Episiotomy

Hoped in the past benefit of the episiotomy

The episiotomy was supposed to prevent serious tears of the Périnée. Research shows that not only the systematic practice of the episiotomy does not make it possible to reduce the tears of the 3^e or 4^e degree, but that in certain cases, the result is opposite of that discounted.

In the same way, one practiced the episiotomy while hoping to decrease the urinary incontinences or fecal. Research showed that it of it is nothing, and that it is even associated with more fecal incontinence in the 3 months after the childbirth.

The prevention of the genital Prolapsus by the episiotomy is not shown, because no medical study relates to one enough long period of time to check it. One just knows that the muscular force of the Périnée is less, three months after the childbirth, at the women having had a episiotomy.

The great hoped benefit of the episiotomy are thus invalidated by the medical studies.

Other indications of the episiotomy in particular cases

instrumental extractions , i.e. by suction cups or Forceps: research shows quil is not necessary to carry out systematically a episiotomy in these cases, more especially as rate of serious lesions périnéales is increased if there is a episiotomy during an instrumental extraction. The professionals add nevertheless that the conditions which carried out to decide on an extraction instrumental can justify a episiotomy in this case.

the operations obstétricales' (extraction of a Twin second , dystocie of the shoulders), the macrosomia (large baby), the nontraditional presentations of the fetus (in seat, by the face…), the prematurity: there is not not evidence to recommend or not the practice of the episiotomy in these cases. It seems however logical that the obstetrician can have to practice the episiotomy to facilitate the operations. Certain studies observe well rates of episiotomy in lower parts of the 100% for nontraditional presentations of the fetus (for example, 30% of épisiotomies in the event of complete seat, in a French study of 2005).

périnées at the risks: the only type of Périnée known as " with risques" who would justify, according to research, the practice of the episiotomy is the short périnée , defined as a distance fork-center of the anus lower or equal to 3 cm. For the cicatricial périnées (antécédants of lesions périnéales of high degree), there is a strong rate of repetition (the childbirth by low way must thus be discussed) but the episiotomy does not protect from this risk.

the fetal state not reassuring : the realization of épisiotomies in this case does not improve the results néonatals , according to the researchers. However, the professionals can have to carry out the episiotomy if it is necessary to reduce the time of expulsion.

the nulliparity : the studies conclude all that the birth of a first baby does not justify a systematic episiotomy .

Techniques of realization: types of episiotomy, analgesia, joining

Types of episiotomy

Épisiotomie median : incision of the fourchette directly towards the Anus on surroundings 4 cm. Although it is that still attends in the Anglo-Saxon countries, it is known that it creates a zone of median weakness which can slip by to the bottom and cause a rupture of the anal sphincter in nearly 20% of the cases.
Épisiotomie médio-side : incision which is illustrated on the drawing of the article. It is practiced in France. The incision must leave the median part of the fork and in moving laterally and outwards towards the ischiatic area (that is to say an angle of 45° compared to the vertical) on six centimetres on average.
Other completely abandoned types of episiotomy : bilateral épisiotomies, épisiotomies with multiple erased incisions, épisiotomies side which significantly increased the risk of a lesion of the glands of Bartholin at the time of the incision.

Analgesia for the episiotomy and the joining

Types of joinings

Complications of the episiotomy

Recommendations of clinical practice (France)

History

It can appear surprising to write a recommendation for the clinical practice for a also simple gesture and as current as the episiotomy, most frequently carried out in room of childbirth apart from the section of the umbilical cord! In fact, since the first surgical incision of périnée of a parturient carried out in 1742 by Felding Ould, the episiotomy knew various fortunes. Without remaking the history of it, it is only very gradually that she knew a passion such as some did not hesitate to practice it in a systematic way for the childbirth of first calf cow. The alarm bell was drawn by a first review from the literature, of 1860 to 1980, was published in 1983 by Thacker and Banta: no truly rigorous study comparing risks and benefit of the prophylactic episiotomy had never been carried out. But the first indictment really structured against the broad use of the episiotomy was developed in a very complete review of Robert Woolley in 1995.
Following the information campaign carried out by a French association (world Week for the respected childbirth, 10 May 16th, 2004), collective CIANE wrote to the Minister Health, the 7/2/2004, to require a sasine of ANAES (National agency of accreditation and evaluation in health) about the episiotomy. This initiative profited from the support of the National bank of health insurance of the employed persons (CNAMTS) and the national College from the gynecologists and French obstetricians (CNGOF).

During the first meeting of the technical Committee “Périnatalité” with the High health official (HAS, which replaces ANAES), on May 24th, 2005, the technical Committee decided unanimously to retain the topic “in practice Places episiotomy obstétricale” among the top priority of program 2005 of recommendations of clinical practice (RPC). (The report DBPPC/Programmation/CRP-NC/5/24/2005 recalls that the applicants were the CIANE, the CNAMTS and the CNGOF.)

Thereafter, the CNGOF took the initiative to work with the development of a RPC apart from the framework of HAS, but several members of the CIANE were invited by Professor Michel Dreyfus to comment on the documents of the rapporteurs. The CIANE thus constituted its own work group which, in agreement with the representatives of associations, gave to the CNGOF, in September 2005, a document of second reading.

(9/27/2005)
(11/18/2005)

Discussion of the rate of 30%

The Collective of users was declared disappointed by the partially contradictory conclusions of these RPC with the analysis of the scientific literature, like by the objective initially reducing the national rate to “30% of épisiotomies”, knowing that this rate was fixed arbitrarily by the CNGOF without any scientific justification: (…) the national total rate should be in lower part of 30% of the childbirth by low way, percentage which could in the future continue to drop if it is confirmed that this policy of reduction has positive consequences, with the image of other countries which adopted it.

The rates of épisiotomies are actually quite lower than 30% in the countries which revised their practice systematically: approximately 13% in the United Kingdom and less than 6% in Sweden. In France, the rate varies from an area with another, a population with another, an establishment with another and even from an operator to another. (…) “Since 1994, my rate of episiotomy is to 0”, flatters Jack Mouchel, gynecologist-obstétricien with the private clinic of the Hillock-red (Mans) .

To evaluate the anticipated profit of a national rate of 30%, it is instructive to compare two études^- carried out on more 10 000 childbirth, at the same time, with average rates of épisiotomies close to 34% (of Leeuw, with the Netherlands) and to 4% (Rockner, in Sweden).

The severe rates of tears in these two studies are equivalent. It is thus not the episiotomy which protects the Périnée. Two possible explanations:

the data are false, i.e a significant proportion of the severe tears is not registered in the files. With this point, that appears improbable.
the statistical sample was heterogeneous, which amounts saying that there were confusing Variables (hidden) not taken into account.

The statistical sample of Leeuw and colleagues is indeed very heterogeneous, gathering all maternities and the childbirth in residence. As other authors quoted in the same article show it, that results in results very dispersed according to maternities.

The Dutch practice and the Swedish practice are also rather different. The second is particularly respectful physiological mechanism of the Accouchement, not imposing on the parturient a position to be confined, nor the immobility during work, and calling upon the drugs and the active management of work only in the really pathological cases.

Legal aspects

(To be supplemented)

Jurisprudence of the episiotomy

In Spain (translation)
In France

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