On their part, women too readily accepted that medical interventions were always in the best interests of themselves or their babies. Epidurals, for example, can result in the loss of the urge to push, thus necessitating the use of forceps. Forceps, in turn, require the use of a large episiotomy to make enough room to place the blades of the forceps around the baby's head.
The First North American Episiotomy Trial
Dr. Michael Klein, has been a pioneer in Canada in raising the whole question of whether routine episiotomies are justified scientifically. The subject was and still is considered too trivial to deserve serious study. Through hard work and persistence, Dr. Klein obtained funding for a proper randomized trial on episiotomy, the first of its kind in North America.
"Far from a trivial matter, episiotomy can involve a woman's sense of mastery or control over her birth," says Dr. Klein,
"and for some it can become a central or symbolic issue."
Dr. Klein's trial was reported in the Family Practice journal (Aug/91) and published in the Online Journal of Current Clinical Trials in 1992. The trial ran from July 1988 to May 1990 and involved 47 physicians and more than 1,000 women aged 18 to 40. It compared two groups of women, one in which episiotomy was used liberally, and the other in which doctors were asked to try to avoid an episiotomy i.e. to restrict its use. In the liberal or routine use group, episiotomy rates were 81 percent for first babies and 47 percent for subsequent babies, contrasted to 57 percent and 31 percent in the restricted use group.
The trial found that restricting episiotomies increased the length of second stage slightly without harming the baby. Second stage was only increased in women having their first babies by an average of nine minutes. In women having their second or more pregnancy, there was no increase in the length of second stage.
The two groups were followed up for three months after delivery. There was no difference found in pelvic floor functioning. Constipation, pain on moving the bowel, urinary incontinence, and bulging three months after the birth were the same for both groups. Objective measurement of pelvic floor function also showed no differences for the two groups.
Women with no stitches for repair of either a tear or an episiotomy were found to have the least pain and did the best overall (six to seven percent of women having their first babies and 19 to 31 percent of women with second or more babies). In this study, women who had episiotomies compared with women who had tears, experienced the same amount of pain with first babies, but with subsequent babies, tears were less painful.
Severe perineal trauma, with tears that extend into the rectum, "occurs virtually exclusively in the presence of an episiotomy." So much so that Dr. Klein feels that episiotomy should be redefined as being equivalent to a second degree tear, with a 21 percent chance of a tear into the rectum with the first birth and a one percent chance for subsequent births.
Women with severe perineal trauma have the worst outcomes overall: more pain immediately following the birth and for a longer time after discharge from hospital. Women in this group are more likely to describe their pain as being "horrible" or "excruciating." These women also resumed sex later, had more pain during sex and reported less sexual satisfaction, at least in the first three months after birth.
Since the study failed to demonstrate any benefit from routine use of the episiotomy to either mother or baby, Dr. Klein's research team recommended that this practice be abandoned and that episiotomy be used instead only when necessary for the health of mother or baby.
In another arm of the study, Dr. Klein examined the belief systems of participating doctors and how those beliefs impacted on their practice. He found that episiotomy rates depended on the belief system of the individual doctor. Doctors who performed a lot of episiotomies (80 to 90 percent or more for first births) were responsible for most of the severe perineal trauma experienced by women in the study. They also tended to be more interventionist in other ways as well (more Cesarean sections, forceps, epidurals, inductions, etc).
In England, a similar trial involving 1,000 women showed that overall there was considerably less trauma to the mother if episiotomies were restricted. The episiotomy rates were ten percent in the restricted group and 51 percent in the liberal use group.
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