TEALE FENNING

Xerxes I · Posted: Fri Jan 25, 2008 12:39 pm Post subject:

baby was fine but not sure about mums pelvic floor!!, easy liftout ventouse with intact perineum though which opens an interesting discussion.

Has anyone seen the recent BJOG paper on episiotomy in instrumentals?Click here for the abstract.

Basically they are saying you'd better do episiotomies in all your instrumentals. "The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries."

And its not a crappy paper. Amongst other things, their numbers was over 32000 instrumentals; its a retrospective study though.

I used to be proud of myself for avoiding episiotomies in more than 90% of my ventouses and around 20% of forcepses (i have looked at my numbers) and have had one 3rd degree tear in my first month as registrar and I actually had made an episiotomy in that one and no 4th so far (or am I very bad at recognising them Confused

) but now I'm not so sure. I can understand the ratonale for forceps but not sure about straight forward ventouses. Any thoughts?

Raj, feel free to move this elsewhere if you feel it deserves discussion, although not strictly exam worthy.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

hi xerxes,

i've left the basic post where it was but have also started this thread so we can keep the discussion going.

well, i've just skimmed thru the paper will read it over the weekend if i get a breather ( have guests over for the weekend). are they speaking about overt as well as unrecognized injuries, what about sphincter damage with an intact perineum?

even in presence of symptoms sometimes one gets an ok endoanal USS picture or a massive defect on the scan but no symptoms at all. the correlation is just not consistent enough

instrumental with an intact perineum will always feel good and get kudos from our midwifery colleagues and any trauma with or without an epis will, may be, never be overly symptomatic. so , is it then justifiable to cut and stitch and increase immediate post deli discomfort ? don't know.

anyone has any other views?

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

My main objective is that this is a retrospective trial. Prospective, randomized trials are difficult to perform in these situations, but I am proud to say that I helped out with the data collection last year of one. I can't tell you the results before the paper gets published, all I can say is...don't give an epis if you think you can get away without one!

I also completely agree with Raj, there must be a reason why we get a pat on our backs when we have left a woman with an intact perineum after an instrumental and I rarely give episiotomies to primips having a ventouse or to multips having either ventouse or forceps deliveries.

I have, however, wondered at times whether it might be better for a pelvic floor to have a cut that is subsequently sutured, rather than all those muscles being stretched up even more and then stying rather "baggy"afterwards. It would be interesting if the women in the trial you referred to would be followed up long term, to see whether there is any long term difference in prolapse etc.