To cut or not: debate on childbirth procedure
By Amanda Dunn
Health
Reporter
August 13, 2004
A surgical cut to make room for the baby's head in a
vaginal birth is too commonly performed in private Victorian hospitals, an
obstetric expert has warned.
Obstetric epidemiologist James King also told The Age that,
conversely, severe vaginal tears during childbirth are more prevalent in public
hospitals, which may indicate the need for better supervision of inexperienced
doctors.
"Sometimes it (cutting) is absolutely necessary, but it's probably overused,"
he said.
His comments followed a report commissioned by the Department of Human
Services, which found that between 1999 and 2002, an episiotomy - in which an
incision is made through the perineum at the entrance to the vagina - was given
to one in every three private patients, compared with one in five public
patients.
The issue has long been a controversial one in maternity circles, with little
agreement on the relative benefits of cutting versus tearing.
Professor King, who led the review, said the difference between public and
private rates may be because vaginal deliveries were more likely to be
supervised by midwives in the public system, who supported lower episiotomy
rates.
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In contrast, births in the private system were supervised by obstetricians
who may be slower to take up the most recent evidence on episiotomy.
The report also found that the most severe lacerations, which can tear
through to the anus, damaging muscles and causing long-term incontinence,
occurred for 16 in every 1000 public patients, and 11 in every 1000 private
patients.
"It may be that there's a requirement for more supervision of these
individual deliveries," Professor King said.
Episiotomy and severe lacerations were far more common when forceps were used
than the vacuum extraction during the birth, he said, and were also higher for
women having their first babies.
Euan Wallace, an obstetrician at Monash Medical Centre, said it was once the
orthodox view that episiotomy was preferable to allowing a vaginal tear because
it preserved pelvic floor muscles. But evidence since has challenged that
view.
"It's quite clear now that in terms of long-term health it's much better to
tear than it is to cut," Professor Wallace said.
He believed that some severe lacerations were probably unavoidable, but there
was also a small number of cases when an episiotomy could reduce that risk.
Shane Higgins, director of delivery suites at the Royal Women's Hospital,
agreed that registrars and midwives needed to be better supervised to reduce
severe tears, but there was likely to be more than one reason for the difference
in the rates.
Leslie Arnott, Victorian president of the Maternity Coalition, said
episiotomy rates were another example of too much intervention in childbirth,
and would be reduced by better access to one-to-one midwifery.
She said severe tears would also be reduced by better supervision of doctors
and more willingness to allow natural childbirth to occur rather than trying to
hurry it.
Kate Duncan, a private obstetrician and Victorian vice-president of the
Australian Medical Association, said it was difficult to judge whether
episiotomy rates were too high, as the ideal rate was unknown.