Consortium for the Evidence-based practice of Obstetrics -- 
C.E.O. is dedicated to bringing science-based 
maternity care to all childbearing women
 

 Quotes and Excerpts from www.eObGynNews.com and 
 other respected sources  of professional information
on safety, complications & practice trends for obstetricians  

Bibliography, Recommended Reading and Scientific Citation from obstetrical sources:

Episiotomies /Forceps / Incontinence

   

   


Episiotomies Still Favored by Private Physicians -- more common in whites, privately insured,  Ob.Gyn.News July 1, 2002 Vol 37, No 13


Episiotomy Scars Have Increased Failure Rate
– subsequent vaginal delivery
 
Ob.Gyn.News  July 1, 2002, Vol 37, No 13


Risk of Bad Perineal Tear Higher with Midline
Episiotomy -- long term pain 
Ob.Gyn.News Nov 15, 2001 Vol 36, No 22  

 

Maternal Deaths associated with necrotizing fasciitis ~ study by David Banta M.D. & Stephen B. Thacker M.D.

Forceps Double Risk of Incontinence; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18

 

Forceps Associated with Severe Perineal Tears – Risk increased 12-fold, 
Ob.Gyn.News Sept 15, 2003 Vol 38, No 18;

 

Perineal Tears Raise Anal Incontinence Risk Fivefold Ob.Gyn.News, Feb 1, 2003, Vol 37

 

Sequential Use of Vacuum, Forceps Raises Injury Risk – hemorrhages, nerve injury, lacerations seen; Ob.Gyn.News, Aug 01, 2001, Vol 36, No 7

 

New Subgaleal Hemorrhage Code (type of brain bleeding known to be a complication of vacuum extraction); Ob.Gyn.News, Aug 1, 2003, Vol 38, No 15  

 

Most extensive research published on the efficacy (or lack thereof) of Episiotomy ~
Benefits and risks of episiotomy: A review of the English-language literature since 1980
. Woolley RJ.  Part I. Obstet Gynecol Survey 1995; 50:806-820// Part II. Obstet Gynecol Survey 1995; 50:821-835.


 

Episiotomies Still Favored by Private Physicians -- more common in whites, privately insured: Ob.Gyn.News July 1, 2002 Vol 37, No 13

Routine episiotomies are falling out of favor in response to a growing body of evidence that they are medically unjustified but white women, those with private insurance and those with private practitioners are still disproportionately receiving that the popular press has called the “unkindest cut.”  

“Episiotomy was at one time almost universally performed in vaginal births in the US but has been increasingly called into question. Some studies have linked episiotomy with increased perineal damage, postpartum pain, blood loss and infection

A number of studies … found a decline in the percentage of episiotomies from 56% in 1979 to 31% in 1997.  … findings that black women were at considerably lower risk …than white women. 

Spontaneous vaginal deliveries less likely to be associated with an episiotomy, while forceps delivery and 4th degree lacerations were positively associated…”   

“Even more striking however was the difference in the episiotomy rate between [medical] residents … and private practitioners … [who] performed episiotomies in 65.7% of vaginal deliveries. “This analysis demonstrates the persistence of high rates of episiotomy use among private practitioners, despite current evidence-based literature that support restricted use…” 


Episiotomy Scars Have Increased Failure Rate; – subsequent vaginal delivery 
Ob.Gyn.News  July 1, 2002, Vol 37, No 13

Scars resulting from episiotomies were nearly twice as likely to fail during a subsequent delivery as scars that resulted from a spontaneous laceration during vaginal delivery…” … 

“Of the 130 women with episiotomy scars, 62 lacerated [greater than 50%] during their second delivery. Of the 40 women with scars from spontaneous lacerations, 14 lacerated ….”  


Risk of Bad Perineal Tear Higher with Midline Episiotomy, long term pain: 

 Ob.Gyn.News Nov 15, 2001 Vol 36, No 22

“The greatest risk factors for 3rd degree perineal tears during vaginal delivery are midline episiotomy, forceps delivery, and oxytocin use…   Although 3rd degree perineal tears are rare … they can eventually lead to long-term pain and incontinence

Of the 242 women with underwent episiotomy, 9.1% had 3rd degree tears, compared with 1.7% of women who didn’t have episiotomy. 

Among women who had forceps deliveries, 9.3% suffered 3rd degree tears, compared to 2.9% who had spontaneous deliveries. Tears were also more frequent with oxytocin use, occurring in 5.6% … and 2.3% of the women who didn’t. 


Report on maternal deaths from necrotizing infection of her episiotomy incision:


"Infection of the episiotomy site was found to occasionally lead to a serious problem called necrotizing fasciitis. 

Death associated with this problem accounted for 20-30 percent of all maternal mortality in the populations studied."

Quote from "Episiotomy and the Second Stage of Labor";  Sheila Kitzinger ed. page 85

Benefits and Risks of episiotomy, David Banta M.D. & Stephen B. Thacker M.D. Woman and Health 7:161-177, 1982

Maternal deaths associated with postpartum vulvar edema; Ewing, et al; Am JObstet Gynecol 134:173-179, 1979

Fatal perineal cellulitis from an episiotomy site; Shy et al; Obstet Gynecol 54:292-298, 1979

Necrotizing Fasciitis in postpartum patients; Golde S, et al; Obstet Gynecol 50:670-673, 1977


Forceps Double Risk of Incontinence; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18

 

“A woman whose baby is delivered with forceps has almost twice the chance of postpartum [bowel] incontinence than a woman who delivers vaginally, results of a multicenter study suggest”.   


 

Forceps Associated with Severe Perineal Tears – Risk increased 12-fold, Ob.Gyn.News Sept 15, 2003 Vol 38, No 18;  

 

The risk for a 3rd or 4th degree perineal tear increased 12-fold in women who underwent forceps-assisted deliveries in a retrospective study of 267 vaginal births. 

 

Having an episiotomy was associated with a threefold increase in 3rd and 4th degree lacerations...


 

Perineal Tears Raise Anal Incontinence Risk Fivefold Ob.Gyn.News, Feb 1, 2003, Vol 37, No 3  

Forceps delivery and third- or fourth-degree perineal tears both significantly increase the risk for long-term anal incontinence in primiparous women” … “In addition, women who had third- or fourth-degree perineal tears [associated with episiotomies] during delivery were at nearly fivefold greater risk, ... 

The women were interviewed at 2 weeks, 3 months, and 1 year.  At 2 weeks, incontinence [of stool] was higher in both the patients delivered by vacuum (17%) and forceps (35%) than among those who delivered spontaneously (7%). By 3 months, the forceps group remained at increased risk (21%). 

Those proportions had not changed significantly at 1 year, with continued anal incontinence reported by 2% of the spontaneous delivery patients, 4% of the vacuum group, and 20% of the forceps patients.    


Sequential Use of Vacuum, Forceps Raises Injury Risk – hemorrhages, nerve injury, lacerations seen; Ob.Gyn.News, Aug 01, 2001, Vol 36, No 7

“The risks of both maternal and fetal injury are increased with the sequential use of vacuum extraction and forceps for assisted vaginal delivery”    

“A …study of more than 33,000 birth using Washington state birth certificate data found increased risks of intracranial hemorrhage, facial nerve injury, maternal lacerations and postpartum hemorrhage with combined assisted vaginal deliveries

Stats per 1,000             Normal birth                forceps             Vacuum            Both

Brain bleed                               0.6                   1.4                   2.8                     7.8
   
         Facial Nerve Injury                  0.4                   6.8                   1.7                   13.3
   
         Fourth Degree Lac                   0.9                   2.4                   2.4                     4.2

                   Combined total for all complications of NSVD                      1.9
                   Total for all complication of forceps alone                           10.6
                   Total for all Vacuum complications alone                               6.9

                   Total for all complication both instruments                          25.3

No stats were given for maternal hemorrhage, neonatal seizures and depressed 5-minute Apgar scores associated with operative deliveries but this would be in addition to those listed  


New Subgaleal Hemorrhage Code (type of brain bleeding known to be a complication of vacuum extraction); Ob.Gyn.News, Aug 1, 2003, Vol 38, No 15  

Beginning in October, physicians who deliver a baby that sustains a subgaleal hemorrhage should begin using a new diagnosis code for the injury. The new code, 767.11, will be used instead of 767.1 and was developed to separate subgaleal hemorrhage from other birth injuries, said Dr. Victor Vines of Medical City Hospital in Dallas. In addition to subgaleal hemorrhage, code 767.1 was used to indicate diagnoses of caput succedaneum, cephalhematoma, and chignon, a situation that made it difficult to track the incidence and causes of subgaleal hemorrhage.

“This particular injury has been erroneously reported for decades because we've never had an ability to code it accurately, he said. “It's been lumped into a category of injuries that are really benign and nonsignificant to fetal outcome.”

Because [subgaleal hemorrhage] is such a big injury and has severe implications for the baby—and therefore legal implications for the doctor and the hospital—if we try to do procedures to decrease its incidence and don't have way of tracking whether there's any benefit to the things we're doing, then we're shooting in the dark,” he said.

Interest in subgaleal hemorrhage intensified in 1998, when the Food and Drug Administration issued a public health advisory about complications with vacuum-assisted deliveries. “Over the past 4 years,
FDA has received reports of 12 deaths and nine serious injuries among newborns on whom vacuum-assisted delivery devices were used,” the advisory said. “[Although] the total number of serious complications reported to FDA from vacuum-assisted delivery devices remains small in relation to the total number of births per year in which these devices are used … we are concerned that at least some of these complications might be avoidable.”

Dr. Barry Schifrin, of the department of ob.gyn. at Loma Linda (Calif.) University, applauded the new code. “The major benefit is that it will call attention to proper surveillance and perhaps proper awareness of the complication,” he said.

“The normal failure rate of vacuum extraction is maybe 5%-10%, but it is highly, highly unusual to have that encoded as part of hospital records,” he said.

He recommended having all babies delivered by vacuum assessed for head size and vital signs during the immediate newborn period.

Dr. Michael Ross, who is professor and chair of obstetrics and gynecology at Harbor-University of California, Los Angeles Medical Center, noted that diagnosing and treating subgaleal hemorrhages is important. “
With these injuries only occurring in less than one in a thousand vacuum-assisted deliveries, if someone sees one in their lifetime, that's significant. How are you going to pick up that one?”

Dr. Vines and his colleagues are developing recommendations for ways to prevent subgaleal hemorrhage. He cited three of them: