Episiotomy: When will we cut it out?

1
Episiotomy When will we cut it out?

• Alice Teich, PGY1
• Dept of Family and Social Medicine
• April 27, 2010

2
Case

• 3/26/10
• HPI 16yo G1P0010 _at_38w1d by LMP (7/5/09) EDD
  4/8/10 c/w 11w sono p/w CTX q5min since 3pm
  today. LOF en route to hospital (30min ago.)
  No VB, FM
• PNI Intake BP 102/50 (102-132/50-90). Weight
  gain 31lbs (intake 158 --gt189)
• Adolescent pregnancy saw SW, and nutritionist.
  Attended all prenatal appointments. Has WIC and
  Medicaid filled out.
• PNL wnl/unremarkable
• Sonos 9/20/09 dating sono _at_11w
• 11/14/09 anatomy scan _at_ 19wks. No anat.
  Anomalies. Fetus 50tile
• 2/17/10 no anat. Anomalies _at_31w. Fetus 55tile w
  adequate interval growth. AFI 14.
• PObHx 2008 TOP 1st trim. DC. uncomplicated
• PGynHx no cysts/fibroids/STIs/abnl pap.
• 12/reg/5.

3
Case continued..

• PMH asthma -no intubations or hospitalizations.
  Albuterol PRN
• PSH DC only
• Meds PNV
• Allergies NKDA
• SH lives w mom. No tob/EtOH/drugs at all. In
  high school. FOB involved.
• FH non-contributory.
• PE BP 112/60 HR 74 Tmax 36.6
• FHT 140/mod/accels, -decels (EFM)
• Toco CTX q2-3 min (monitored externally)
• SVE 9/10/0 Vsono EFW 3100g (Leopolds)
• A/P 16yo G1P0010 _at_38w1d in active labor
• Admit to LD -- anticipate NSVD

4
Case continued..

• Pt c/o pain and need to make bm. Found to be
  FD and ready to push.
• SVE 10/100/1
• Toco CTX q2-3min
• Pt is in significant pain while pushing and
  requesting pain medication infants head has
  been crowning for approx 2 minutes/too late for
  epidural or IV analgesia.
• Pt is screaming, thrashing around, and FHT begins
  to decel to 70s, 80s, then comes back up to 120s,
  then decels again. Pt repositioned to lateral
  decub on both sides, but unable to stay in these
  positions, given discomfort.
• Episiotomy is cut midline, attempt made to
  deliver head for approx 30 seconds, then
  additional space cut, creating 2nd degree
  episiotomy. Infant is quickly delivered without
  instrumentation.
• Delivery of vigorous female infant w apgars of
  9/9. Cord clamped, cut, and gases sent. 3 cord
  placenta delivered spontaneously and intact.
  Fundus firmed with fundal massage and pitocin
  administration. Lidocaine administered locally
  and 2nd degree episiotomy repaired with 2-0 and
  3-0 vicryl w/o further complication. No 3rd
  degree extension into rectal sphincter.
  Hemostasis achieved. EBL 500cc.

5
Episiotomy

• Definition a surgical incision of the perineum
  usually performed at point when perineum is
  stretched and distended, just prior to crowning
  of the fetal head.
• Median/Midline vertical incision from fourchette
  straight back towards anus
• Easier to repair
• Mediolateral episiotomy incision perpendicular
  to midline, with angle becoming smaller (45º)
  beyond fetal presenting part
• Less extension to rectum
• J incision hybrid

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Episiotomy
The purpose is to increase the diameter of the
soft tissue pelvic outlet, thereby preventing
perineal lacerations, facilitating delivery, and
reducing the time for expulsion of the infant.
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Episiotomy

• One of the most common operations performed on
  women
• Prevalence is decreasing

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Indication for Episiotomy?

• The only indication for episiotomy that cannot be
  categorically dismissed is for fetal concerns
  (non-reassuring tracing, etc) that arise urgently
  during advanced labor.
• Other historical indications for episiotomy are
  not evidence-based and are proven to do more harm
  than good.
• Nulliparity
• Imminent tear
• Shoulder dystocia
• Need for vacuum or forceps delivery

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Not an Indication for Episiotomy

• Nulliparity

10
Not an Indication for Episiotomy

• Tearing is imminent

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Not an Indication for Episiotomy

• Severe Shoulder dystocia

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Not an Indication for Episiotomy

• Using vacuum or forceps for delivery

13
Episiotomy

• Other enduring myths about episiotomy
• It prevents pelvic floor weakness
• It is easier to repair than a tear
• It heals better than a tear
• It minimizes intraventricular hemorrhage in
  preterm infants

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Evidence against routine use of episiotomy

• Increases the following
• Wound extension, dehiscence, infection, and
  healing time
• Blood loss
• Postpartum pain
• Likelihood of leaking stool and gas (bowel
  incontinence)
• Dyspareunia
• /- urine incontinence

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Episiotomy Why is it still performed?

• High-intervention standards for childbirth
• Practice style and values of individual providers
  
• Practice style and values in specific birth
  settings
• Influence of colleagues
• Influence of medical education

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Avoiding episiotomy

• As early as possible in pregnancy
• Encourage pts to learn about episiotomy as part
  of learning about pregnancy, labor and delivery
• Encourage pts to create a birth plan that takes
  into account their values, preferences
• Even if you have been the provider for a pt
  throughout their entire pregnancy and especially
  if you havent, ask pts about their birth plans
  again at the time of labor/admission.

17
Avoiding episiotomy

• Kegel exercises
• Perineal massage
• Warm Compresses
• Slowed, spontaneous pushing during second stage
  of labor
• Upright birthing position

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References

• http//www.childbirthconnection.org
• Hartmann K, Viswanathan M, Palmieri R, Gertlehner
  G, Thorp J, Lohr KN. Outcomes of routine
  episiotomy a systematic review. JAMA 2005
  2932141-8
• UptoDate
• ACOG PRACTICE BULLETIN. CLINICAL MANAGEMENT
  GUIDELINES FOR OBSTETRICIAN/GYNECOLOGISTS NUMBER
  71, APRIL 2006