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Re: ob profession (was postpartum intercourse)From: Robert J. Woolley (wooll005@gold.tc.umn.edu)Mon Jun 30 00:16:50 1997
In message <v01540b01afdce0c4cac8@[169.132.116.216]> writes: > >In other words, did your RCTs ask the > >right questions? And in all five RCTs that you mention were they the > >same, and who decided on them? > > Not to argue the merits of episiotomies, but my two main indications are to > shorten the second stage, usually because the FH is bottoming out, This leads to consideration of an indirect line of evidence of potential benefit of routine episiotomy on early neonatal outcome. If (1) the length of the second stage of labor is proportionate to the deterioration of fetal acid-base status, and if (2) episiotomy shortens the second stage, then one might expect to see results such as those of Friese et al [120]. Because the first component of this syllogism is independent of the use of episiotomy, it is outside the scope of this paper. Suffice it to say that the preponderance of published reviews appears to disclaim any arbitrary upper limit on the safe duration of second stage in a non-distressed fetus [1, 81, 121-125]. The second part of this syllogismÑthat episiotomy abbreviates the second stageÑseems obvious, but actually has surprisingly little evidentiary support. Because it is a point of lesser importance, I will merely list the recent observational studies by their conclusions without consideration of their relative strengths. The expected direction of effect is reported only by Reynolds and Yudkin [8]. No difference in length of second stage with or without episiotomy has been reported by five papers [10, 18-20, 64]. Four studies demonstrated a longer second stage with use of episiotomy [22, 30, 38, 126]. Three of these [30, 38, 126] can reasonably be understood as employing episiotomy to terminate the longest labors, but one is not so easily dismissed. In it, as discussed previously, Chambliss et al randomized patients to management by obstetric residents or midwives within the same hospital [22]. The midwives managed a shorter mean second stage (33 versus 45 minutes) despite less frequent use of episiotomy, oxytocin, and operative deliveries. The RCTs add little support to this presumed benefit of episiotomy. Harrison et al compared those randomized to receive episiotomy and those who sustained a spontaneous second-degree tear; length of second stages were similar (35 and 32.5 minutes, respectively) [43]. Sleep et al mention in passing that the liberal use group had a longer average labor, but provided no data on this point [47]. House et al found no significant difference in the length of first or second stages [48]. Such information was not collected in the Argentine trial [49]. Klein et al saw a non-significant trend toward shorter second stage with liberal use of episiotomy in nulliparous women (84 versus 75 minutes), but no difference in their parous patients [50].
or the
> perineum is *not* stretching, usually secondary to scarring from previous Well, if I'm reading between the lines correctly, your concern is not that the baby won't get past the perineum (they *almost* always do, of course), but that the perineum will be torn in the process. Is that correct? If so, then we are left with two questions. (1) Can you actually rpedict accurately which patients will suffer a tear in the absence of an episiotomy, and (1) is an epis preferable, from the patient's POV, to that tear? The first has never been demonstrated. But for the sake of argument, let's assume that you have exceptional skills, and can predict 2nd-degree tears with perfect accuracy. Is an epis preferable to a psontaneous tear? There are many ways of addressing that question (pain, risk of infection, risk of later pelvic relaxation, risk of extension to the anal sphincter, etc). Each of these has been addressed in various trials, not always in the RCTs, though. E.g., the risk of infection is low enough that only one study has found a difference, probably because others had too little power, and it found higher risk with epis than with spontaneous tear. However, it was retrospective, non-randomized, observational, subjet to many biases. Midline epis definitely has higher risk of anal extension than spontaneous tears. Spontaneous tears have less pain in the first few postpartum days, though no difference long-term. Etc. Does that answer your question? ---------------------------------------------------------------------------
--------------------------------------------------------------------------- Bob Woolley -- --------------------------------------------------------------------------- St. Paul, Minnesota
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