Joy, you said >We have good statistical data telling us that the number of perineal tears and the severity of the tears is consistently less in women who give birth at home (or in the car or for that matter) than for women in hospital. Why is that? Is it possible that a woman who is 'unobserved' (read bright lights and strangers looking intently at the business end - M Odent talks a lot about this) is more able to let go of her baby, and her muscles and skin go into a softer, more pliable state to let the baby make its way out of the birth passage? That's my theory. I think its simpler than that, just don't cut episiotomies, particularly routinely for operative vaginal birth. The epis rate at our regional hospital was 7.2% in 99, 6% last year and will be lower this year. Our "intact" rate was 55% in 99, 60% in 2000. This may rise simply by a gradual change to not suturing first degree tears. We probably have less primips (36%) than the rest of the state (42%) which would account for some of this high intact rate. Our third degree tear rate (ANY external anal sphincter involvement) is higher than state average, but I think this is ascertainment bias. Studies (see below) suggest there is much underreporting of sphincter tears and I am paranoid about the sphincter being correctly identified and so repaired. (I think a PR must be done to properly assess any tear) We are planning a retrospective, then prospective audit of our third degree tears and follow-up to ascertain a rate of anal incontinence in a low epis environment. In this unselected population, the caesar rate is around 18% (falling) and operative vaginal birth rate about 12% (pretty stable). We have a fairly "traditional" model of GP or obstetrician-led public care here (though is more like private care as its in the country). We do have a large midwifery input antenatally and intrapartum though. Listing the factors in no particular order that I believe help us with the low perineal damage rate are 1. Docs use vacuum over forceps 2. No routine epis for operative vag birth 3. Antenatal perineal massage encouraged 4. Low ( but climbing) epidural rate (10-15%) 5. Midwives catch most of the babies (but own doctor present) 6. No time limit in second stage (but listen after every contraction) 7. I always consider ppposition change than vacuum or post-anal pressure rather than epis if head very low and worrying FH 8. I could add - discourage the stranded beetle position. I'm sure the upright position encourages spont birth but I suspect it may encourage the head to sometimes "blast" out with a larger tear.
Have a culture of (mostly) directed pushing which is probably not helpful. Also, I agree too much peri watching is unlikely to be helpful, and must certainly be a bit demeaning. We have almost no waterbirth - again probably more a cultural thing than any specific directive against it. In regard to number 2, using 99 Victorian figures, if selective epis (lets say 10%) was used for operative vaginal birth, the episiotomy rate (+/- tear) in Vic would drop from 23.3% to 11.9%. The rcog website has great evidence-based guideline on perineal trauma and repair http://www.rcog.org.uk/guidelines/guideline29.html http://www.rcog.org.uk/guidelines/perineal.html David -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
