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To the editor:
Giulia et al show association between forceps without episiotomy and rising severe perineal trauma.(1) This large, retrospective study of administrative data examined hospital births only. The study does not report breakdown by provider type, though the CIHI database includes provider. Home birth data is absent from the CIHI database but available from other sources. In our 4-year study of all home births in BC, episiotomy and 3rd/4th degree tears were lower than the Giulia study, as were instrumentation rates after transfer. (2)
A retrospective study of administrative data cannot provide causal inferences. Giulia et al show us something is going on that needs explanation. But other temporal changes are also taking place: increasing maternal age, steadily rising epidural and EFM rates. Importantly, episiotomy use declined in spontaneous vaginal deliveries, which represented over 85% of deliveries in this study, associated with corresponding decline in 3rd/4th degree tears. By contrast, the main conclusion of the study is based on forceps deliveries among nulliparous women and those attempting vaginal birth after cesarean, which accounted for less than 2.3% of deliveries included in the study.
Ecker et al urged clinicians to separate decision to use forceps from use of episiotomy. In so doing, they dramatically reduced their 3rd/4th degree tear rate. (3) Klein et al, in still the only RCT of episiotomy in North America (4), demonstrated a powerful association between episiotomy use and 3rd/4th degree tears. 46 of 47 primiparous women had 3rd/4th degree tears in the presence of median episiotomy. Those physicians with the highest episiotomy rates had the highest 3rd/4th degree tear rates and used instrumentation and cesarean more often in women who were not randomized.
Looking forward to seeing results by provider type.
1. Giulia M et al. Episiotomy use among vaginal deliveries and the association with anal sphincter injury: a population-based retrospective cohort study. CMAJ 2019 October 231;191:E1149-58
2. Janssen P, Saxell L, Page L, Klein MC, Liston R, Lee SK. Outcomes of planned home birth with registered midwives versus planned hospital birth with a midwife or a physician. CMAJ.2009. http://www.cmaj.ca/cgi/content/abstract/cmaj.081869v1
3. Ecker JL, Tan WM, Bansal RJ, Bishop JT, Kilpatrick SJ. Is there a benefit t episiotomy at operative vaginal delivery? Observations over ten year in a stable population. Am J Obstet Gynecol 1997:176:411-4.
4. Klein M, Gauthier R, Robbins J, Kaczorowski J, Jorgensen S, Franco E, Johnson B, Waghorn K, Gelfand M, Guralnick M, Luskey G, Joshi J: Relation of Episiotomy to Perineal Trauma and Morbidity, Sexual Dysfunction and Pelvic Floor Relaxation. Am J Obstet Gynaecol, 1994 171(3):591-98