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Re: 1389 (http://www.bmj.com/cgi/content/full/317/7169/1389) From: João Batista Marinho de Castro Lima (jblima@horizontes.net) Sun, 22 Nov 1998 10:16:38 -0200 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: JOSE LUIS QUELHO: "Ajude me a compor a minha homepage" Previous message: João Batista Marinho de Castro Lima: "En: Oligdramnia" Maybe in reply to: agostinho: "1389 (http://www.bmj.com/cgi/content/full/317/7169/1389)" Caro Agostinho, Como eu já disse antes nesta lista, a episiotomia é um dos muitos exemplos de práticas incorporadas a obstetrícia sem validação científica. Juntamente com a mesma podemos acrescentar a tricotomia dos pelos pubianos, o enema de rotina, a dieta zero no trabalho de parto, a amniotomia precoce, entre outras, que carecem de fundamentação para o seu uso rotineiro. A dificuldade para se mudar tais procedimentos reside no fato de que a mentalidade que rege a prática obstétrica é muito mais baseada num sistema de crenças, como uma religião, do que baseada em evidências científicas. Afinal não temos os nossos papas, aiatolás, budas, etc.? Com certeza seria muito difícil você propor a um padre mudanças no ritual da liturgia, como aconteceu quando as missas deixaram de ser celebradas em latim. Só para lembrar, a episiotomia foi realizada pela primeira vez em 1742, época em que se utilizava da sangria e tratamento com mercuriais para as mais diversas patologias. Parece que a clínica médica evoluiu um pouco mais. João Batista Marinho de Castro Lima Belo Horizonte - MG jblima@horizontes.net -----Mensagem original----- De: agostinho <aguedes@yahoo.com> Para: Multiple recipients of list <obstet-l@talk.obgyn.net> Data: Sábado, 21 de Novembro de 1998 12:41 Assunto: 1389 (http://www.bmj.com/cgi/content/full/317/7169/1389) >------=_NextPart_000_0004_01BE154B.7389E520 >Content-Type: text/plain; > charset="iso-8859-1" >Content-Transfer-Encoding: quoted-printable > >O que os colegas acham a respeito do artigo abaixo ? > >Home Help Search/Archive Feedback Table of Contents > >------------------------------------------------------------------------->------- >------------------------------------------------------------------------->Send a response to this article =20 >-------------------------------------------------------------------------> Electronic responses to this article > Related editorials in BMJ > PubMed citation > Related articles in PubMed > Download to Citation Manager > Search Medline for articles by: > Belizán, J. M || Carroli, G. > Alert me when: > New articles cite this article > > BMJ 1998;317:1389 ( 14 November ) > >Letters >Routine episiotomy should be abandoned > >EDITORIn their editorial Maduma-Butshe et al discussed the need to >abandon the routine use of episiotomy in developing countries.1 > > View this table: > [in this window] > [in a new window] > Episiotomy rates in one hospital in Rosario, >Argentina, before, during, and after episiotomy trial.3 Values are >percentages (proportions) > >The use of episiotomy is a paradigmatic example of the many >interventions that are introduced into clinical practice without >scientific evidence and found after well performed research to be not >only unjustified but also possibly harmful.2 In addition, once an >intervention has been established in clinical practice it is not easily >abandoned, even when strong scientific evidence shows its uselessness >and harmfulness. > >We have presented the results of our study on episiotomy3 and the >reviews about it 2 4 many times, but clinicians have often remained >sceptical and expressed little desire for change. > >The table shows the trend in the use of episiotomy in one of the >hospitals where the Argentine episiotomy trial was performed (Maternidad >Martin, Rosario, Argentina).3 Overall rates of episiotomy changed from >47.9% before the trial to 28.4% four years after completion of the >trial. However, the decrease in the rate of episiotomy was observed >predominately in multiparous women, with little change in nulliparous >women. During the trial nulliparous women had an episiotomy rate of >39.5%, but rates in daily practice increased to 82%; four years after >the end of the study and an intense dissemination of the results, rates >were nearly double those obtained during the trial. > >There is no obvious way to change a practice that has strong evidence >against it once the practice has been implemented. The challenge is now >to look for and test strategies to obtain such a change for routine >episiotomy. > >José M Belizán, Director. >Latin American Centre for Perinatology, Pan-American Health >Organisation-World Health Organisation, Montevideo, Uruguay > >Guillermo Carroli, Director. >Centro Rosarino de Estudios Perinatales, Rosario, Argentina > >------------------------------------------------------------------------->------- >-------------------------------------------------------------------------> >-------------------------------------------------------------------------> 1.. Maduma-Butshe A, Dyall A, Garner P. Routine episiotomy in >developing countries. BMJ 1998; 316: 1179-1180[Full Text]. (18 April.) > 2.. Lede R, Belizán JM, Carroli G. Is routine use of episiotomy >justified? Am J Obstet Gynecol 1996; 174: 1399-1402[Medline] > 3.. Argentine Episiotomy Trial Collaborative Group. Routine vs >selective episiotomy: a randomised controlled trial. Lancet 1993; 342: >1517-1518[Medline]. > 4.. Carroli G, Belizán JM, Stamp G. Episiotomy policies in vaginal >births. In: Pregnancy and childbirth module of the Cochrane database of >systematic reviews. Cochrane Library. Oxford: Update Software, 1997. > >------------------------------------------------------------------------->------- >------------------------------------------------------------------------->=A9 British Medical Journal 1998=20 >------------------------------------------------------------------------->Send a response to this article > Electronic responses to this article > Related editorials in BMJ > PubMed citation > Related articles in PubMed > Download to Citation Manager > Search Medline for articles by: > Belizán, J. M || Carroli, G. > Alert me when: > New articles cite this article > >Electronic responses to this article: >Read all electronic responses > > "And the costs ?" > TOLCK Paul, Serv. gyn.-obst. , Hospital > eBMJ, 13 Nov 1998 [Response] > Are we in a haste? > Dr Suresh Deshpande, Consultant, Ob-Gyn , Pune, India > eBMJ, 16 Nov 1998 [Response] >Related editorials in BMJ: > Routine episiotomy in developing countries. > A Maduma-Butshe, Adele Dyall, and Paul Garner > BMJ 1998 316: 1179-1180. [Full text] > >------=_NextPart_000_0004_01BE154B.7389E520 >Content-Type: text/html; > charset="iso-8859-1" >Content-Transfer-Encoding: quoted-printable > ><!DOCTYPE HTML PUBLIC "-//W3C//DTD W3 HTML//EN"> ><HTML> ><HEAD> > ><META content=text/html;charset=iso-8859-1 >http-equiv=Content-Type><TITLE>BMJ -- Belizán and Carroli 317 >(7169): 1389</TITLE><BASE >href=http://www.bmj.com/cgi/content/full/317/7169/1389> ><SCRIPT language=JavaScript> > <!-- > function startTarget(windowname,wid,hei) { > var sizestring = 'width=' + wid + ',height=' + hei > window.open('',windowname,'scrollbars,resizable,' + sizestring + '\'') > } > // --> > </SCRIPT> > ><META content='"MSHTML 4.72.3110.7"' name=GENERATOR> ></HEAD> ><BODY bgColor=#ffffff> ><DIV><FONT color=#000000 size=2>O que os colegas acham a respeito do >artigo >abaixo ?</FONT></DIV> ><DIV>&nbsp;</DIV> ><DIV>&nbsp;</DIV><A name=top><!-- null --></A><NOBR><MAP > name=home_button><AREA coordsW,22,110,40 href="/help/" >shape=RECT><AREA > coords=0,0,110,40 href="/" shape=RECT></MAP><A href="/" >style="TEXT-DECORATION: none" target=_top><IMG alt=BMJ border=0 >heightD >src="/icons/banner/title.gif" width"0></A> <A >href="/cgi/adclick?journal=bmj&ad=SCIENCE Online&url=http://www>.sciencemag.org &side=only" >target=_top><IMG alt="SCIENCE Online " border=2 height@ >src="/adgifs/892716247.gif" width"0></A> </NOBR><BR><NOBR> ><TABLE cellPadding=1 cellSpacing=2 widthE0> > <TBODY> > <TR> > <TD align=middle bgColor=#63ceff noWrap vAlign=top><A >href="/" > style="TEXT-DECORATION: none" target=_top><FONT >color=#000080 > face=arial,helvetica size=-1>Home</FONT></A></TD> > <TD align=middle bgColor=#63ceff noWrap vAlign=top><A >href="/help/" > style="TEXT-DECORATION: none" target=_top><FONT >color=#000080 > face=arial,helvetica size=-1>Help</FONT></A></FONT></TD> > <TD align=middle bgColor=#63ceff noWrap vAlign=top><A > href="/all.shtml" style="TEXT-DECORATION: none" >target=_top><FONT > color=#000080 face=arial,helvetica >size=-1>Search/Archive</FONT></A></TD> > <TD align=middle bgColor=#63ceff noWrap vAlign=top><A > href="/cgi/feedback" style="TEXT-DECORATION: none" >target=_top><FONT > color=#000080 face=arial,helvetica >size=-1>Feedback</FONT></A></TD> > <TD align=middle bgColor=#63ceff noWrap vAlign=top><A > href="/content/vol317/issue7169/" >style="TEXT-DECORATION: none" > target=_top><FONT color=#000080 face=arial,helvetica >size=-1>Table > of Contents</FONT></A></TD></TR></TBODY></TABLE></NOBR> ><HR align=left noShade widthE0> > ><TABLE align=right border=1 cellPadding=5 VSPACE = 4 HSPACE = >4> > <TBODY> > <TR> > <TD align=left noWrap> > <TABLE border=0 cellPadding=0 NOWRAP> > <TBODY> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1><STRONG><A > href="/cgi/eletter-submit/317/7169/1389">Send >a > response</A> to this article</STRONG> ></FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > href="#responses">Electronic responses</A> to >this > article </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Related <A > href="#related_editorials">editorials</A> in >BMJ > </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="/cgi/external_ref?access_num˜12952&link_type=MED">PubMed > citation</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="/cgi/external_ref?access_num˜12952&link_type=MED&report=n>brs">Related > articles in PubMed</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="http://www4.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form= >6&uid˜12952&Dopt=l">Download > to Citation Manager</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Search Medline for articles by: ><BR><IMG > alignºseline alt="" border=0 height > > src="/icons/spacer.gif" width> <A > >href="/cgi/external_ref?access_num¾lizan%2BJM&link_type=AUTHORSEA>RCH">Beliz&aacute;n, > J. M</A> || <A > >href="/cgi/external_ref?access_numÊrroli%2BG&link_type=AUTHORSEAR>CH">Carroli, > G.</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Alert me when: <BR><IMG align=bottom >border=0 > height src="/icons/spacer.gif" >width> </FONT><A > >href="/cgi/ctalert?alertType=citedby&resid=bmj;317/7169/1389&page_n>ame=options&return_type=article&return_url=%2Fcgi%2Fcontent%2Ffull%>2F317%2F7169%2F1389%3F"><FONT > size=2>New articles cite this > >article<BR></A></FONT></TD></TR></TBODY></TABLE></TD></TD><!-- end of >inner table --></TR></TBODY></TABLE><!-- end of content box --><VARDEF >id=TEXT><!-- Pages created by the Electronic Press Engine >from Atypon Systems, Inc. Visit >http://www.atypon.com/ --> <FONT size=-1><I>BMJ</I> 1998;317:1389 >( 14 November )</FONT><BR><A >name=art><!-- comment for Mosaic --></A> ><H3>Letters</H3> ><H2>Routine episiotomy should be abandoned </H2> ><P><!-- #### ARTICLE NAV #### --><TXT><A >name=SEC0><!-- comment for mosaic --></A> ><P>E<FONT size=-1>DITOR</FONT><IMG alignºseline alt=--- >border=0 >src="/math/12pt/normal/mdash.gif">In their editorial Maduma-Butshe et >al >discussed the need to abandon the routine use of episiotomy in >developing >countries.<A href="#B1"><SUP>1</SUP></A><SUP> </SUP> ><P> ><CENTER> ><TABLE border=1 cellPadding=0 cellSpacing=0 width•%> > <TBODY> > <TR bgColor=#e1e1e1> > <TD> > <TABLE cellPadding=2 cellSpacing=2> > <TBODY> > <TR bgColor=#e1e1e1> > <TD align=middle bgColor=#ffffff > >vAlign=top><NOBR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&>nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; > </NOBR><BR><NOBR><STRONG>View this > table:</STRONG></NOBR> <BR><NOBR><A > href="/cgi/content/full/317/7169/1389/Fu1">[in >this > window]</A></NOBR><BR><NOBR><A > href="/cgi/content-nw/full/317/7169/1389/Fu1" > onclick="startTarget('Fu1', 500, 400); >this.href='/cgi/content-nw/full/317/7169/1389/Fu1'" > onmouseover="window.status='View table in a >separate window'; > return true" target=Fu1>[in a new > window]</A><BR></NOBR>&nbsp;</TD> > <TD align=left vAlign=top><A > name=""><!-- TABLE --></A><STRONG> > <P align=left></STRONG>Episiotomy rates in one >hospital > in Rosario, Argentina, before, during, and after > > episiotomy trial.<SUP>3</SUP> Values are >percentages > (proportions) ></P></TD></TR></TBODY></TABLE></TD></TR></TBODY></TABLE></CENTER> ><P></P> ><P>The use of episiotomy is a paradigmatic example of the many >interventions >that are introduced into clinical practice without<SUP> </SUP>scientific > >evidence and found after well performed research to<SUP> </SUP>be not >only >unjustified but also possibly harmful.<A href="#B2"><SUP>2</SUP></A> >In >addition,<SUP> </SUP>once an intervention has been established in >clinical >practice<SUP> </SUP>it is not easily abandoned, even when strong >scientific >evidence<SUP> </SUP>shows its uselessness and<SUP> </SUP>harmfulness. ></P> ><P>We have presented the results of our study on episiotomy<A >href="#B3"><SUP>3</SUP></A> and the reviews about it <A >href="#B2"><SUP>2</SUP></A> <A href="#B4"><SUP>4</SUP></A> many >times, but >clinicians have<SUP> </SUP>often remained sceptical and expressed little >desire >for<SUP> </SUP>change. </P> ><P>The table shows the trend in the use of episiotomy in one of the >hospitals >where the Argentine episiotomy trial was performed<SUP> ></SUP>(Maternidad >Martin, Rosario, Argentina).<A href="#B3"><SUP>3</SUP></A> Overall >rates of<SUP> ></SUP>episiotomy changed from 47.9% before the trial to 28.4% four >years<SUP> ></SUP>after completion of the trial. However, the decrease in the >rate<SUP> ></SUP>of episiotomy was observed predominately in multiparous >women,<SUP> ></SUP>with little change in nulliparous women. During the trial >nulliparous<SUP> ></SUP>women had an episiotomy rate of 39.5%, but rates in daily >practice<SUP> ></SUP>increased to 82%; four years after the end of the study and >an<SUP> ></SUP>intense dissemination of the results, rates were nearly >double<SUP> ></SUP>those obtained during the<SUP> </SUP>trial. </P> ><P>There is no obvious way to change a practice that has strong evidence >against >it once the practice has been implemented. The<SUP> </SUP>challenge is >now to >look for and test strategies to obtain such<SUP> </SUP>a change for >routine<SUP> ></SUP>episiotomy. <BR> >Beliz&aacute;n</STRONG><NOWRAP>, <I>Director</I>.&nbsp; <FONT >size=-1><BR>Latin >American Centre for Perinatology, Pan-American Health Organisation-World >Health >Organisation, Montevideo, Uruguay<BR></FONT><BR><STRONG>Guillermo >Carroli</STRONG><NOWRAP>, <I>Director</I>.&nbsp; <FONT >size=-1><BR>Centro >Rosarino de Estudios Perinatales, Rosario, Argentina<BR></FONT><!-- >misplaced figures --><!-- Footnotes --><!-- Acknowledgements --><!-- >Notes Added in Proof --><!-- Abbreviations --><!-- Bibliography --> ><P> ><HR align=left width0%> > ><OL> > <LI value=1><A name±>Maduma-Butshe A, Dyall A, Garner P. >Routine > episiotomy in developing countries. BMJ 1998; 316: 1179-1180<!-- >MEDLINE ID="317:7169:1389:1" --><A > >href="/cgi/ijlink?linkType=FULL&journalCode=bmj&resid16/7139/11>79">[Full > Text]</A><!-- /MEDLINE -->. (18 April.) > <LI value=2><A name²>Lede R, Beliz&aacute;n JM, Carroli G. Is >routine use > of episiotomy justified? Am J Obstet Gynecol 1996; 174: >1399-1402<!-- MEDLINE ID="317:7169:1389:2" --><A > >href="/cgi/external_ref?access_num65102&link_type=MED">[Medline]></A><!-- /MEDLINE --> > <LI value=3><A name³>Argentine Episiotomy Trial Collaborative >Group. > Routine vs selective episiotomy: a randomised controlled trial. >Lancet 1993; > 342: 1517-1518<!-- MEDLINE ID="317:7169:1389:3" --><A > >href="/cgi/external_ref?access_numy02901&link_type=MED">[Medline]></A><!-- /MEDLINE -->. > <LI value=4><A name´>Carroli G, Beliz&aacute;n JM, Stamp G. >Episiotomy > policies in vaginal births. In: Pregnancy and childbirth module of >the > Cochrane database of systematic reviews. Cochrane Library. Oxford: >Update > Software, 1997. </LI></OL><!-- Appendices --> ><P> ><HR> ><FONT size=-1><A href="/misc/terms.shtml"><B>&copy; British Medical >Journal >1998</B></A></FONT><!-- Pages created by the Electronic Press >Engine from Atypon Systems, Inc. Visit >http://www.atypon.com/ --></VARDEF> ></FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > href="#responses">Electronic responses</A> to >this > article </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Related <A > href="#related_editorials">editorials</A> in >BMJ > </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="/cgi/external_ref?access_num˜12952&link_type=MED">PubMed > citation</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="/cgi/external_ref?access_num˜12952&link_type=MED&report=n>brs">Related > articles in PubMed</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT >size=-1><A > >href="http://www4.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form= >6&uid˜12952&Dopt=l">Download > to Citation Manager</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Search Medline for articles by: ><BR><IMG > alignºseline alt="" border=0 height > > src="/icons/spacer.gif" width> <A > >href="/cgi/external_ref?access_num¾lizan%2BJM&link_type=AUTHORSEA>RCH">Beliz&aacute;n, > J. M</A> || <A > >href="/cgi/external_ref?access_numÊrroli%2BG&link_type=AUTHORSEAR>CH">Carroli, > G.</A> </FONT></TD></TR> > <TR> > <TD><IMG alignºseline alt="" border=0 >height > src="/icons/toc/rarrowsm.gif" width=9><FONT > size=-1>Alert me when: <BR><IMG align=bottom >border=0 > height src="/icons/spacer.gif" >width> </FONT><A > >href="/cgi/ctalert?alertType=citedby&resid=bmj;317/7169/1389&page_n>ame=options&return_type=article&return_url=%2Fcgi%2Fcontent%2Ffull%>2F317%2F7169%2F1389%3F"><FONT > size=2>New articles cite this > >article<BR></A></FONT></TD></TR></TBODY></TABLE></TD></TD><!-- end of >inner table --></TR></TBODY></TABLE><!-- end of content box --> ><A name=responses><!-- eletters --></A> ><H2>Electronic responses to this article:</H2> ><P>Read all <A href="/cgi/eletters/317/7169/1389">electronic >responses</A> ><DL> > <DT><STRONG>&quot;And the costs ?&quot;</STRONG> > <DD>TOLCK Paul, Serv. gyn.-obst. , <EM>Hospital</EM> > <DD>eBMJ, 13 Nov 1998 <A > href="/cgi/eletters/317/7169/1389#EL1">[Response]</A> > <DT><STRONG>Are we in a haste?</STRONG> > <DD>Dr Suresh Deshpande, Consultant, Ob-Gyn , <EM>Pune, India</EM> > <DD>eBMJ, 16 Nov 1998 <A > href="/cgi/eletters/317/7169/1389#EL2">[Response]</A> </DD></DL><A > >name=related_editorials><!-- editorials --></A> ><H2>Related editorials in BMJ:</H2> ><DL> > <DT><STRONG>Routine episiotomy in developing countries.</STRONG> > <DD>A Maduma-Butshe, Adele Dyall, and Paul Garner<BR>BMJ 1998 316: > 1179-1180. <NOBR><A href="/cgi/content/full/316/7139/1179">[Full >text]</A> > </NOBR> > <P></P></DD></DL> > >------=_NextPart_000_0004_01BE154B.7389E520-- > Next message: JOSE LUIS QUELHO: "Ajude me a compor a minha homepage" Previous message: João Batista Marinho de Castro Lima: "En: Oligdramnia" Maybe in reply to: agostinho: "1389 (http://www.bmj.com/cgi/content/full/317/7169/1389)" busca recomendada... OBGYN.net somente forums endozone.org Web Entre as palavras-chaves para a busca: Mensagens por tela: 10 25 50 100 250 Mostrar apenas as mensagens que incluam todas as palavras-chave: Voltar para Administrador da lista: flavio.monteiro.desouza@obgyn.net Solicitações à lista: obstet-l-request@obgyn.net Última atualização: Mon May 19 16:36:47 2008