Tuesday, October 14, 2008

Episiotomy is avoided with elective cesarean delivery

The 2006-07 NHS Maternity Statistics for England were published in September, and it is very interesting to look beyond the highlighted 'key facts and summary' and delve into the details and numbers contained in specific tables.

For example, the key facts state that 13% of women had an episiotomy, but this does not mean that there is a 13% chance of having an episiotomy during a planned vaginal delivery (PVD). In fact, the percentage risk is much higher. Take a look at Table 16. It states that "The highest proportion of Episiotomies were carried out for Instrumental deliveries. For spontaneous deliveries the highest proportion were carried out in the London Strategic Health Authority (31.9%) and the lowest proportion in the South East Coast Strategic Health Authority (20.5%)." So at least 1 in 5 women have an episiotomy with a PVD.

Why are these numbers so much higher?
Because the 13% figure is the number of times episiotomies occur in ALL deliveries, including cesarean deliveries. Since the rate of occurrence is "0.0%" during an elective cesarean and ""0.3%" during an emergency cesarean, you can see how this helps bring the overall total down to 13.3%.

So what is the risk of having an episiotomy with a planned vaginal delivery (PVD)?
Table 16 separates PVD into a number of different outcome categories, and while a woman can never predict which outcome will be her personal experience, this is what we know about episiotomy occurrence (and therefore likelihood) in England:

With a spontaneous vertex delivery, 7.8% of women had an episiotomy. For other types of spontaneous deliveries, 16.1% of women had an episiotomy. With a low forceps delivery, 84.8% of women had an episiotomy, and for other types of forceps deliveries, 82.5% of women had an episiotomy. With a ventouse delivery, 63.6% of women had an episiotomy. For breech deliveries, and breech extraction, 23.4% and 17.7% of women had an episiotomy respectively.
So with a PVD outcome of forceps, 4 out of every 5 women have an episiotomy.

Why is this an elective cesarean 'benefit'?
Because medical studies have cited the negative repercussions of episiotomies; in particular, the risk of severe perineal trauma and its related long-term health issues. Many medical professionals believe that episiotomies were overused in the past and have sought to reduce their incidence (see Table 15 to witness falling rates over the years). Clearly, women don't decide to have a planned cesarean 'only' to avoid an episiotomy, but its avoidance is certainly a legitimate factor in their risk-benefit analysis. You can read a list of medical studies on episiotomy here.


Birthkeeper said...

It's sad that I'm not surprised in the least bit that this type of ignorance and misinformation, or misdirection, is being plastered all over the internet.

Once women decide that they actually want to research childbirth, they might find that they can AVOID all of the things that makes vaginal birth "risky", such as episiotomy, instrumental deliver, and fecal/urinary incontinence.

But, that would mean that women would have to strap on their brain and their big girl panties. Which, judging by blogs like this, and the general hideously ignorant mainstream ideas...is not likely to happen.

So more cesareans will be performed upon maternal request. More babies will end up in the NICU, costing tax payers billions of dollars for those who are on state-funded medical, and more women will begin dying.

Is that really the answer?

cesarean debate said...

birthkeeper - I think you demonstrate great misunderstanding and a lack of compassion here. You claim that women can categorically avoid the risks associated with vaginal delivery if they follow certain guidelines.

Women are NOT to blame for their traumatic birth experiences, and even if you try to lay the 'blame' at the door of hospital interventions, you're ignoring the fact that the overwhelming majority of women CHOOSE to deliver their babies in a hospital - with access to emergency medical care.

Finally, even if you believe there IS a fail-safe way to avoid an episiotomy during a vaginal delivery, that does not change the FACTS of episiotomy occurrence that I refer to here.

Whatever your - or my - opinion on the use of episiotomy is, the fact remains that it is more likely to occur during a PVD than a PCD, and for some women, this is an important factor to consider in their risk-benefit analysis.

Birthkeeper said...

Yes, the majority of women choose hospital birth. That is why more and more women are being traumatized. Study after study shows that the incidence of trauma - both physical and emotional - are decreased by having the baby out of hospital. With no difference in the infant mortality, and SIGNIFICANT difference in maternal and infant morbidity.

And of course you're right. LOL How could an episiotomy occur with planned cesarean delivery? Instead you get a nice gash across your belly.

Who would want to work harder to avoid a gash in the perineum, when they can sign up for one in the belly?

Silly me.

Birthkeeper said...

In fact, just for your own stores of information...

A study done in the Journal of the American Board of Family Medicine found that severe perineal trauma is directly increased with epidural use.

They found a 2 fold increase of severe perineal lacerations amongst the women who were given epidural anesthesia. ( 10.25% vs. 5.22% )

They also found a three fold increased risk with instrumental delivery amongst those who had an epidural, resulting in the dramatic rise in risk for perineal injury.

The answer is not major abdominal wound instead. The answer is less epidural anesthesia, less intervention in childbirth.

( http://www.jabfm.org/cgi/content/full/16/1/1 )

cesarean debate said...

birthkeeper - If your answer then is for women to give birth outside of a hospital, then we will have to agree to disagree on this point.

You see, despite your home birth recommendations, most women DON'T want to make this birth choice, and for those of us who want to choose a cesarean delivery, your advice to give birth at home is simply not relevant here. I (and women with similar views to mine) would never ever choose to give birth at home. Never.

And while you will never understand this - for many women, an abdominal incision IS preferable to a perineal incision. You may be shocked by this, but it is true. Is it so difficult for you to be as tolerant of my birth choice as I am of yours?

Birthkeeper said...

Tolerance for birthing decisions doesn't change the statistical outcome.

My point in all of this, is that you are not wholly representing ALL options in childbirth, and comparing the outcome.

Is planned abuse on mother and baby really that much better than unplanned abuse on mother and baby? ( Planned cesarean vs. planned hospital vaginal birth ).

I have had all three types of birth. A planned, and very average, hospital vaginal birth. An elective cesarean, and then a home birth.

Unless you are willing to look at the research for ALL options in delivery, and compare them, you are doing a grave injustice to ignorant women who come to read, as well as fueling the ability for doctors to continue to traumatize women.

And funnily enough, I was in the "I would never give birth at home. Ever." camp just 4 years ago.

Funny how education, information, and experience can change things. ;)