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- Page navigation anchor for RE: “Response to ‘Encouraging routine use of episiotomy with forceps questioned’”RE: “Response to ‘Encouraging routine use of episiotomy with forceps questioned’”
To The Editor:
We thank Drs. Klein and Kaczorowski (1) for their interest in our article (2). Although we found some of their arguments distracting and dated, we welcome this opportunity to clarify our position.
Klein and Kaczorowski are correct in pointing out that our analysis focused on hospital deliveries, which included approximately 98% of all deliveries in Canada (excluding Quebec) (3). We characterized trends in episiotomy use in Canada and are unaware of data sources that contains such information for home births. Comparing differences in rates of episiotomy, operative vaginal delivery (OVD), and obstetric anal sphincter injury (OASI) in our study with those in the study by Janssen et al. (4) is not particularly meaningful as the latter was restricted to low risk women. Additionally, the Janssen et al. study included deliveries from 15 to 20 years ago when OASI rates were significantly lower (5).
Klein and Kaczorowski appear to have missed the main conclusion of our study which showed a) that episiotomy use in Canada has declined among both spontaneous vaginal deliveries and among operative vaginal deliveries (OVD) and b) that episiotomy use in spontaneous vaginal deliveries increases the risk of OASI, while episiotomy use in operative vaginal deliveries protects against OASI. The former finding, namely, that episiotomy increases OASI risk in spontaneous vaginal deliveries, has been documented in several randomized trials (6) and is not und...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Encouraging Routine Use of Episiotomy with Forceps QuestionedRE: Encouraging Routine Use of Episiotomy with Forceps Questioned
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), demonstrate...
Show MoreCompeting Interests: None declared.