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Revista Colombiana de Obstetricia y Ginecología

Print version ISSN 0034-7434
On-line version ISSN 2463-0225

Rev Colomb Obstet Ginecol vol.69 no.2 Bogotá Apr./June 2018

http://dx.doi.org/10.18597/rcog.3211 

EDITORIAL

Episiotomy in nulliparous women: an entrenched habit?

Jorge Andrés Rubio-Romero 1  

1Universidad Nacional de Colombia, Tenured Professor; Department of Obstetrics and Gynaecology; Associate Editor Associate Editor; Revista Colombiana de Obstetricia y Ginecología

This issue of Revista Colombiana de Obstetricia y Ginecología brings the study by Mellizo-Gaviria et al. entitled “Frequency of episiotomy and complications in the Obstetrics Service of Hospital Universitario San José, Popayán (Colombia), 2016. Exploration of maternal and perinatal factors associated with its performance.” This cross-sectional observational study was designed to determine the frequency with which episiotomy is performed and its related complications, and to explore some factors associated with its use during delivery. Based on random sampling done in an institution with a 50% proportion of cesarean deliveries reported in 2015, the study found a 30.5% frequency in the overall use of episiotomy for term deliveries, performed in 58.2% of the nulliparous women but only in 6.6% of the multiparous women. As stated by the authors, nulliparity was associated with an eight-fold increase in the probability of performing an episiotomy in the patients seen at the institution.

Episiotomy is an intervention designed to widen the opening of the vagina to facilitate birth, thus protecting the pelvic floor and preventing severe perineal lacerations, reducing the risk of hypoxic and ischaemic injury to the foetus, and facilitating the anatomical and physiological repair of the perineum 1. However, scientific evidence has not supported all the proposed benefits, leading to the rejection of its routine use. On the other hand, national and international recommendations involve the selective use of episiotomy, even in cases of instrumented deliveries2-7. As a result of these recommendations, there is a world trend towards a lower use of this intervention8-11, a fact that is more visible in high income countries, where episiotomy rates are lower than 30%, while they can be higher than 70% in lower income countries11.

In Colombia, episiotomy rates have been falling according to some reports in the literature, down from more than 50% of all births to rates between 12 and 30% over the past twenty years12. However, the reduction in episiotomy rates in nulliparous women is not so evident. While rates of use in nulliparous women reported between 2001 and 2005 were close to 90%9,,12, recent reports, including the article published in this issue, describe rates of use in 60 to 70% of these women. In Colombia, in some hospitals, this frequency has dropped below 30% with the implementation of stringent policies for selective episiotomy12,13, closer to the global 10% rate recommended for this procedure by the World Health Organisation since 199614.

Episiotomy use and indication are left to the judgement and experience of the practitioner caring for the pregnant woman, given that existing evidence does not allow for consensus on standards and indications that can guide clinical practice7,8. Emphasis on the use of episiotomy in nulliparous women must focus on the preferences and training of the obstetricians and the role they play in training healthcare talent in teaching hospitals, because it is their duty to supervise staff in training and teach them how to recognise patients at risk of severe perineal tear in order to be able to implement timely and effective measures for the prevention of these events such as the use of warm packs, teach techniques for perineal protection, and indicate the use of episiotomy selectively4,5,12,13.

The restricted use of episiotomy is crucial, as are also the availability of pain management methods, ambulation during labour, the presence of a companion at all times, fluid intake, and maternal freedom to adopt a position at the time of delivery6,7,14-16, all of which improve maternal and perinatal outcomes, humanise the experience for all the people involved in the birth, and counteract the perception of obstetric violence.

REFERENCES

1. Rubio-Romero JA. Indicaciones actuales de la episiotomía. Rev Fac Med. 2004;52(2):132-9. [ Links ]

2. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081. https://doi.org/10.1002/14651858.CD000081.pub3Links ]

3. Guidelines for operative vaginal birth. J Obstet Gynaecol Can. 2004;26(8):747-53. https://doi.org/10.1016/S1701-2163(16)30647-8. [ Links ]

4. Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. In: The Cochrane Collaboration, editor. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons; 2011 (visited 2018 jun 26). https://doi.wiley.com/10.1002/14651858.CD006672.pub2Links ]

5. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics. Practice Bulletin 165: Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2016;128(1):e1-15. https://doi.org/10.1097/AOG.0000000000001523Links ]

6. Colombia. Ministerio de Salud y Protección Social. Guía de Práctica Clínica (GPC) para la prevención, detección temprana y tratamiento de las complicaciones del embarazo, parto o puerperio (visited 2018 jun 26). Available in: http://gpc.minsalud.gov.co/gpc_sites/Repositorio/Conv_500/GPC_embarazo/gpc_embarazo.aspxLinks ]

7. WHO | Managing complications in pregnancy and childbirth: A guide for midwives and doctors, 2 ed. WHO. (visited 2018 jun 26. Available in: http://www.who.int/maternal_child_adolescent/documents/managing-complications-pregnancy-childbirth/en/Links ]

8. Hale RW, Ling FW. Episiotomy: Procedure and repair techniques. Washington, D.C: American College of Obstetricians and Gynecologists; 2007. p. 24. [ Links ]

9. Graham ID, Carroli, Davies C, Medves JM. Episiotomy rates around the world: an update. Birth Berkeley Calif. 2005;32(3):219-23. https://doi.org/10.1111/j.0730-7659.2005.00373.xLinks ]

10. Conde-Agudelo A, Rosas-Bermudez A, Gülmezoglu AM. Evidence-based intrapartum care in Cali, Colombia: A quantitative and qualitative study. BJOG Int J Obstet Gynaecol. 2008;115(12):1547-56. https://doi.org/10.1111/j.1471-0528.2008.01930.xLinks ]

11. Clesse C, Lighezzolo-Alnot J, De Lavergne S, Hamlin S, Scheffler M. Statistical trends of episiotomy around the world: Comparative systematic review of changing practices. Health Care Women Int. 2018;39(6):644-62. [ Links ]

12. Rubio JA. Política selectiva de episiotomía y riesgo de desgarro perineal en un hospital universitario. Rev Colomb Obstet Ginecol. 2005;56(2):116-26. [ Links ]

13. Abril-González FP, Guevara-Villareal AS, Ramos-Cruz A, Rubio-Romero JA. Risk factors for perineal tearing during births without episiotomy atended by personnel being trained at a teaching hospital in Bogotá, Colombia 2007. Rev Colomb Obstet Ginecol . 2009;60(2):143-51. [ Links ]

14. Technical Working Group, World Health Organization. Care in normal birth: A practical guide. Birth Berkeley. 1997;24(2):121-3. https://doi.org/10.1111/j.1523-536X.1997.tb00352.xLinks ]

15. Rubio-Romero JA, Ruiz-Parra AI, Martínez F, Muñoz-Restrepo J, Muñoz LA, Arévalo-Rodríguez I, et al. Guía de Práctica Clínica para la detección temprana de las anomalías durante el trabajo de parto, atención del parto normal y distócico. Rev Colomb Obstet Ginecol . 2013;64(4):379-424. [ Links ]

16. OMS Recomendaciones de la OMS para la conducción del trabajo de parto. WHO (visited 2018 jun 26). Available in: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation-labour/es/Links ]

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