]. Klein et al initially found no difference between the allocation groups for either measurement [50]. However, when re-analyzed by actual perineal management, pain at first postpartum intercourse was less among those with spontaneous tears than among those with episiotomies, while fractions having resumed sexual relations at six weeks and level of sexual satisfaction were similar [23]. Could you please turn off whatever is causing this mess to follow your posts?
> ABQBAAABAAAADAAAAAMAADADAAAACwAPDgAAAAACAf8PAQAAAEMAAAAAAAAAgSsfpL6jEBmdbgDd ---------------------------------------------------------------------------
--------------------------------------------------------------------------- Bob Woolley -- --------------------------------------------------------------------------- St. Paul, Minnesota
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