doi: 10.56294/nds2024104

 

ReviEW

 

Towards respectful obstetric care

 

Hacia una atención obstétrica respetuosa

 

Agustina Campo1 *

 

1Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Carrera de Medicina. Buenos Aires, Argentina.

 

Cite as: Campo A. Towards respectful obstetric care. Nursing Depths Series. 2024; 3:104. https://doi.org/10.56294/nds2024104

 

Submitted: 18-06-2023                   Revised: 16-09-2023                   Accepted: 01-01-2024                 Published: 02-01-2024

 

Editor: Dra. Mileydis Cruz Quevedo

 

Corresponding author: Agustina Campo *

 

ABSTRACT

 

Episiotomy was a common procedure in vaginal deliveries for decades, performed to prevent maternal complications. However, recent research has questioned its effectiveness and safety, promoting a more restrictive, evidence-based approach. It was found that routine use did not significantly reduce severe perineal tears or shorten the second stage of labour, and in some cases led to major complications. Factors associated with its practice were also identified, such as primiparity and the use of oxytocin, and the importance of informed consent was emphasised. From a clinical and ethical perspective, it was recommended that it should only be performed when strictly necessary, always prioritising respect for women’s autonomy and humanised care.

 

Keywords: Episiotomy; Informed Consent; Vaginal Deliveries; Women’s Autonomy; Humanised Care.

 

RESUMEN

 

La episiotomía fue durante décadas una intervención común en los partos vaginales, realizada con el fin de prevenir complicaciones maternas. Sin embargo, investigaciones recientes cuestionaron su eficacia y seguridad, promoviendo una aplicación más restrictiva basada en la evidencia. Se observó que su uso rutinario no redujo significativamente los desgarros perineales graves ni acortó la segunda etapa del parto, y en algunos casos, generó complicaciones mayores. También se identificaron factores asociados a su práctica, como la primiparidad y el uso de oxitocina, y se subrayó la importancia del consentimiento informado. Desde un enfoque clínico y ético, se recomendó su aplicación solo cuando fuera estrictamente necesaria, priorizando siempre el respeto a la autonomía de la mujer y una atención humanizada.

 

Palabras clave: Episiotomía; Consentimiento Informado; Partos Vaginales; Autonomía de la Mujer; Atención Humanizada.

 

 

 

INTRODUCTION

Episiotomy, a common surgical intervention in the obstetric setting, has been part of the routine management of vaginal delivery to prevent maternal complications for decades. However, its use has been the subject of much debate in recent years, fuelled by new scientific evidence questioning its efficacy and safety. In this context, it becomes necessary to critically analyze this practice, considering its clinical, emotional, and ethical implications and the importance of promoting a woman-centered approach based on respect for her rights during the birthing process.

 

DEVELOPMENT

Episiotomy is a widely used obstetric practice during vaginal birth, based on the belief that a controlled surgical incision of the perineum would facilitate delivery, prevent severe tearing and allow for better tissue repair and healing.(1) Traditionally, this intervention was justified by the idea that prevention of spontaneous lacerations could decrease postpartum maternal morbidity.(2) However, recent studies have questioned its efficacy and safety, promoting a more restrictive and evidence-based approach.

Research has shown that the routine use of episiotomy does not necessarily reduce the incidence of severe perineal tears and may even be a predisposing factor for more severe injuries such as third and fourth-degree tears, especially when the technique is not applied correctly.(3,4) Furthermore, no significant decrease in the duration of the second stage of labor has been observed between women who underwent episiotomy and those with spontaneous tears,(5) suggesting that this practice does not offer significant functional advantages in many cases.

The incidence of episiotomy remains high in specific settings, and its use has been associated with factors such as primiparity, oxytocin use, epidural anesthesia, and high body mass index.(1) In addition, the information provided to pregnant women about this practice significantly influences their perception and acceptance, and it is essential to ensure informed and informed consent.(6,7)

From a clinical perspective, perineal tears are classified into four grades, with the third and fourth grades being the most severe due to their involvement of the anal sphincter complex. These injuries carry a high risk of complications such as fecal or urinary incontinence, chronic pain, dyspareunia, and psychological disturbances such as anxiety or depression.(8) It is, therefore, essential to prioritize strategies that minimize these risks, such as pelvic floor muscle training during pregnancy, respect for the physiological timing of labor, and selective and appropriate application of episiotomy.(9)

Furthermore, the use of tools such as EPISCISSORS-60® has shown promising results in reducing anal sphincter injuries when episiotomy is unavoidable, thanks to the safer orientation of the cutting angle.(4) This indicates the importance of the correct indication and the technique used in the procedure.

On the emotional and social side, many women report traumatic experiences associated with episiotomy, especially when they were not informed beforehand. This situation has been interpreted by some as a form of obstetric violence,(5,10) highlighting the need for a respectful, humanized, and woman-centered approach to childbirth care.(11)

Therefore, the current literature suggests a critical re-evaluation of episiotomy, highlighting the need for its individualized application, based on clear clinical criteria, to reduce unnecessary interventions and preserve women’s overall health.(12)

 

CONCLUSIONS

Episiotomy should not be considered a routine practice but a medical intervention that requires individualized assessment and well-founded clinical criteria. Current evidence indicates that its indiscriminate use may generate more risks than benefits, compromising both the physical and emotional health of the woman. It is, therefore, essential to promote respectful, informed, and humanized obstetric care that prioritizes the safety, well-being, and autonomy of pregnant women and that uses episiotomy only when it is necessary and applied with the appropriate technique.

 

BIBLIOGRAPHICAL REFERENCES

1. Bączek G, Rychlewicz S, Sys D, Rzońca P, Teliga-Czajkowska J. Episiotomy for medical indications during vaginal birth—retrospective analysis of risk factors determining the performance of this procedure. J Clin Med. 2022;11(15):4334. Disponible en: https://doi.org/10.3390/jcm11154334

 

2. Aguiar BM, Silva TPRD, Pereira SL, et al. Factors associated with the performance of episiotomy. Rev Bras Enferm. 2020;73(suppl 4):e20190899. Disponible en: https://doi.org/10.1590/0034-7167-2019-0899

 

3. Sultan AH, de Leeuw JW. Episiotomy and operative vaginal delivery: do we need more evidence? BJOG. 2021;128(10):1672–3. Disponible en: https://doi.org/10.1111/1471-0528.16783

 

4. Koh LM, van Roon Y, Pradhan A, Pathak S. Impact of the EPISCISSORS-60 mediolateral episiotomy scissors on obstetric anal sphincter injuries: a 2-year data review in the United Kingdom. Int Urogynecol J. 2020;31(9):1729–34. Disponible en: https://doi.org/10.1007/s00192-019-04201-7

 

5. He S, Jiang H, Qian X, Garner P. Women’s experience of episiotomy: a qualitative study from China. BMJ Open. 2020;10(7):e033354. Disponible en: https://doi.org/10.1136/bmjopen-2019-033354

 

6. Alexander JW, Karantanis E, Turner RM, Faasse K, Watt C. Patient attitude and acceptance towards episiotomy during pregnancy before and after information provision: a questionnaire. Int Urogynecol J. 2020;31(3):521–8. Disponible en: https://doi.org/10.1007/s00192-019-04003-x

 

7. MacLellan J, Webb SS, Byrne C, et al. Informed consent in episiotomy: co-analysis with midwives and distillation of best practice. Birth. 2023;50(4):773–80. Disponible en: https://doi.org/10.1111/birt.12721

 

8. Hartinah A, Usman AN, Sartini, et al. Care for perineal tears in vaginal delivery: an update for midwife. Gac Sanit. 2021;35(Suppl 2):S216–20. Disponible en: https://doi.org/10.1016/j.gaceta.2021.10.024

 

9. Zhang D, Bo K, Montejo R, et al. Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: systematic review and meta-analysis of randomized clinical trials. Acta Obstet Gynecol Scand. 2024;103(6):1015–27. Disponible en: https://doi.org/10.1111/aogs.14744

 

10. Klein MC, Kaczorowski J. Routine use of episiotomy with forceps should not be encouraged. CMAJ. 2020;192(8):E190. Disponible en: https://doi.org/10.1503/cmaj.74132

 

11. Radnia N, Khansari S, Jiriaei N, Hosseini SA, Salemi L, Hamoon M. The relationship between perineal size and episiotomy during delivery. J Med Life. 2022;15(11):1379–83. Disponible en: https://doi.org/10.25122/jml-2021-0390

 

12. Tantengco OAG, Velayo CL. Episiotomy practice and perineal trauma in the Philippines. Lancet Reg Health West Pac. 2022;19:100381. Disponible en: https://doi.org/10.1016/j.lanwpc.2022.100381

 

FINANCING

None.

 

CONFLICT OF INTEREST

None.

 

AUTHORSHIP CONTRIBUTION

Conceptualisation: Agustina Campo.

Data curation: Agustina Campo.

Formal analysis: Agustina Campo.

Research: Agustina Campo.

Methodology: Agustina Campo.

Project management: Agustina Campo.

Resources: Agustina Campo.

Software: Agustina Campo.

Supervision: Agustina Campo.

Validation: Agustina Campo.

Visualisation: Agustina Campo.

Writing - original draft: Agustina Campo.

Writing - proofreading and editing: Agustina Campo.