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Nurse Advocacy for Selective Versus Routine Episiotomy
Nurse Advocacy for Selective Versus Routine Episiotomy Jeanmarie Sharp Maier, RN, BSN, Judith A. Maloni, RN, PhD
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Although episiotomy is one of the most commonly performed surgeries, little scientific support exists for this procedure. Furthermore, the suggested advantages of routine episiotomy are challenged easily and the surgery is not without risks. Adverse effects arising from episiotomy include an increased incidence of severe lacerations, blood loss, pain, delayed healing, dyspareunia, psychologic trauma, and medical cost. Nurses can assist women in avoiding perineal trauma resulting from unnecessary episiotomy through patient education, patient advocacy, and direct care. JOGNN, 26,155-1 61 ; 1997.
Accepted: October
1995
Perineal injury, including episiotomy, long has been accepted as a standard outcome of vaginal delivery (Olson, Olson, & Smith-Cox, 1990).Until recently, U.S. obstetric texts recommended that an episiotomy be performed during every vaginal birth to avoid damage to the perineum (Pritchard, MacDonald, & Gant, 1985). As with any surgery, episiotomy carries risks, but researchers have shown episiotomy does not offer any of the benefits cited as indicators for its use (Banta & Thacker, 1982; Cunningham, MacDonald, Gant, Leveno, & Gilstrap, 1993; Helwig, Thorp, & Bowes, 1993; McGuinness, Norr, & Nacion, 1991). Thus, there is evidence that the practice of routine episiotomy is obsolete (Ahn, Cha, & Phelan, 1992; Sleep, Roberts, & Chalmers, 1989). In this article, the advantages and disadvantages associated with episiotomy are reviewed. Factors that place women at a greater risk of having an episiotomy are outlined. Nursing care measures, such as the use of researchbased practice and patient and staff education, are discussed to assist the nurse in decreasing the in-
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cidence of unnecessary perineal trauma (i.e., routine episiotomy). Episiotomy dates back to 1742, when a perineal incision first was used to facilitate difficult deliveries (Gass, Dunn, & Stys, 1986). However, episiotomy did not become common until the early 1900s when the shift from home to hospital delivery occurred (Banta & Thacker, 1982). The popularity of episiotomy among physicians continued to grow with the introduction of local anesthetic and suture material and as a result of advocacy for its performance by two obstetricians, DeLee and Pomeroy (DeLee, 1920; Pomeroy, 1918). It was claimed that an episiotomy should be performed for every woman delivering her first child to avoid perineal lacerations and damage to the pelvic floor (Rooks, Weatherby, & Ernst, 1992). An estimated 4 million births occur in the United States each year (U.S. Department of Health and Human Services, 1994). Of these, two thirds are accompanied by episiotomy (Banta & Thacker, 1982; Henriksen, Moller Bek, Hedegaard, & Secher, 1992). Episiotomy is the second most common surgery performed in the United States; cutting of the umbilical cord is the most common surgery (Pritchard et al., 1985). The continuing prevailing view among physicians is that routine episiotomy is justified (Banta & Thacker, 1982; Smith, Ruffin, & Green, 1993).
Suggested Advantages of Episiotomy Five suggested advantages are associated with routine episiotomy (Cunningham et al., 1993; Pritchard & MacDonald, 1980). These include (a) prevention of lacerations; (b) creation of a clean, straight incision that, in turn, is easier to repair; (c) facilitation of healing; (d) shortening of the second JOG"
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stage of labor, thereby preventing the weakening of pelvic floor muscles; and (e) reduction of neonatal brain injury by reducing pressure on the fetal head. Although it is a common belief among physicians that episiotomy decreases the incidence of spontaneous lacerations, this belief is not supported in the literature. In two random trials of more than 3,000 women, Sleep et al. (1984) and Henriksen et al. (1992) found that women who do not undergo an episiotomy frequently either do not tear at all, or tear to a lesser extent than the perineal injury caused by episiotomy itself. Perineal injury resulting from episiotomy appears to vary with the type of episiotomy performed (i.e., midline or mediolateral episiotomy). Midline episiotomy increases the likelihood of major perineal trauma fourfold, with subsequent extensive tears being common (Helwig et al., 1993; Walker, Farine, Rolbin, & Ritchie, 1991). Mediolateral episiotomy protects the perineum from severe lacerations but has been associated with more difficult surgical repairs, faulty healing, increased pain, negative cosmetic effects, and dyspareunia (Cunningham et al., 1993; Shiono, Klebanoff, & Carey, 1990).
A l t h o u g h episiotomy is a routine, common practice, little scientific evidence exists to support its benefit.
Another suggested advantage is that an episiotomy creates an incision that is easier to repair than a spontaneous laceration. However, researchers found that using a selective rather than a routine mediolateral episiotomy policy resulted in 90,000 fewer perineal repairs each year (Argentine Episiotomy Trial Collaborative Group, 1993).Women in the selective episiotomy group had an increase in anterior tears. However, this type of tear rarely is associated with the pain, discomfort, and infection that commonly occur with either episiotomies or posterior tears (Argentine Episiotomy Trial Collaborative Group, 1993). A third suggested advantage is that episiotomy facilitates perineal healing (Larsson, Platz-Christensen, Bergman, & Wallstersson, 1991). However, no research exists to support this belief. McGuinness, Norr, and Nacion (1991) reported a 7.7% delayed healing rate among women with episiotomies compared with a 2.2% rate among women without an episiotomy. Furthermore, faulty healing is a commonly cited disadvantage of mediolateral episiotomy (Cunningham et al., 1993). 156 JOGNN
The fourth suggested advantage is that episiotomy prevents pelvic floor damage by shortening the second stage of labor (Smith et al., 1993). This belief is based on a poorly controlled study conducted in 1935 that showed decreased pelvic muscle damage among women undergoing episiotomy (Nugent, 1935). Recent controlled studies have not supported this finding. In the first North American randomized controlled trial of median (midline) episiotomy among 697 women at lowrisk, Klein et al. (1994)found that women who delivered over an intact perineum had the strongest pelvic floor musculature at 3 months postpartum, whereas those with an episiotomy had the weakest musculature. In a random trial of 1,000 women, Sleep et al. (1984)found no group differences in the incidence of urinary incontinence at 10 days postpartum and 3 months postpartum for women allocated to either liberal or restrictive performance of an episiotomy. In a 3-year follow-up of the same women (Sleep & Grant, 1987), the incidence of urinary incontinence was the same in both groups, thus disputing the argument that episiotomy prevents pelvic musculature damage. Likewise, in a quasi-randomized study of 2,188 women, Henriksen et al. (1992) found no increased risk of having a tear of the anal sphincter among women cared for by midwives who seldom performed episiotomy. However, episiotomy was associated with a significantly increased risk of anal tears. It also has been suggested that exercise of perineal muscles is more predictive of perineal muscle tone after delivery than is the degree of perineal injury (Gordon & Lougue, 1985; Kegel, 1948). Paciornick (1990)reports that, contrary to popular belief that stretching damages the perineum, the pelvic floor is made up of striated muscle that does not lose strength after stretching. However, shortening of the second stage of labor may be advantageous in instances of acute fetal distress (Banta & Thacker, 1983). Finally, another commonly cited advantage of episiotomy is that it decreases pressure on the fetal head and thus improves neonatal outcome, especially for lowbirth-weight neonates. However, researchers found no difference in Apgar scores or neonatal mortality rates for low-birth-weight neonates who were delivered by an episiotomy versus those who were not (The, 1990). Sleep et al. (1984) also found no difference in Apgar scores or number of admissions to intensive-care units for neonates delivered with or without an episiotomy. Ahn et al. (1992)concluded that there is insufficient data to support the belief that routine use of episiotomy protects the fetus from injury.
Adverse Effects of Episiotomy Numerous adverse effects are associated with episiotomy. These include an increased risk of third- and
Volume 26, Number 2
fourth-degree perineal lacerations, infection, delayed wound healing, blood loss, scars, perineal cysts, postoperative pain, dyspareunia, psychologic trauma, and increased health care costs (Banta & Thacker, 1982; Helwig et al., 1993; McGuinness et al., 1991; Simkin, 1986). Third- and fourth-degree lacerations extending from an episiotomy are not uncommon (Helwig et al., 1993; Klein et al., 1994). In a prospective multicenter study of more than 24,000 women, Shiono et al. (1990) found that women having a midline episiotomy were 50 times more likely to experience a third- or fourth-degree laceration than women without an episiotomy. Similarly, women with a mediolateral episiotomy were eight times more likely to suffer a severe laceration than women without an episiotomy. Another risk associated with episiotomy is infection. McGuinness et al. (1991) found a 4.9% infection rate among women with an episiotomy. In addition, women infected with the human papillomavirus have been found to have poorer episiotomy healing, leading to increased infection and dehiscence (Faro, 1988; Synder, Hammond, & Hankins, 1990). Blood loss is another adverse effect of episiotomy. Women with spontaneous lacerations bleed less than those with episiotomies (House, 1980; Newton et al., 1961). House (1980) found that women undergoing an episiotomy lost 115 ml of blood more than women with spontaneous tears. Other complications that result from an episiotomy include perineal cysts and endometriosis arising from the episiotomy scar (Koger, Shatney, Hodge, & McClenathan, 1993; Pradhan & Tobon, 1986; Wittich, 1982). Episiotomy scars can develop surgical scar endometrioma up to 20 years later (Koger et al., 1993).
Undergoing episiotomy puts women at increased risk of third- and fourth-degree lacerations, infection, delayed wound healing, blood loss, scars, perineal cysts, pain, dyspareunia, psychologic trauma, and increased health care costs.
The most bothersome adverse effect of episiotomy, yet the most overlooked and underestimated, is pain from the incision (Hordnes & Bergsjo, 1993). Klein et al. (1994)found not only that perineal pain was less for
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women who gave birth with an intact perineum, but also that the pain resulting from spontaneous lacerations was less than that from an episiotomy. Women who have an episiotomy report more postoperative pain with activities of daily living and a higher incidence of prolonged dyspareunia than women who do not have an episiotomy (Sleep & Grant, 1987; Walker et al., 1991). Sleep et al. (1984) found that 498 women delivered by midwives who were instructed to avoid episiotomy were more likely to have resumed intercourse within a month after delivery. Episiotomy and perineal tears also can cause psychologic pain. During postpartum interviews, Simkin (1986) found that 64% of women viewed episiotomy as stressful and that their satisfaction with childbirth increased when they had more control during labor and delivery.
N u r s e s can reduce the incidence of unnecessary perineal trauma by educating patients and staff, encouraging use of alternative birthing positions, and encouraging spontaneous second-stage bearing-down efforts.
Finally, an indirect adverse effect of episiotomy is increased health care costs. In a comparison of routine versus restrictive performance of episiotomy, Sleep et al. (1984)found that 502 women allocated to a routine episiotomy policy required 100 more packets of suture material and 13 more hours of time to repair perineal trauma than women allocated to a restrictive episiotomy policy. Thus, the potential monetary savings could be significant when considering the number of women who undergo episiotomy each year.
Risk Factors that Predispose Women to Episiotomy The following are some factors that place women at greater risk for having an episiotomy or a spontaneous laceration: nulliparity, increased neonate birth weight, shoulder dystocia, posterior presentation, use of vacuum extraction, and use of forceps (Hordnes & Bergesjo, 1993). African American women also are more apt to undergo episiotomy than white women (Hordnes & Bergesjo, 1993). Other factors that predispose women to perineal trauma sometimes can be mitigated by nurses. These
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factors include the use of a recumbent position, such as the lithotomy position, for delivery (Olson et al., 1990); use of sustained breath holding and pushing rather than spontaneous bearing down efforts (Yeates & Roberts, 1984); and placement of time limits on second-stage labor (McKay & Roberts, 1985). Although a recumbent position is common during labor and delivery, no evidence suggests that it is advantageous to the mother or the fetus (McKay & Roberts, 1989; Smith et al., 1993). The lithotomy position and sustained breath holding during bearing down cause excessive perineal pressure and stretching, both of which increase the likelihood of perineal tears (Hordnes & Bergsjo, 1993; Liu, 1989; Olson et al., 1990; Rooks et al., 1992). In contrast, spontaneous bearing-down efforts are shorter in duration and result in less perineal pressure and tearing, which also reduce the likelihood that someone will intervene to perform an episiotomy (Yeates & Roberts, 1984). Provider reluctance to support spontaneous maternal pushing may be based on the belief that it slows the second stage of labor. However, researchers have shown that prolonged labor does not result from pushing spontaneously, but rather results in improved fetal outcomes (Liu, 1989; McKay & Roberts, 1989; Roberts et al. 1987). For example, researchers have found a greater incidence of fetal heart decelerations and hypoxia among neonates whose mothers engaged in vigorous, prolonged bearing-down efforts (Caldeyro-Barcia, 1979; Roberts et al., 1987). Despite 30 years of research that fails to support the efficacy of prolonged breath holding, the practice of encouraging women to use sustained bearing down during the second stage of labor persists (Liu, 1989; Roberts et al., 1987). Another factor that contributes to increased use of episiotomy is the arbitrary time limit that physicians frequently impose on the length of second-stage labor (Sleep & Grant, 1987). This practice is based on the belief that a long second-stage labor contributes to negative maternal and fetal outcomes (McKay & Roberts, 1985). Therefore, episiotomy frequently is performed to shorten the second stage of labor. Physician convenience may also contribute to efforts to shorten the second stage. As a result, the longer a woman remains in second-stage labor, the more likely she is to have an episiotomy (McGuinness et al., 1991). However, no evidence exists to support the belief that a long secondstage increases fetal mortality and morbidity during a normal, uncomplicated labor (Smith et al., 1993). When second-stage labor is progressing and the conditions of mother and fetus are satisfactory, the imposition of any arbitrary time limit is unjustified and results in increased incidence of severe lacerations and episiotomy (Hordnes & Bergsjo, 1993; Sleep & Grant, 1987). 158
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Methods to Decrease the Number of Episiotomies Nurses can help women reduce the likelihood of undergoing episiotomy and unnecessary perineal trauma. Whether involved in direct or indirect clinical practice, nurses can help promote a selective episiotomy policy. Nurses can (a) encourage women to use alternative birthing positions; (b)encourage spontaneous second-stage bearing down efforts; (c) educate women about the advantages and disadvantages of episiotomy so they can make informed decisions; and (d) educate clinical staff, including physicians, about research on episiotomy . Empowering women with knowledge of the advantages and disadvantages of episiotomy enables them to make informed decisions about their care and gives them increased choices throughout childbearing. Women who have choices enjoy greater control of their bodies and their birth experience, all of which can enhance perception of self and of outcome (Rooks et al., 1992; Shiono et al., 1990). One of the first decisions a woman makes during pregnancy is choice of a care provider. To avoid unnecessary interventions and perineal trauma, women need to know that there is variation in practice and that they can choose a practitioner who can help them avoid unnecessary perineal trauma and who shares their values and beliefs. The woman's choices about care then can be based on her individual needs rather than tradition and routine physician practice. If a partnership in care develops, the woman can discuss concerns about procedures, such as episiotomy (Cochrane, 1992). Inquiry into the episiotomy rate of practitioners and whether the practitioner frequently delivers over an intact perineum can be helpful, because some practitioners are more adept at minimizing perineal trauma during delivery than others. For example, nurse-midwives and family practice physicians frequently have lower episiotomy rates than do obstetricians (Champen, 1991; Olson et al., 1990; Rooks et al., 1992). Nurse-midwives frequently have episiotomy rates of 14% to 25%, with a large percentage of clients delivering over an intact perineum, or a small, first-degree tear (Lydon-Rochelle, Albers, & Teaf, 1995; Olson et al., 1990; University of Wisconsin-Madison, 1993). Midwives long have used methods, such as perineal massage, hot perineal compresses, warm oil perineal massage during expulsion, and slow delivery of the fetal head, to avoid perineal lacerations and the need for episiotomy (Rooks et al., 1992). Nurses also can provide patients with information on alternative birthing positions. Books, slides, films, or pictures depicting women laboring and delivering in nontraditional positions assist in establishing a new model of care (McKay & Roberts, 1985). In addition, Volume 26, Number 2
childbearing women and their support persons can be encouraged to practice for labor and delivery using alternative positions and aids, such as squat bars, to decrease the likelihood of perineal trauma. Nursing care that promotes choices about birthing positions not only can promote easier births but also assists women in avoiding unnecessary perineal trauma. Alternative positions, such as standing, kneeling, squatting, hands and knees, and the lateral Sims position, direct the fetal head to the introitus and reduce the pressure on the perineum (Golay, Vedum, & Sorger, 1993; Nodine & Roberts, 1987; Rooks et al., 1992). The lateral Sims position allows greater control of the fetal head with more relaxation and less tension on the perineum, leading to fewer perineal lacerations and a decreased likelihood of episiotomy (Olson et al., 1990; Rooks et al., 1992; Smith et al., 1993). Although some researchers have found limited relationships between maternal positions and perineal outcome (Sleep et al., 1989), most findings suggest that women who deliver in positions other than the recumbent position are less likely to have perineal trauma (Lydon-Rochelle et al., 1995; McKay & Roberts, 1989; Rossi & Lindell, 1985; Smith et al., 1993). Upright positions, such as squatting, have been shown to increase the diameter of the pelvic outlet by 0.5 to 2.0 cm (Borell, 1967; Borgatta, Hutson, & Lynch, 1989; Liu, 1989; Paciornik, 1990; Rooks et al., 1992). The squatting position not only shortens the second stage of labor, reduces the incidence of labor stimulation by oxytocin, and results in fewer mechanically assisted deliveries, but also reduces perineal lacerations and the incidence of episiotomy (Golay et al., 1993).Forty-five percent of women who used the squatting position delivered over an intact perineum compared with 18% in the semirecumbent group (Golay et al., 1993). Apgar scores of neonates born to mothers using the squatting position also were higher, and there were no cases of shoulder dystocia in 200 deliveries (Golay et al., 1993).The use of alternative birthing positions also may be a deterrent to episiotomy because women are not in a position where the perineum is easily accessed. An additional method by which nurses can assist women in avoiding unnecessary perineal trauma is by encouraging women to bear down during second-stage labor only when they feel the urge. Bearing-down efforts of this type, with intermittent breath holding, ease the head out slowly and decrease the incidence of spontaneous lacerations and episiotomy (Yeates & Roberts, 1984).In a review of the literature on second-stage pushing, Sleep et al. (1989) concluded that methods that direct women to forcefully hold their breath for prolonged periods during second-stage contractions offer no benefit. Dissemination of research-based information about the disadvantages of prolonged breath holding and bear-
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ing down, along with providing role models of more appropriate nursing care, will increase the likelihood that lacerations and episiotomy will be avoided. Nurses have little control over a physician's decision to perform an episiotomy. However, because physicians rarely prescribe a pushing position and there often is minimal medical supervision during second-stage labor for women at low risk, nurses can encourage women to use birthing positions that maximize comfort, improve labor progress, and decrease the incidence of perineal trauma. Despite advances in research, health care remains steeped in tradition, and some providers discourage or resist use of alternative methods of care for laboring women. The second stage of labor is not an ideal time for the laboring woman or the nurse to engage in a debate with other practitioners about differences in philosophies of care because the focus is the laboring woman. However, at a practical level, statements by the nurse that indicate that the woman is most comfortable in an alternative birthing position, or suggest that she is laboring effectively (e.g., that she is moving the fetal head down better in a particular position), can be used to discourage unnecessary intervention and promote perineal integrity.
Summary and Conclusion Researchers indicate that routine performance of episiotomy during an uncomplicated labor presents greater risks than benefits to the childbearing woman. Therefore, nurse advocacy for an episiotomy policy that is guided by protocols that are research-based, rather than tradition-based, is indicated. Furthermore, nurses can advocate against unnecessary perineal trauma by educating childbearing women and health care staff about the advantages and disadvantages of episiotomy and the risk factors that predispose women to episiotomy. Dissemination of research-based knowledge to nurses will empower them to function as patient advocates against unnecessary episiotomy during labor and delivery care. Providing role models of research-based practice also can help change personal and institutional philosophies of care, traditional beliefs, and obstetric practices to assist childbearing women in avoiding unnecessary perineal trauma. REFERENCES Ahn, M., Cha, K., & Phelan, J. (1992).The low birth weight infant: Is there a preferred route of delivery? Clinics in Perinatology, 19(2),411-414. Argentine Episiotomy Trial Collaborative Group. (1993). Routine vs selective episiotomy: A randomized controlled trial. Lancet, 342, 1517-1518.
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Banta, D., & Thacker, S. B. (1982).The risks and benefits of episiotomy: A review. Birth, 9( l),25-30. Banta, D., & Thacker, S. B. (1983).Benefits and risks of episiotomies: An interpretative review of the English language literature, 1960-1980. Obstetric and Gynecologic Survey, 38, 232-238. Borell, U. (1967).The mechanism of labor. Radiologic Clinics of North America, 5, 73-85. Borgatta, J., Hutson, N., & Lynch, C. B. (1989).Randomized controlled trial of squatting in the second stage of labour. Lancet, 2, 74-77. Caldeyro-Barcia, R. (1979).The influence of maternal bearing down efforts during the second stage of labor on fetal well-being. Birth and the Family Journal, 6(l),19-23. Champen, J. M., (1991).Routine episiotomy: Medical dogma versus medical wisdom. Childbirth Instructor, 1 (l),2933. Cochrane, S. (1992).Perineal trauma. Nursing Times, 88(21), 147. Cunningham, F. G., MacDonald, P., Gant, N., Leveno, K., & Gilstrap, K. (1993). Williams obstetrics (9th ed.). Norwalk, CT: Appleton & Lange. DeLee, J. B. (1920).Prophylactic forceps operation. American Journal of Obstetrics and Gynecology, 1, 33-44. Faro, S. (1988).Management and treatment of human papilloma virus. Clinical Advances in Treating Infections, 2, 6-7. Gass, M., Dunn, C., & Stys, S. (1986).Effect of episiotomy on the frequency of vaginal outlet lacerations. Journal of Reproductive Medicine, 31 (4),240-244. Golay, J., Vedam, S., & Sorger, L. (1993).The squatting position for the second stage of labor: Effects on labor and on maternal and fetal well-being. Birth, 20(2),73-78. Gordon, H., & Logue, M. (1985). Perineal muscle function after childbirth. Lancet, 2, 123-125. Helwig, J., Thorp, J., & Bowes, W. (1993).Does midline episiotomy increase the risk of third-and-fourth degree lacerations in operative vaginal deliveries? Obstetrics and Gynecology, 82, 275-279. Henriksen, T. B., Moller Bek, K. M., Hedegaard, M., & Secher, N. (1992). Episiotomy and perineal lesions in spontaneous vaginal deliveries. British Journal of 0 6 stetrics and Gynecology, 99, 950-954. Hordnes, K., & Bergsjo, P. (1993). Severe lacerations after childbirth. Acta Obstetrica et Gynecologica Scandinavica, 72, 413-422. House, M. (1981).Episiotomy: Indications, techniques and results. Midwife, Health Visitor and Community Nurse, 6-9. Kegel, A. H. (1948). Progressive resistance exercises in the functional restoration of the perineal muscles. American Journal of Obstetrics and Gynecology, 56, 238-248. Klein, M., Gauthier R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., Johnson, B., Waghorn, K., Gelfand, M., Guralnick, M., Luskey, G., & Joshi, A. (1994).Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171 (3), 591-598. Koger, K., Shatney., Hodge, K., & McClenathan, J. (1993).
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Surgical scar endometrioma. Surgery, Gynecology and Obstetrics, 177, 243-246. Larsson, P. G., Platz-Christensen, J. J., Bergman, B., & Wallstersson, G. (1991).Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynecologic & Obstetric Investigation, 31, 213-216. Liu, Y. (1989).The effects of the upright position during childbirth. Image, 21(1), 14-18. Lydon-Rochelle, M., Albers, L., & Teaf, D. (1995).Perineal outcomes and nurse-midwifery management. Journal of Nurse-Midwifery, 40(1), 13-17. McKay, S., & Roberts, J. (1985).Second stage labor: What is normal? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 14, 101-105. McKay, S., & Roberts, J. (1989). Maternal position during labor and birth: What have we learned? ICEA Review. Focusing on Today's Issues in Perinatal Care, 13(2),2228. McGuinness, M., Norr, K., & Nacion, K. (1991).Comparison between different perineal outcomes on tissue healing. Journal of Nurse-Midwifery, 36(3), 192-197. Newton, M., Mosey, L. M., & Egli, G. (1961).Blood loss during and immediately after delivery. Obstetrics and Gynecology, 17, 9-18. Nodine, P. M., & Roberts, J. (1987).Factors associated with perineal outcome during childbirth. Journal of NurseMidwifery, 32(3), 123-130. Nugent, P. (1935).The primparous perineum after forceps delivery: A follow-up comparison of results with and without episiotomy. American Journal of Obstetrics and Gynecology, 30, 249-256. Olson, R., Olson, C., & Smith Cox, N. (1990).Maternal birthing positions and perineal injury. Journal of Family Practice, 30(5),553-557. Paciornik, M. (1990).Commentary: Arguments against episiotomy and in favor of squatting for birth. Birth, 17(2), 104-105. Pomeroy, R. (1918).Shall we cut and reconstruct the perineum for every primipara? American Journal of Obstetrics and Diseases of Women and Children, 78, 211-220. Pradhan, S., & Tobon, H. (1986). Vaginal cysts: A clinicopathological study of 41 cases. International Journal of Gynecology & Pathology, 5, 35-46. Pritchard, J. A., MacDonald, P. C., & Gant, N. F. (1985). Williams obstetrics (17th ed.). New York: AppletonCentury-Crofts. Roberts, J., Faan, S., Goldstein, A., Gruener, J., Maggio, M., & Mendez-Bauer, C. (1987). A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 16, 48-55. Rooks, J. P., Weatherby, N., & Ernst, E. (1992).The national birth center study. Journal of Nurse-Midwifery, 37(5), 301-338. Rossi, M. A., & Lindell, S. G. (1985).Maternal positions and pushing techniques in a nonprescriptive environment. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 15, 203-207. Shiono, P., Klebanoff, M., & Carey, C. (1990).Midline epi-
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siotomies: More harm than good? Obstetrics and Gynecology, 75, 765-769. Simkin, P. (1986). Stress, pain, and catecholamine in labor: Part 2. Stress associated with childbirth events: A pilot survey of new mothers. Birth, 13(4),234-240. Sleep, J., & Grant, A. (1987).West Berkshire perineal management trial, three-year follow up. British Medical Journal, 295, 749-751. Sleep, J., Grant, A., Garcia, J., Elbourn, D., Spencer, J., & Chalmers, I. (1984). West Berkshire perineal management trial. British Medical Journal, 289, 587-590. Sleep, J., Roberts, J., & Chalmers, I. (1989).Care during the second stage of labour. In I. Chalmers, M. Enkin, & M. Keirse (Eds.), Effective care in pregnancy and childbirth (Vol. 2, pp. 1129-1144). Oxford: Oxford University Press. Smith, M., Ruffin, M., & Green, L. (1993).The rational management of labor. American Family Physician, 47(6), 1471-1479. Synder, R., Hammond, R., & Hankins, G. (1990). Human papillomavirus associated with poor healing of episiotomy repairs. Obstetrics and Gynecology, 76, 664-666. The, T. G. (1990).Is routine episiotomy beneficial in the low birth weight delivery. International Journal of Gynaecology and Obstetrics, 31, 135-140.
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U.S. Department of Health and Human Services. (1994). Monthly vital statistics report, 42(9), 1. University of Wisconsin-Madison. (1993).Certified nurse-midwife service program report. Unpublished data. Walker, M., Farine, D., Rolbin, S., & Ritchie, J. (1991).Epidural anesthesia, episiotomy, and obstetric laceration. Obstetrics and Gynecology, 77, 668-670. Wittich, A. C. (1982). Endometriosis in an episiotomy scar: Review of the literature and report of a case. Journal of the American Osteopathic Association, 82, 22-23. Yeates, D., & Roberts, J. (1984).A comparison of two bearing down techniques during the second stage of labor. Journal of Nurse-Midwifery, 29(1),3-1 1.
Jeanmarie Sharp Maier is a staff nurse in the birthing suite of Meriter Hospital and a graduate student in the Women’s Health Nurse Practitioner Program, University of Wisconsin, Madison, School of Nursing. Judith A. Maloni is an assistant professor in the Women’s Health Program, University of Wisconsin, Madison, School of Nursing. Address for correspondence: Jeanmaire Sharp Maier, RN, BSN, 5409 Whitcomb Drive, Madison, WI 53 711.
JOGNN 261
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Although episiotomy is one of the most commonly performed surgeries, little scientific support exists for this procedure. Furthermore, the suggested advantages of routine episiotomy are challenged easily and the surgery is not without risks. Adverse effects arising from episiotomy include an increased incidence of severe lacerations, blood loss, pain, delayed healing, dyspareunia, psychologic trauma, and medical cost. Nurses can assist women in avoiding perineal trauma resulting from unnecessary episiotomy through patient education, patient advocacy, and direct care. JOGNN, 26,155-1 61 ; 1997.
Accepted: October
1995
Perineal injury, including episiotomy, long has been accepted as a standard outcome of vaginal delivery (Olson, Olson, & Smith-Cox, 1990).Until recently, U.S. obstetric texts recommended that an episiotomy be performed during every vaginal birth to avoid damage to the perineum (Pritchard, MacDonald, & Gant, 1985). As with any surgery, episiotomy carries risks, but researchers have shown episiotomy does not offer any of the benefits cited as indicators for its use (Banta & Thacker, 1982; Cunningham, MacDonald, Gant, Leveno, & Gilstrap, 1993; Helwig, Thorp, & Bowes, 1993; McGuinness, Norr, & Nacion, 1991). Thus, there is evidence that the practice of routine episiotomy is obsolete (Ahn, Cha, & Phelan, 1992; Sleep, Roberts, & Chalmers, 1989). In this article, the advantages and disadvantages associated with episiotomy are reviewed. Factors that place women at a greater risk of having an episiotomy are outlined. Nursing care measures, such as the use of researchbased practice and patient and staff education, are discussed to assist the nurse in decreasing the in-
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cidence of unnecessary perineal trauma (i.e., routine episiotomy). Episiotomy dates back to 1742, when a perineal incision first was used to facilitate difficult deliveries (Gass, Dunn, & Stys, 1986). However, episiotomy did not become common until the early 1900s when the shift from home to hospital delivery occurred (Banta & Thacker, 1982). The popularity of episiotomy among physicians continued to grow with the introduction of local anesthetic and suture material and as a result of advocacy for its performance by two obstetricians, DeLee and Pomeroy (DeLee, 1920; Pomeroy, 1918). It was claimed that an episiotomy should be performed for every woman delivering her first child to avoid perineal lacerations and damage to the pelvic floor (Rooks, Weatherby, & Ernst, 1992). An estimated 4 million births occur in the United States each year (U.S. Department of Health and Human Services, 1994). Of these, two thirds are accompanied by episiotomy (Banta & Thacker, 1982; Henriksen, Moller Bek, Hedegaard, & Secher, 1992). Episiotomy is the second most common surgery performed in the United States; cutting of the umbilical cord is the most common surgery (Pritchard et al., 1985). The continuing prevailing view among physicians is that routine episiotomy is justified (Banta & Thacker, 1982; Smith, Ruffin, & Green, 1993).
Suggested Advantages of Episiotomy Five suggested advantages are associated with routine episiotomy (Cunningham et al., 1993; Pritchard & MacDonald, 1980). These include (a) prevention of lacerations; (b) creation of a clean, straight incision that, in turn, is easier to repair; (c) facilitation of healing; (d) shortening of the second JOG"
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stage of labor, thereby preventing the weakening of pelvic floor muscles; and (e) reduction of neonatal brain injury by reducing pressure on the fetal head. Although it is a common belief among physicians that episiotomy decreases the incidence of spontaneous lacerations, this belief is not supported in the literature. In two random trials of more than 3,000 women, Sleep et al. (1984) and Henriksen et al. (1992) found that women who do not undergo an episiotomy frequently either do not tear at all, or tear to a lesser extent than the perineal injury caused by episiotomy itself. Perineal injury resulting from episiotomy appears to vary with the type of episiotomy performed (i.e., midline or mediolateral episiotomy). Midline episiotomy increases the likelihood of major perineal trauma fourfold, with subsequent extensive tears being common (Helwig et al., 1993; Walker, Farine, Rolbin, & Ritchie, 1991). Mediolateral episiotomy protects the perineum from severe lacerations but has been associated with more difficult surgical repairs, faulty healing, increased pain, negative cosmetic effects, and dyspareunia (Cunningham et al., 1993; Shiono, Klebanoff, & Carey, 1990).
A l t h o u g h episiotomy is a routine, common practice, little scientific evidence exists to support its benefit.
Another suggested advantage is that an episiotomy creates an incision that is easier to repair than a spontaneous laceration. However, researchers found that using a selective rather than a routine mediolateral episiotomy policy resulted in 90,000 fewer perineal repairs each year (Argentine Episiotomy Trial Collaborative Group, 1993).Women in the selective episiotomy group had an increase in anterior tears. However, this type of tear rarely is associated with the pain, discomfort, and infection that commonly occur with either episiotomies or posterior tears (Argentine Episiotomy Trial Collaborative Group, 1993). A third suggested advantage is that episiotomy facilitates perineal healing (Larsson, Platz-Christensen, Bergman, & Wallstersson, 1991). However, no research exists to support this belief. McGuinness, Norr, and Nacion (1991) reported a 7.7% delayed healing rate among women with episiotomies compared with a 2.2% rate among women without an episiotomy. Furthermore, faulty healing is a commonly cited disadvantage of mediolateral episiotomy (Cunningham et al., 1993). 156 JOGNN
The fourth suggested advantage is that episiotomy prevents pelvic floor damage by shortening the second stage of labor (Smith et al., 1993). This belief is based on a poorly controlled study conducted in 1935 that showed decreased pelvic muscle damage among women undergoing episiotomy (Nugent, 1935). Recent controlled studies have not supported this finding. In the first North American randomized controlled trial of median (midline) episiotomy among 697 women at lowrisk, Klein et al. (1994)found that women who delivered over an intact perineum had the strongest pelvic floor musculature at 3 months postpartum, whereas those with an episiotomy had the weakest musculature. In a random trial of 1,000 women, Sleep et al. (1984)found no group differences in the incidence of urinary incontinence at 10 days postpartum and 3 months postpartum for women allocated to either liberal or restrictive performance of an episiotomy. In a 3-year follow-up of the same women (Sleep & Grant, 1987), the incidence of urinary incontinence was the same in both groups, thus disputing the argument that episiotomy prevents pelvic musculature damage. Likewise, in a quasi-randomized study of 2,188 women, Henriksen et al. (1992) found no increased risk of having a tear of the anal sphincter among women cared for by midwives who seldom performed episiotomy. However, episiotomy was associated with a significantly increased risk of anal tears. It also has been suggested that exercise of perineal muscles is more predictive of perineal muscle tone after delivery than is the degree of perineal injury (Gordon & Lougue, 1985; Kegel, 1948). Paciornick (1990)reports that, contrary to popular belief that stretching damages the perineum, the pelvic floor is made up of striated muscle that does not lose strength after stretching. However, shortening of the second stage of labor may be advantageous in instances of acute fetal distress (Banta & Thacker, 1983). Finally, another commonly cited advantage of episiotomy is that it decreases pressure on the fetal head and thus improves neonatal outcome, especially for lowbirth-weight neonates. However, researchers found no difference in Apgar scores or neonatal mortality rates for low-birth-weight neonates who were delivered by an episiotomy versus those who were not (The, 1990). Sleep et al. (1984) also found no difference in Apgar scores or number of admissions to intensive-care units for neonates delivered with or without an episiotomy. Ahn et al. (1992)concluded that there is insufficient data to support the belief that routine use of episiotomy protects the fetus from injury.
Adverse Effects of Episiotomy Numerous adverse effects are associated with episiotomy. These include an increased risk of third- and
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fourth-degree perineal lacerations, infection, delayed wound healing, blood loss, scars, perineal cysts, postoperative pain, dyspareunia, psychologic trauma, and increased health care costs (Banta & Thacker, 1982; Helwig et al., 1993; McGuinness et al., 1991; Simkin, 1986). Third- and fourth-degree lacerations extending from an episiotomy are not uncommon (Helwig et al., 1993; Klein et al., 1994). In a prospective multicenter study of more than 24,000 women, Shiono et al. (1990) found that women having a midline episiotomy were 50 times more likely to experience a third- or fourth-degree laceration than women without an episiotomy. Similarly, women with a mediolateral episiotomy were eight times more likely to suffer a severe laceration than women without an episiotomy. Another risk associated with episiotomy is infection. McGuinness et al. (1991) found a 4.9% infection rate among women with an episiotomy. In addition, women infected with the human papillomavirus have been found to have poorer episiotomy healing, leading to increased infection and dehiscence (Faro, 1988; Synder, Hammond, & Hankins, 1990). Blood loss is another adverse effect of episiotomy. Women with spontaneous lacerations bleed less than those with episiotomies (House, 1980; Newton et al., 1961). House (1980) found that women undergoing an episiotomy lost 115 ml of blood more than women with spontaneous tears. Other complications that result from an episiotomy include perineal cysts and endometriosis arising from the episiotomy scar (Koger, Shatney, Hodge, & McClenathan, 1993; Pradhan & Tobon, 1986; Wittich, 1982). Episiotomy scars can develop surgical scar endometrioma up to 20 years later (Koger et al., 1993).
Undergoing episiotomy puts women at increased risk of third- and fourth-degree lacerations, infection, delayed wound healing, blood loss, scars, perineal cysts, pain, dyspareunia, psychologic trauma, and increased health care costs.
The most bothersome adverse effect of episiotomy, yet the most overlooked and underestimated, is pain from the incision (Hordnes & Bergsjo, 1993). Klein et al. (1994)found not only that perineal pain was less for
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women who gave birth with an intact perineum, but also that the pain resulting from spontaneous lacerations was less than that from an episiotomy. Women who have an episiotomy report more postoperative pain with activities of daily living and a higher incidence of prolonged dyspareunia than women who do not have an episiotomy (Sleep & Grant, 1987; Walker et al., 1991). Sleep et al. (1984) found that 498 women delivered by midwives who were instructed to avoid episiotomy were more likely to have resumed intercourse within a month after delivery. Episiotomy and perineal tears also can cause psychologic pain. During postpartum interviews, Simkin (1986) found that 64% of women viewed episiotomy as stressful and that their satisfaction with childbirth increased when they had more control during labor and delivery.
N u r s e s can reduce the incidence of unnecessary perineal trauma by educating patients and staff, encouraging use of alternative birthing positions, and encouraging spontaneous second-stage bearing-down efforts.
Finally, an indirect adverse effect of episiotomy is increased health care costs. In a comparison of routine versus restrictive performance of episiotomy, Sleep et al. (1984)found that 502 women allocated to a routine episiotomy policy required 100 more packets of suture material and 13 more hours of time to repair perineal trauma than women allocated to a restrictive episiotomy policy. Thus, the potential monetary savings could be significant when considering the number of women who undergo episiotomy each year.
Risk Factors that Predispose Women to Episiotomy The following are some factors that place women at greater risk for having an episiotomy or a spontaneous laceration: nulliparity, increased neonate birth weight, shoulder dystocia, posterior presentation, use of vacuum extraction, and use of forceps (Hordnes & Bergesjo, 1993). African American women also are more apt to undergo episiotomy than white women (Hordnes & Bergesjo, 1993). Other factors that predispose women to perineal trauma sometimes can be mitigated by nurses. These
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factors include the use of a recumbent position, such as the lithotomy position, for delivery (Olson et al., 1990); use of sustained breath holding and pushing rather than spontaneous bearing down efforts (Yeates & Roberts, 1984); and placement of time limits on second-stage labor (McKay & Roberts, 1985). Although a recumbent position is common during labor and delivery, no evidence suggests that it is advantageous to the mother or the fetus (McKay & Roberts, 1989; Smith et al., 1993). The lithotomy position and sustained breath holding during bearing down cause excessive perineal pressure and stretching, both of which increase the likelihood of perineal tears (Hordnes & Bergsjo, 1993; Liu, 1989; Olson et al., 1990; Rooks et al., 1992). In contrast, spontaneous bearing-down efforts are shorter in duration and result in less perineal pressure and tearing, which also reduce the likelihood that someone will intervene to perform an episiotomy (Yeates & Roberts, 1984). Provider reluctance to support spontaneous maternal pushing may be based on the belief that it slows the second stage of labor. However, researchers have shown that prolonged labor does not result from pushing spontaneously, but rather results in improved fetal outcomes (Liu, 1989; McKay & Roberts, 1989; Roberts et al. 1987). For example, researchers have found a greater incidence of fetal heart decelerations and hypoxia among neonates whose mothers engaged in vigorous, prolonged bearing-down efforts (Caldeyro-Barcia, 1979; Roberts et al., 1987). Despite 30 years of research that fails to support the efficacy of prolonged breath holding, the practice of encouraging women to use sustained bearing down during the second stage of labor persists (Liu, 1989; Roberts et al., 1987). Another factor that contributes to increased use of episiotomy is the arbitrary time limit that physicians frequently impose on the length of second-stage labor (Sleep & Grant, 1987). This practice is based on the belief that a long second-stage labor contributes to negative maternal and fetal outcomes (McKay & Roberts, 1985). Therefore, episiotomy frequently is performed to shorten the second stage of labor. Physician convenience may also contribute to efforts to shorten the second stage. As a result, the longer a woman remains in second-stage labor, the more likely she is to have an episiotomy (McGuinness et al., 1991). However, no evidence exists to support the belief that a long secondstage increases fetal mortality and morbidity during a normal, uncomplicated labor (Smith et al., 1993). When second-stage labor is progressing and the conditions of mother and fetus are satisfactory, the imposition of any arbitrary time limit is unjustified and results in increased incidence of severe lacerations and episiotomy (Hordnes & Bergsjo, 1993; Sleep & Grant, 1987). 158
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Methods to Decrease the Number of Episiotomies Nurses can help women reduce the likelihood of undergoing episiotomy and unnecessary perineal trauma. Whether involved in direct or indirect clinical practice, nurses can help promote a selective episiotomy policy. Nurses can (a) encourage women to use alternative birthing positions; (b)encourage spontaneous second-stage bearing down efforts; (c) educate women about the advantages and disadvantages of episiotomy so they can make informed decisions; and (d) educate clinical staff, including physicians, about research on episiotomy . Empowering women with knowledge of the advantages and disadvantages of episiotomy enables them to make informed decisions about their care and gives them increased choices throughout childbearing. Women who have choices enjoy greater control of their bodies and their birth experience, all of which can enhance perception of self and of outcome (Rooks et al., 1992; Shiono et al., 1990). One of the first decisions a woman makes during pregnancy is choice of a care provider. To avoid unnecessary interventions and perineal trauma, women need to know that there is variation in practice and that they can choose a practitioner who can help them avoid unnecessary perineal trauma and who shares their values and beliefs. The woman's choices about care then can be based on her individual needs rather than tradition and routine physician practice. If a partnership in care develops, the woman can discuss concerns about procedures, such as episiotomy (Cochrane, 1992). Inquiry into the episiotomy rate of practitioners and whether the practitioner frequently delivers over an intact perineum can be helpful, because some practitioners are more adept at minimizing perineal trauma during delivery than others. For example, nurse-midwives and family practice physicians frequently have lower episiotomy rates than do obstetricians (Champen, 1991; Olson et al., 1990; Rooks et al., 1992). Nurse-midwives frequently have episiotomy rates of 14% to 25%, with a large percentage of clients delivering over an intact perineum, or a small, first-degree tear (Lydon-Rochelle, Albers, & Teaf, 1995; Olson et al., 1990; University of Wisconsin-Madison, 1993). Midwives long have used methods, such as perineal massage, hot perineal compresses, warm oil perineal massage during expulsion, and slow delivery of the fetal head, to avoid perineal lacerations and the need for episiotomy (Rooks et al., 1992). Nurses also can provide patients with information on alternative birthing positions. Books, slides, films, or pictures depicting women laboring and delivering in nontraditional positions assist in establishing a new model of care (McKay & Roberts, 1985). In addition, Volume 26, Number 2
childbearing women and their support persons can be encouraged to practice for labor and delivery using alternative positions and aids, such as squat bars, to decrease the likelihood of perineal trauma. Nursing care that promotes choices about birthing positions not only can promote easier births but also assists women in avoiding unnecessary perineal trauma. Alternative positions, such as standing, kneeling, squatting, hands and knees, and the lateral Sims position, direct the fetal head to the introitus and reduce the pressure on the perineum (Golay, Vedum, & Sorger, 1993; Nodine & Roberts, 1987; Rooks et al., 1992). The lateral Sims position allows greater control of the fetal head with more relaxation and less tension on the perineum, leading to fewer perineal lacerations and a decreased likelihood of episiotomy (Olson et al., 1990; Rooks et al., 1992; Smith et al., 1993). Although some researchers have found limited relationships between maternal positions and perineal outcome (Sleep et al., 1989), most findings suggest that women who deliver in positions other than the recumbent position are less likely to have perineal trauma (Lydon-Rochelle et al., 1995; McKay & Roberts, 1989; Rossi & Lindell, 1985; Smith et al., 1993). Upright positions, such as squatting, have been shown to increase the diameter of the pelvic outlet by 0.5 to 2.0 cm (Borell, 1967; Borgatta, Hutson, & Lynch, 1989; Liu, 1989; Paciornik, 1990; Rooks et al., 1992). The squatting position not only shortens the second stage of labor, reduces the incidence of labor stimulation by oxytocin, and results in fewer mechanically assisted deliveries, but also reduces perineal lacerations and the incidence of episiotomy (Golay et al., 1993).Forty-five percent of women who used the squatting position delivered over an intact perineum compared with 18% in the semirecumbent group (Golay et al., 1993). Apgar scores of neonates born to mothers using the squatting position also were higher, and there were no cases of shoulder dystocia in 200 deliveries (Golay et al., 1993).The use of alternative birthing positions also may be a deterrent to episiotomy because women are not in a position where the perineum is easily accessed. An additional method by which nurses can assist women in avoiding unnecessary perineal trauma is by encouraging women to bear down during second-stage labor only when they feel the urge. Bearing-down efforts of this type, with intermittent breath holding, ease the head out slowly and decrease the incidence of spontaneous lacerations and episiotomy (Yeates & Roberts, 1984).In a review of the literature on second-stage pushing, Sleep et al. (1989) concluded that methods that direct women to forcefully hold their breath for prolonged periods during second-stage contractions offer no benefit. Dissemination of research-based information about the disadvantages of prolonged breath holding and bear-
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ing down, along with providing role models of more appropriate nursing care, will increase the likelihood that lacerations and episiotomy will be avoided. Nurses have little control over a physician's decision to perform an episiotomy. However, because physicians rarely prescribe a pushing position and there often is minimal medical supervision during second-stage labor for women at low risk, nurses can encourage women to use birthing positions that maximize comfort, improve labor progress, and decrease the incidence of perineal trauma. Despite advances in research, health care remains steeped in tradition, and some providers discourage or resist use of alternative methods of care for laboring women. The second stage of labor is not an ideal time for the laboring woman or the nurse to engage in a debate with other practitioners about differences in philosophies of care because the focus is the laboring woman. However, at a practical level, statements by the nurse that indicate that the woman is most comfortable in an alternative birthing position, or suggest that she is laboring effectively (e.g., that she is moving the fetal head down better in a particular position), can be used to discourage unnecessary intervention and promote perineal integrity.
Summary and Conclusion Researchers indicate that routine performance of episiotomy during an uncomplicated labor presents greater risks than benefits to the childbearing woman. Therefore, nurse advocacy for an episiotomy policy that is guided by protocols that are research-based, rather than tradition-based, is indicated. Furthermore, nurses can advocate against unnecessary perineal trauma by educating childbearing women and health care staff about the advantages and disadvantages of episiotomy and the risk factors that predispose women to episiotomy. Dissemination of research-based knowledge to nurses will empower them to function as patient advocates against unnecessary episiotomy during labor and delivery care. Providing role models of research-based practice also can help change personal and institutional philosophies of care, traditional beliefs, and obstetric practices to assist childbearing women in avoiding unnecessary perineal trauma. REFERENCES Ahn, M., Cha, K., & Phelan, J. (1992).The low birth weight infant: Is there a preferred route of delivery? Clinics in Perinatology, 19(2),411-414. Argentine Episiotomy Trial Collaborative Group. (1993). Routine vs selective episiotomy: A randomized controlled trial. Lancet, 342, 1517-1518.
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Banta, D., & Thacker, S. B. (1982).The risks and benefits of episiotomy: A review. Birth, 9( l),25-30. Banta, D., & Thacker, S. B. (1983).Benefits and risks of episiotomies: An interpretative review of the English language literature, 1960-1980. Obstetric and Gynecologic Survey, 38, 232-238. Borell, U. (1967).The mechanism of labor. Radiologic Clinics of North America, 5, 73-85. Borgatta, J., Hutson, N., & Lynch, C. B. (1989).Randomized controlled trial of squatting in the second stage of labour. Lancet, 2, 74-77. Caldeyro-Barcia, R. (1979).The influence of maternal bearing down efforts during the second stage of labor on fetal well-being. Birth and the Family Journal, 6(l),19-23. Champen, J. M., (1991).Routine episiotomy: Medical dogma versus medical wisdom. Childbirth Instructor, 1 (l),2933. Cochrane, S. (1992).Perineal trauma. Nursing Times, 88(21), 147. Cunningham, F. G., MacDonald, P., Gant, N., Leveno, K., & Gilstrap, K. (1993). Williams obstetrics (9th ed.). Norwalk, CT: Appleton & Lange. DeLee, J. B. (1920).Prophylactic forceps operation. American Journal of Obstetrics and Gynecology, 1, 33-44. Faro, S. (1988).Management and treatment of human papilloma virus. Clinical Advances in Treating Infections, 2, 6-7. Gass, M., Dunn, C., & Stys, S. (1986).Effect of episiotomy on the frequency of vaginal outlet lacerations. Journal of Reproductive Medicine, 31 (4),240-244. Golay, J., Vedam, S., & Sorger, L. (1993).The squatting position for the second stage of labor: Effects on labor and on maternal and fetal well-being. Birth, 20(2),73-78. Gordon, H., & Logue, M. (1985). Perineal muscle function after childbirth. Lancet, 2, 123-125. Helwig, J., Thorp, J., & Bowes, W. (1993).Does midline episiotomy increase the risk of third-and-fourth degree lacerations in operative vaginal deliveries? Obstetrics and Gynecology, 82, 275-279. Henriksen, T. B., Moller Bek, K. M., Hedegaard, M., & Secher, N. (1992). Episiotomy and perineal lesions in spontaneous vaginal deliveries. British Journal of 0 6 stetrics and Gynecology, 99, 950-954. Hordnes, K., & Bergsjo, P. (1993). Severe lacerations after childbirth. Acta Obstetrica et Gynecologica Scandinavica, 72, 413-422. House, M. (1981).Episiotomy: Indications, techniques and results. Midwife, Health Visitor and Community Nurse, 6-9. Kegel, A. H. (1948). Progressive resistance exercises in the functional restoration of the perineal muscles. American Journal of Obstetrics and Gynecology, 56, 238-248. Klein, M., Gauthier R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., Johnson, B., Waghorn, K., Gelfand, M., Guralnick, M., Luskey, G., & Joshi, A. (1994).Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171 (3), 591-598. Koger, K., Shatney., Hodge, K., & McClenathan, J. (1993).
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Surgical scar endometrioma. Surgery, Gynecology and Obstetrics, 177, 243-246. Larsson, P. G., Platz-Christensen, J. J., Bergman, B., & Wallstersson, G. (1991).Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynecologic & Obstetric Investigation, 31, 213-216. Liu, Y. (1989).The effects of the upright position during childbirth. Image, 21(1), 14-18. Lydon-Rochelle, M., Albers, L., & Teaf, D. (1995).Perineal outcomes and nurse-midwifery management. Journal of Nurse-Midwifery, 40(1), 13-17. McKay, S., & Roberts, J. (1985).Second stage labor: What is normal? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 14, 101-105. McKay, S., & Roberts, J. (1989). Maternal position during labor and birth: What have we learned? ICEA Review. Focusing on Today's Issues in Perinatal Care, 13(2),2228. McGuinness, M., Norr, K., & Nacion, K. (1991).Comparison between different perineal outcomes on tissue healing. Journal of Nurse-Midwifery, 36(3), 192-197. Newton, M., Mosey, L. M., & Egli, G. (1961).Blood loss during and immediately after delivery. Obstetrics and Gynecology, 17, 9-18. Nodine, P. M., & Roberts, J. (1987).Factors associated with perineal outcome during childbirth. Journal of NurseMidwifery, 32(3), 123-130. Nugent, P. (1935).The primparous perineum after forceps delivery: A follow-up comparison of results with and without episiotomy. American Journal of Obstetrics and Gynecology, 30, 249-256. Olson, R., Olson, C., & Smith Cox, N. (1990).Maternal birthing positions and perineal injury. Journal of Family Practice, 30(5),553-557. Paciornik, M. (1990).Commentary: Arguments against episiotomy and in favor of squatting for birth. Birth, 17(2), 104-105. Pomeroy, R. (1918).Shall we cut and reconstruct the perineum for every primipara? American Journal of Obstetrics and Diseases of Women and Children, 78, 211-220. Pradhan, S., & Tobon, H. (1986). Vaginal cysts: A clinicopathological study of 41 cases. International Journal of Gynecology & Pathology, 5, 35-46. Pritchard, J. A., MacDonald, P. C., & Gant, N. F. (1985). Williams obstetrics (17th ed.). New York: AppletonCentury-Crofts. Roberts, J., Faan, S., Goldstein, A., Gruener, J., Maggio, M., & Mendez-Bauer, C. (1987). A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 16, 48-55. Rooks, J. P., Weatherby, N., & Ernst, E. (1992).The national birth center study. Journal of Nurse-Midwifery, 37(5), 301-338. Rossi, M. A., & Lindell, S. G. (1985).Maternal positions and pushing techniques in a nonprescriptive environment. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 15, 203-207. Shiono, P., Klebanoff, M., & Carey, C. (1990).Midline epi-
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siotomies: More harm than good? Obstetrics and Gynecology, 75, 765-769. Simkin, P. (1986). Stress, pain, and catecholamine in labor: Part 2. Stress associated with childbirth events: A pilot survey of new mothers. Birth, 13(4),234-240. Sleep, J., & Grant, A. (1987).West Berkshire perineal management trial, three-year follow up. British Medical Journal, 295, 749-751. Sleep, J., Grant, A., Garcia, J., Elbourn, D., Spencer, J., & Chalmers, I. (1984). West Berkshire perineal management trial. British Medical Journal, 289, 587-590. Sleep, J., Roberts, J., & Chalmers, I. (1989).Care during the second stage of labour. In I. Chalmers, M. Enkin, & M. Keirse (Eds.), Effective care in pregnancy and childbirth (Vol. 2, pp. 1129-1144). Oxford: Oxford University Press. Smith, M., Ruffin, M., & Green, L. (1993).The rational management of labor. American Family Physician, 47(6), 1471-1479. Synder, R., Hammond, R., & Hankins, G. (1990). Human papillomavirus associated with poor healing of episiotomy repairs. Obstetrics and Gynecology, 76, 664-666. The, T. G. (1990).Is routine episiotomy beneficial in the low birth weight delivery. International Journal of Gynaecology and Obstetrics, 31, 135-140.
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U.S. Department of Health and Human Services. (1994). Monthly vital statistics report, 42(9), 1. University of Wisconsin-Madison. (1993).Certified nurse-midwife service program report. Unpublished data. Walker, M., Farine, D., Rolbin, S., & Ritchie, J. (1991).Epidural anesthesia, episiotomy, and obstetric laceration. Obstetrics and Gynecology, 77, 668-670. Wittich, A. C. (1982). Endometriosis in an episiotomy scar: Review of the literature and report of a case. Journal of the American Osteopathic Association, 82, 22-23. Yeates, D., & Roberts, J. (1984).A comparison of two bearing down techniques during the second stage of labor. Journal of Nurse-Midwifery, 29(1),3-1 1.
Jeanmarie Sharp Maier is a staff nurse in the birthing suite of Meriter Hospital and a graduate student in the Women’s Health Nurse Practitioner Program, University of Wisconsin, Madison, School of Nursing. Judith A. Maloni is an assistant professor in the Women’s Health Program, University of Wisconsin, Madison, School of Nursing. Address for correspondence: Jeanmaire Sharp Maier, RN, BSN, 5409 Whitcomb Drive, Madison, WI 53 711.
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