1
|
Mirouse L. Ignoring international alerts? The routinization of episiotomy in France in the 1980s and 1990s. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2022; 14:42-52. [PMID: 34693044 PMCID: PMC8517717 DOI: 10.1016/j.rbms.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 05/20/2021] [Accepted: 07/12/2021] [Indexed: 06/13/2023]
Abstract
As scientific evidence from the UK and the USA in the 1980s was questioning the usefulness of episiotomy, the rate in France increased from 38% in 1981 to 58.4% in 1996. In 1996, the World Health Organization recommended limiting the episiotomy rate to 10%. This article aims to examine this paradox through an analysis of the French medical debate on episiotomy during the 1980s and 1990s. Drawing on an analytical corpus composed of 192 articles published in French professional journals of obstetrician-gynaecologists and midwives, it shows that the majority of these health professionals considered episiotomy to be a preventive intervention. The most influential professional organizations and experts manage to refute most of the international alerts on the limitations and side effects of episiotomy through the constant production of new justifications and competing knowledge for the procedure. In the 1980s, episiotomy was seen as a means to prevent tearing and thus avoid perineal dysfunction. Episiotomy and perineal re-education (which developed into a new health sector) were put forward as 'the' solution to the problem. From the mid-1990s onwards, the focus shifted from the mother to the baby as episiotomy was promoted as a way to reduce the risk of newborn mortality and morbidity. This article shows that the alerts and controversies on the assumed iatrogenic effects of biomedical technologies and practices were silenced through efficient and dynamic production of competing knowledge about their assumed benefits.
Collapse
Affiliation(s)
- Lola Mirouse
- Centre for the Study of Social Movements (EHESS/CNRS UMR8044/Inserm U1276), Paris, France
- ANR Hypmedpro, School for Advanced Studies in the Social Sciences, Paris, France
| |
Collapse
|
2
|
Clesse C, Cottenet J, Lighezzolo-Alnot J, Goueslard K, Scheffler M, Sagot P, Quantin C. Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries. Sci Rep 2020; 10:20208. [PMID: 33214621 PMCID: PMC7677317 DOI: 10.1038/s41598-020-70881-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/28/2020] [Indexed: 02/08/2023] Open
Abstract
Episiotomy use has decreased due to the lack of evidence on its protective effects from maternal obstetric anal sphincter injuries. Indications for episiotomy vary considerably and there are a great variety of factors associated with its use. The aim of this article is to describe the episiotomy rate in France between 2013 and 2017 and the factors associated with its use in non-operative vaginal deliveries. In this retrospective population-based cohort study, we included vaginal deliveries performed in French hospitals (N = 584) and for which parity was coded. The variable of interest was the rate of episiotomy, particularly for non-operative vaginal deliveries. Trends in the episiotomy rates were studied using the Cochran-Armitage test. Hierarchical logistic regression was used to identify variables associated with episiotomy according to maternal age and parity. Between 2013 and 2017, French episiotomy rates fell from 21.6 to 14.3% for all vaginal deliveries (p < 0.01), and from 15.5 to 9.3% (p < 0.01) for all non-operative vaginal deliveries. Among non-operative vaginal deliveries, epidural analgesia, non-reassuring fetal heart rate, meconium in the amniotic fluid, shoulder dystocia, and newborn weight (≥ 4,000 g) were risk factors for episiotomy, both for nulliparous and multiparous women. On the contrary, prematurity reduced the risk of its use. For nulliparous women, breech presentation was also a risk factor for episiotomy, and for multiparous women, scarred uterus and multiple pregnancies were risk factors. In France, despite a reduction in episiotomy use over the last few years, the factors associated with episiotomy have not changed and are similar to the literature. This suggests that the decrease in episiotomies in France is an overall tendency which is probably related to improved care strategies that have been relayed by hospital teams and perinatal networks.
Collapse
Affiliation(s)
- Christophe Clesse
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine & Dentistry, Queen Mary, University of London, Old Anatomy Building Charterhouse Square, London, EC1M 6BQ, UK.,Interpsy Laboratory (EA 4432), Universite de Lorraine - Campus Lettres Et Sciences Humaines, Nancy, France.,Majorelle Polyclinic, Nancy, France
| | - Jonathan Cottenet
- Biostatistics and Bioinformatics (DIM), University Hospital, University of Burgundy and Franche-Comté, Dijon, France
| | | | - Karine Goueslard
- Biostatistics and Bioinformatics (DIM), University Hospital, University of Burgundy and Franche-Comté, Dijon, France
| | - Michele Scheffler
- Obstetricial Gynecologist, Endocrinologist, Gynecologist, The FNCGM (National Federation of Gynecology Medical Colleges), Cabinet de Gynécologie Médicale Et Obstétrique, 21 avenue Foch, 54000, Nancy, France
| | - Paul Sagot
- Department of Obstetrics and Gynecology, University Hospital, Dijon, France
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), University Hospital, University of Burgundy and Franche-Comté, Dijon, France. .,Inserm, CIC 1432, Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France. .,Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, Paris, France.
| |
Collapse
|
3
|
Clesse C, Lighezzolo-Alnot J, Hamlin S, De Lavergne S, Scheffler M. [The practice of episiotomy in France 10 years after the recommendations of CNGOF: What inventory?]. ACTA ACUST UNITED AC 2016; 44:232-8. [PMID: 26997462 DOI: 10.1016/j.gyobfe.2016.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 02/09/2016] [Indexed: 12/14/2022]
Abstract
Since its creation, the practice of episiotomy has evolved, being influenced by several factors. Various stances on its use were stated, until the eventual reduction of this practice, as suggested by numerous practical guides. In 2005, the National College of Obstetricians and Gynecologists in France published its French Guidelines for Clinical practice in this area. Today, it seems appropriate to focus on the evolution of the use of episiotomy, ten years after the publication of these recommendations. The authors propose a literature review, browsing through all the available epidemiological data in France related to episiotomy, recording all national statistics and some local trends, as there are regional specificities. This review allows to follow the overall evolution of the practice of episiotomy in France between 1981 and 2014, and to identify territorial disparities. Finally, in the specific context of the practice of episiotomy in French gynecological and obstetrics field, the authors conclude it by considering the possible evolution of this surgical practice, as well as, the Clinical Practice Recommendations related to it.
Collapse
Affiliation(s)
- C Clesse
- Laboratoire interpsy (EA4432), université de Lorraine, Nancy 2, 3, place Godeffroy-de-Bouillon, 54000 Nancy, France; Centre hospitalier de Jury-les-Metz, route d'Ars-Laquenexy, BP 75088, 57073 Jury-Les-Metz cedex 03, France.
| | - J Lighezzolo-Alnot
- Laboratoire interpsy (EA4432), université de Lorraine, Nancy 2, 3, place Godeffroy-de-Bouillon, 54000 Nancy, France
| | - S Hamlin
- Polyclinique Majorelle, 1240, avenue Raymond-Pinchard, 54100 Nancy, France
| | - S De Lavergne
- Polyclinique Majorelle, 1240, avenue Raymond-Pinchard, 54100 Nancy, France
| | - M Scheffler
- Polyclinique Majorelle, 1240, avenue Raymond-Pinchard, 54100 Nancy, France; Cabinet de gynécologie médicale et obstétrique, 21, avenue Foch, 54000 Nancy, France
| |
Collapse
|
4
|
Vendittelli F, Rivière O, Crenn-Hébert C, Giraud-Roufast A. Do perinatal guidelines have an impact on obstetric practices? Rev Epidemiol Sante Publique 2012; 60:355-62. [DOI: 10.1016/j.respe.2012.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 02/25/2012] [Accepted: 03/12/2012] [Indexed: 11/27/2022] Open
|
5
|
Azuar AS, Vendittelli F, Tergny E, Savary D, Accoceberry M, Jacquetin B, Gallot D, Lémery D. [A policy of selective episiotomy in a ward: an example of medical professional assessment]. ACTA ACUST UNITED AC 2012; 41:10-5. [PMID: 22964000 DOI: 10.1016/j.gyobfe.2012.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 03/28/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To reduce the episiotomy rates, according to the Clinical Practice Guidelines, of 2005, from the French College of Obstetricians and Gynaecologists. PATIENTS AND METHODS A cross sectional study was conducted, in the university hospital maternities (Maternity 1 and 2) with a retrospective record from medical files. Patients who had delivered in those maternities, by vaginal route, after 22 weeks amenorrhea were eligible. The global rate of episiotomy was analysed from 2006 to 2008. A descriptive clinical study was performed with a retrospective analysis (from July to December 2005 on 100 medical files and from July to December 2007 on 85 files). Besides, a study of episiotomy rate was conducted from 2006 to 2008. Improvement actions were developed between the two phases of assessment of the audit: sharing and comparing the results to standardized episiotomy rates, and elaborating an informatized regional perinatality file with episiotomy related items and national recommendations. RESULTS Episiotomy rate decreased during the study, from 22.35% in 2005 to 19.34% in 2008, in the Ward 1 (p<0.0001) and from 33.62% in 2005 to 17.93% en 2008 (p<0.0001) in the Ward 2. An improvement was observed between the two periods of audits, for each item of the chart but without statistical signification. DISCUSSION AND CONCLUSION Theses procedures have led to a positive impact on practices thanks to the work group and because of the politics of the perinatal network in favour of an episiotomy reduction. We hope these results could be improved in the future.
Collapse
Affiliation(s)
- A S Azuar
- Pôle de gynécologie-obstétrique et reproduction humaine, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Schinkel N, Colbus L, Soltner C, Parot-Schinkel E, Naar L, Fournié A, Granry JC, Beydon L. Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study. Int J Obstet Anesth 2010; 19:293-7. [DOI: 10.1016/j.ijoa.2009.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 07/06/2009] [Accepted: 11/22/2009] [Indexed: 11/16/2022]
|
7
|
Eckman A, Ramanah R, Gannard E, Clement MC, Collet G, Courtois L, Martin A, Cossa S, Maillet R, Riethmuller D. [Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists]. ACTA ACUST UNITED AC 2009; 39:37-42. [PMID: 19892475 DOI: 10.1016/j.jgyn.2009.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 09/14/2009] [Accepted: 09/22/2009] [Indexed: 10/20/2022]
Abstract
AIM To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001). CONCLUSION An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.
Collapse
Affiliation(s)
- A Eckman
- Service de gynécologie-obstétrique, CHU Saint-Jacques, avenue du 8-Mai-1945, 25000 Besançon, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Vendittelli F, Rivière O, Crenn-Hébert C, Claris O, Tessier V, Pinquier D, Teurnier F, Lansac J, Maria B. Réseau Sentinelle Audipog 2004–2005. Partie 2 : évaluation des pratiques professionnelles. ACTA ACUST UNITED AC 2008; 36:1202-10. [DOI: 10.1016/j.gyobfe.2008.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 08/26/2008] [Indexed: 11/25/2022]
|
9
|
Fritel X, Schaal JP, Fauconnier A, Bertrand V, Levet C, Pigné A. [Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]. ACTA ACUST UNITED AC 2008; 36:991-7. [PMID: 18801690 DOI: 10.1016/j.gyobfe.2008.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 07/01/2008] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare two policies for episiotomy: restrictive and systematic. PATIENTS AND METHODS It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse. RESULTS We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22). DISCUSSION AND CONCLUSION A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.
Collapse
Affiliation(s)
- X Fritel
- Service de gynécologie-obstétrique, hôpital Rothschild, Assistance publique-Hôpitaux de Paris (AP-HP), université Pierre-et-Marie-Curie, 33, boulevard de Picpus, 75012 Paris, France.
| | | | | | | | | | | |
Collapse
|
10
|
Fritel X, Schaal JP, Fauconnier A, Bertrand V, Levet C, Pigné A. Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG 2007; 115:247-52. [PMID: 17970794 DOI: 10.1111/j.1471-0528.2007.01540.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare two policies for episiotomy: restrictive and systematic. DESIGN Quasi-randomised comparative study. SETTING Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. POPULATION Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. METHODS A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. MAIN OUTCOME MEASURES Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. RESULTS We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05-3.22). CONCLUSIONS A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.
Collapse
Affiliation(s)
- X Fritel
- Service de Gynécologie & Obstétrique, Hôpital Rothschild AP-HP, Université Pierre-et-Marie-Curie, Paris, France.
| | | | | | | | | | | |
Collapse
|