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Re: ATTN : CONNIE controversy regarding episiotomiesFrom: D. Ashley Hill, M.D. (anonymous@obgyn.net)Sat, 24 Oct 1998 12:36:22 -0500 (CDT)
Some thoughts on episiotomies and this thread: In my opinion, which is fortunately backed by a fairly large volume of recent medical science, episiotomies are rarely necessary, and lead to an increased chance of producing large tears through the anus and/or rectum. Think of it like tearing a piece of a grocery bag: it's always harder to tear the first piece than it is to make the tear if it's already "jump started" for you. An episiotomy can have this effect, leading to an increase in 3rd- and 4th-degree lacerations. However....there are some instances where an episiotomy is necessary. I have had a number of deliveries where the baby's heart rate dropped to near zero, but the head was "right there." The patient may be delivering her first baby, or may be dead tired from 2 hours of hard pushing. In these cases, but only after I discuss it with the patient, an episiotomy may save 5-15 minutes of pushing time. For a kid that's crashing, that can make the difference between going home with mommy and daddy, or hanging out in the ICU for a month. Please note, however, that I cut episiotomies in about 5% or less of my deliveries. It is debatable whether or not a "large cut" is better or worse than a c/section. C/sections are big operations, with at least twice the blood loss of a vaginal delivery, and the potential for infection, blood clots, incision problems, scar tissue (adhesion) formation, and even death. Both a 4th-degree laceration and a c/section cut can take a long time to heal. Some women are dead set against c/sections, while others are horrified at the thought of a tear through the vagina into the rectum. Thus, it's up to the patient, after hearing the plusses and minuses, to make the choice. There is some debate in the medical literature that episiotomies, with subsequent repair, may decrease the chance of urinary incontinence later in life. Vaginal delivery is the cause of most cases of subsequent urinary incontinence, and the theory is if the pressure on the perineum is "released" prior to delivery, there will be less incontinence. To my knowledge, this has not been proved, and I doubt it's true for most women. Even carrying a baby, but having a c/section, can predispose some women to incontinence. There are experts who would like to evaluate the cost/benefit ratio of c/sections vs vaginal deliveries, to see if the cost of medical care (office visits, lost days from work, surgery) for incontinence outweighs the cost of c/section. We'll see. On another note, someone posted about group practices. I am one of 5 partners in a group. Although there are some benefits to a 2-person group, there are other benefits to a larger group. Many doctors in 4,5, or 6-person groups take "in house" call, where they are available on the labor unit 24-hours a day. That has been proven in a recent medical article to substantially decrease the c/section rate. That's because the doctor is not at home, and can be right there to evaluate things as labor changes. Just a point of information. Finally, I found the comments about female OBs very sexist. Enough is enough. How many people go to a McDonald's, have a hamburger that doesn't taste quite right, and *never* go back to another McDonald's ever again? Probably nobody, because it's obvious that there are multiple thousands of McDonalds, and it's likely the "bad" one had a bad cook, or got a bad batch of hamburgers. The odds are that the hamburgers at the other McDonalds taste just fine. Similarly, I can't see the logic of why someone would change genders of their doctor just because they had a bad experience with one particular gender (it works both ways, as my office is full of women who had a bad experience with a female OB and came to me instead). The woman who posted those comments might be shocked to learn that the worst episiotomy offender I have known in my career was a young female OB who not only cut an episiotomy for *every* delivery, but also cut a huge mediolateral episiotomy. These can be even more painful than a midline episiotomy. Her logic: since she would "just die" if her vagina ever touched her rectum, she assumed all other women felt the same way. Thus, she wanted to prevent this from ever happening by cutting a huge episiotomy to prevent tearing. As you can see, patients should look for the *best* doctor, regardless of gender, race, eye color, type of car, or other inconsequential factors. As medical research progresses, we will know even more information about the risks and benefits of episiotomies. For now, my partners and I will rarely cut them.
-- Ashley Hill David Ashley Hill, M.D. Associate Director Department of Obstetrics and Gynecology Florida Hospital Family Practice Residency Orlando, FL http://home.mpinet.net/dahmd
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