Technology & Health
A Commonly Used Birth Procedure Fuels Doubts
Episiotomy , Once Routine, May Not Ease Delivery and Can Slow Recovery
By Marilyn Chase
The Wall Street Journal Europe
(Copyright (c) 2000, Dow Jones & Company, Inc.)
SAN FRANCISCO -- Justice River Schexnayder is a born trendsetter.
The 3.6-kilogram, 28-gram boy was delivered at the University of California at San Francisco Medical Center earlier this month without the help of a small incision that once ushered in the majority of American babies. Now, however, its routine use has fallen from favor.
The procedure, known as episiotomy , is a small snip in the mother''s perineum, a band of tissue below the opening of the birth canal. But in young Mr. Schexnayder''s birth, a nurse massaged the mother with mineral oil, and physician Matthew Reeves eased the baby out gradually.
"It was a great experience," says new mother Melissa Sandoval, nuzzling her newborn moments after his arrival. She wanted to avoid episiotomy because her pregnancy handbook warned of tenderness during healing. Her doctors agreed. "After this," she says, "I could have 10 kids."
Once considered the kindest cut, episiotomy has been performed on millions of women for its supposed benefits; surprisingly, statistics suggest it wasn''t such a good deal. Across the U.S., a number of hospitals have begun pulling back from the procedure, dramatically reducing the number of episiotomies they perform.
Invented in Europe in the 1740s, episiotomy was popularized in the U.S. in the early 20th century. In an influential paper in 1920, pioneering obstetrician Joseph DeLee of the Chicago Lying-in Hospital declared that childbirth was "a decidedly pathologic process," and compared its impact to a "fall on a pitchfork."
Today that attitude would be dismissed as a gruesome parody of medical overkill, finding pathology in the most natural of events. Back then, however, obstetricians had few tools, fetal monitoring was primitive, and rates of birth-related injury to mother and child were much higher than today. So to spare women the wear and tear of delivery, he proposed that cutting a small incision would speed labor and lessen trauma. Moreover, with the incision neatly sutured up, Dr. DeLee delicately suggested, "Virginal conditions are usually restored."
As childbirth moved from home to hospital during the 1940s, episiotomies took off. By the 1970s and 1980s, the procedure was entrenched as a routine part of normal delivery. It was performed on more than 60% of all women giving birth in the U.S., including 80% of first-time mothers. Driven by faith in the rationale that a little cut could prevent far more severe lacerations, it became one of the most common surgical procedures in the country after the cutting of umbilical cords, says David Grimes, vice president of biomedical affairs at Family Health International, a nonprofit research group in Research Triangle Park, North Carolina.
But was that rationale scientifically sound? No one knew. Obstetric practice before the advent of randomized clinical trials in 1948 was, like much of medicine, an art shaped by tradition. "Fifty or 60 years ago, accepted medical practice was whatever the department chairman said it was," says John Repke, chairman of obstetrics at the University of Nebraska Medical Center in Omaha. "If you trained under a certain individual, you accepted their view. Usually they were skilled, and you left with that as the right way to do things. But that''s not really a scientifically sound way of establishing medical practice."
Skepticism about the benefits of routine episiotomy grew gradually on both sides of the Atlantic. In 1983, Stephen Thacker at the U.S. Centers for Disease Control and Prevention led a critical review of 350 books and articles on episiotomy . The review concluded that arguments in favor of routine cutting -- preventing lacerations, protecting pelvic muscle tone and preserving sexual function -- "do not withstand scientific scrutiny."
Midwives in the U.K. and the U.S. led calls for reform. "The indications for episiotomy -- sparing the fetal head and the maternal bottom -- didn''t hold water," says Judith Bishop, a researcher and nursemidwife at UCSF. "What helps," says Elsa Heros, Ms. Sandoval''s midwife, "is not rushing the birth, just letting the baby''s head do the stretching, and patiently waiting there with Mom."
Eventually, doctors began submitting episiotomy to clinical studies. One of the most powerful and persuasive trials was conducted in Argentina.
Researcher Jose Belizan and his colleagues randomly placed more than 2,600 pregnant women into two separate groups. The women in one group got a routine episiotomy ; women in the other group got one selectively, based on need. The study, published in 1993 in the Lancet, found that pain and healing problems were actually more common among women who were routinely given episiotomies than in the group where it was restricted.
Most recently, a study by Dr. Repke of Nebraska, working with colleagues at Brigham and Women''s Hospital in Boston, reviewed cases of 600 new mothers and found that the women who had episiotomies had an increased risk of intestinal problems for as long as six months after delivery. Most surprisingly, they found that women with the incision had even more complications than women who experienced spontaneous tears during labor.
That study, published in the British Medical Journal in January, drew the attention of William McGuire, a physician and chief executive officer of UnitedHealth Group of Minnetonka, Minnesota. And Dr. McGuire has been speaking out.
"We cannot go to doctors and say, `Don''t do episiotomies,'' " Dr. McGuire says in an interview. "What we have to do is promote this information, distribute it and expect them to follow it, and then measure it to see if this is consistent with best practices."
Doctors in teaching hospitals aren''t waiting for managed-care companies to set the pace. At Massachusetts General Hospital in Boston, Michael Greene, director of maternal-fetal medicine, says his hospital''s rate of episiotomies has fallen to between 10% and 15% of deliveries.
"Quite clearly, it''s not appropriate to routinely perform episiotomies on every single normal vaginal delivery," he says.
To be sure, episiotomies are useful in emergencies: when a baby is very large, labor is very long, or the fetal heart rate is depressed. Some doctors do them when a bad tear seems imminent. Others use them in deliveries where instruments are needed to help the baby out. It''s also undisputed that episiotomy shortens the last stage of labor by 10 to 20 minutes. So where speed is needed to prevent injury or asphyxiation, it can be essential.
As the pendulum of medical fashion swings from routine to restricted episiotomies, doctors disagree about what constitutes the right amount of intervention. The American College of Obstetrics and Gynecology, which doesn''t recommend routine episiotomy , plans to run an article by Canadian researchers in the April issue of its journal that concludes that the procedure -- now involved in 30% of vaginal births -- is still performed too frequently.
But others dispute this view. "We do far too few now," says Karen P. Beckerman, assistant professor of obstetrics and gynecology at UCSF and former chief of obstetrics at San Francisco General Hospital. "I think the pendulum has swung back too far."
"It''s ironic," adds the 45-year-old practitioner. As a resident physician at Washington University in St. Louis in the 1980s, Dr. Beckerman campaigned against automatic incisions, and was criticized for her stand. "I was a crusader for selective use of episiotomies," she says. "But now I find residents are so turned off that they''re not performing them when they''re indicated."
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