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Re: OBSTET-L digest 141From: Dra. Alicia M. Lapidus (alapi@pccp.com.ar)Sun, 26 Apr 1998 19:45:12 -0300
Hablando de episiotomma, quiero compartir con ustedes un articulo aparecido recientemente en el British Medical Journal. En la Argentina es cierto que la practica de la episiotomma esta ampliamente difundida y se enseqa como un medio eficaz para prevenir los desgarros, a pesar de la evidencia bibliografica de que disponemos indicando que la episiotomma no solo no es necesaria, sino que puede ser peligrosa. Yo reconozco que me es muy dificil resistirme a realizarla y muchas veces en el permodo expulsivo realizo una episiotomma que luego pienso que no hubiera sido imprescindible. Debemos aprender un nuevo modo de atender los partos y eso es muy dificil, pero sera en beneficio de nuestras pacientes BMJ 1998;316:1179-1180 ( 18 April ) Editorials Routine episiotomy in developing countries Time to change a harmful practice More women in developing countries are delivering their babies in hospitals. In Latin America institutional births account for 70% of all deliveries; in Africa, 36%; and in developing countries overall some 40%.1 What is becoming apparent is that in some countries virtually all the women delivering in hospital will be surgically cut. If they miss out on a caesarean section they will have an episiotomy. For example, Brazil has caesarean section rates of greater than 30%, and Argentina has episiotomy rates of greater than 80% for vaginal births. Questions about high caesarean sections rates have been raised in the past, but unnecessary episiotomies have not been widely debated. Obstetricians in the tropics continue to instruct health staff to apply a policy of "avoid tears-do episiotomies" routinely. They may be acting in good faith, but the evidence shows that they are wrong.4 Aiming surgically to cut all women delivering vaginally has no demonstrable benefit for the infant or mother but causes the woman unnecessary pain and adverse psychological effects and may cause death.5 In England episiotomies were performed on over half of all women delivering in 1980, falling to 37% in 1985. Recently released figures for 1994-5 indicate a further dramatic fall to about 20%. Although the older figures may not be strictly comparable with those from 1994-5, the overall trend downwards is clear, and local data support this. For example, in Liverpool Women's Hospital, in the first half of 1997 episiotomies were performed in 16% of all deliveries and 5% of normal births ( J Neilson, personal communication). Is this the trend in the world's poorer countries? We conducted a straw poll of 10 midwives from Zambia, Malawi, Nigeria, Ghana, Kenya, and Nepal attending courses in Liverpool. Our respondents had not considered whether policies of routine episiotomy could do more harm than good and found the review by Carroli et al enlightening.4 Most indicated that health professionals performed episiotomies routinely on primigravidas to prevent third degree perineal tears. Some midwives reported that some were performed to allow midwifery and medical students the opportunity to practise the procedure. We sought to document this anecdotal evidence of high episiotomy rates in developing countries, but data are sparse. A systematic search of Medline and contact with the Royal College of Midwives revealed very little quantitative data. We found a study in Botswana, where 1 in 3 mothers having a normal delivery had an episiotomy.8 Another study in Burkina Faso showed that, in primary care facilities, 43% of primigravidas received episiotomiesin a health system that frequently ran out of sutures and antibiotics.9 What is particularly worrying is that when health care resources are short episiotomy is more likely to result in complications. This increases the harm done by the procedure, in people who are least able to cope with the increased pain and suffering and least able to afford the prolonged hospitalisation. The World Health Organisation has taken a clear stand against routine episiotomy, in line with the best available evidence.10 Convincing obstetricians may be more problematical. Yet this is an important ethical issue for doctors and patients alike. In the West the procedure is usually discussed with women at antenatal clinics. In our experience in developing countries this does not happen. When the procedure is routine it therefore becomes a premeditated surgical procedure carried out without consent from the woman. It is important that we rapidly compare episiotomy rates between facilities and countries. Such data will guide more informed discussion about the level of unnecessary interventions. It will then be obvious to obstetricians, midwives, and the public whether obstetric practice is based on doing what is best for women, or persisting with policies that do more harm than good. A Maduma-Butshe, Maternal and child manager. Organisation for Rural Programmes for Women, Khumalo, Bulawayo, Zimbabwe Adele Dyall, Formerly senior nursing officer. Keewatin Regional Health Board, Government of the Northwest Territories, Canada Paul Garner, Head. International Health Division, Liverpool School of Tropical Medicine, Liverpool L3 5QA ---------------------------------------------------------------------------- ---- ---------------------------------------------------------------------------- Family and Reproductive Health Division. Coverage of maternity care: a -- ---------------------------------------------------------------------------- listing of available information. , 4th ed. Geneva: World Health Organisation , 1996. Barros FC, Vaughan JP, Victora CG, Huttly SRA. Epidemic of caesarean sections in Brazil. Lancet 1991; 338: 167-169[Medline]. Argentine Episiotomy Trial Collaboration Group. Routine v selective episiotomy: a randomised control trial. Lancet 1993; 342: 1517-1518[Medline]. Carroli G, Belizan J, Stamp G. Episiotomy policies in vaginal births Pregnancy and childbirth module of the Cochrane database systematic reviews [updated 04 March 1997]. The Cochrane Library. Oxford: Update Software , 1997. Sleep J, Roberts J, Chalmers I. Care during the second stage of labour. In: Chalmers I, Enkin MW, Keirse MJNC, eds. Effective care in pregnancy and childbirth. , Oxford: Oxford University Press, 1989:1136-1141. Graham ID. Episiotomy: challenging obstetric interventions. Oxford: Blackwell Science , 1997. Department of Health. NHS maternity statistics, England: 1989-90 to 1994-5. London: Department of Health , 1997. Mamba F. The liberal use of episiotomy in normal delivery: do women in Botswana accept the practice? Guildford: University of Surrey 1994 (Masters thesis). Lorenz N, Nougtara A, Garner P. Episiotomies in Burkina Faso. Tropical Doctor (in press). Thompson A. Episiotomies should not be routine Safe Motherhood Newsletter , Geneva: World Health Organisation, 1997:12.
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