Judith T. Bishop

Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment

OBJECTIVE Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at spontaneous vaginal delivery. STUDY DESIGN We obtained data from 17,483 consecutive spontaneous vaginal deliveries and compared the yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS Between 1976 and 1994 the use of episiotomy fell significantly (86.8% to 10.4%, R2 = 0.92, p = 0.0001). This change was associated with a fall in the rate of third- and fourth-degree lacerations (9.0% to 4.2%, R2 = 0.59, p = 0.0001) and a rise in the rate of intact perinea (10.3% to 26.5%, R2 = 0.68, p = 0.0001) and vaginal lacerations (5.4% to 19.3%, R2 = 0.77, p = 0.0001). These associations held in separate analyses stratified by parity and birth weight, except for the subgroup of nulliparous women with macrosomic infants. CONCLUSION At our institution a large reduction in the use of episiotomy in spontaneous vaginal deliveries was associated with a significant reduction in perineal trauma in all groups of women except for nulliparous women with macrosomic infants.

Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population

Abstract OBJECTIVE: Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at operative vaginal delivery. STUDY DESIGN: We obtained data from 2041 consecutive operative vaginal deliveries and compared yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS: Between 1984 and 1994 the use of episiotomy for operative vaginal deliveries fell significantly (93.4% to 35.7%, R 2 = 0.85, p = 0.0001). This change was associated with a rise in the rate of vaginal lacerations (16.1% to 40.0%, R 2 = 0.80, p = 0.0002), a decrease in the rate of fourth-degree lacerations (12.2% to 5.4%, R 2 = 0.62, p = 0.004), but no significant change in the rate of third-degree lacerations. These associations held in separate analyses stratified by parity and type of instrument used for delivery. The prevalence of other previously reported risks for perineal morbidity did not change during the study period. CONCLUSION: At our institution a statistically and clinically significant reduction in the use of episiotomy for operative vaginal deliveries was not associated with a change in the rate of third-degree lacerations but was associated with an increase in the rate of vaginal lacerations and a decrease in the rate of fourth-degree lacerations.(Am J Obstet Gynecol 1997;176:411-4.)

Variation in Women's Understanding of Prenatal Testing

OBJECTIVE: To investigate womens understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both. METHODS: This was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their health care providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes. RESULTS: Data were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately two thirds of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial, ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (adjusted odds ratio 0.23 [0.14–0.39]). CONCLUSION: Disparities exist in womens recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.

Is There a Benefit to Episiotomy at Operative Vaginal Delivery? Observations Over Ten Years in a Stable Population

OBJECTIVE Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at operative vaginal delivery. STUDY DESIGN We obtained data from 2041 consecutive operative vaginal deliveries and compared yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS Between 1984 and 1994 the use of episiotomy for operative vaginal deliveries fell significantly (93.4% to 35.7%, R2 = 0.85, p = 0.0001). This change was associated with a rise in the rate of vaginal lacerations (16.1% to 40.0%, R2 = 0.80, p = 0.0002), a decrease in the rate of fourth-degree lacerations (12.2% to 5.4%, R2 = 0.62, p = 0.004), but no significant change in the rate of third-degree lacerations. These associations held in separate analyses stratified by parity and type of instrument used for delivery. The prevalence of other previously reported risks for perineal morbidity did not change during the study period. CONCLUSION At our institution a statistically and clinically significant reduction in the use of episiotomy for operative vaginal deliveries was not associated with a change in the rate of third-degree lacerations but was associated with an increase in the rate of vaginal lacerations and a decrease in the rate of fourth-degree lacerations.