Dear David,
I am not familiar with the post anal pressure you
mention in your mail.What do you do and how will it hasten birth when there
is a low FHR?
Linda
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----- Original Message -----
From: David Simon <[EMAIL PROTECTED]>
To: ozmid <[EMAIL PROTECTED]>
Cc: Joy Johnston <[EMAIL PROTECTED]>
Sent: Wednesday, December 19, 2001 11:23 PM
Subject: Re tears
> Joy, you said
> >We have good statistical data telling us that the number of perineal
tears
> and the severity of the tears is consistently less in women who give birth
> at home (or in the car or for that matter) than for women in hospital.
Why
> is that? Is it possible that a woman who is 'unobserved' (read bright
> lights and strangers looking intently at the business end - M Odent talks
a
> lot about this) is more able to let go of her baby, and her muscles and
> skin go into a softer, more pliable state to let the baby make its way out
> of the birth passage? That's my theory.
> I think its simpler than that, just don't cut episiotomies, particularly
> routinely for operative vaginal birth. The epis rate at our regional
> hospital was 7.2% in 99, 6% last year and will be lower this year. Our
> "intact" rate was 55% in 99, 60% in 2000. This may rise simply by a
gradual
> change to not suturing first degree tears. We probably have less primips
> (36%) than the rest of the state (42%) which would account for some of
this
> high intact rate. Our third degree tear rate (ANY external anal sphincter
> involvement) is higher than state average, but I think this is
> ascertainment bias. Studies (see below) suggest there is much
underreporting
> of sphincter tears and I am paranoid about the sphincter being correctly
> identified and so repaired.
> (I think a PR must be done to properly assess any tear) We are planning a
> retrospective, then prospective audit of our third degree tears and
> follow-up to ascertain a rate of anal incontinence in a low epis
> environment.
> In this unselected population, the caesar rate is around 18% (falling) and
> operative vaginal birth rate about 12% (pretty stable).
> We have a fairly "traditional" model of GP or obstetrician-led public care
> here (though is more like private care as its in the country). We do have
a
> large midwifery input antenatally and intrapartum though.
> Listing the factors in no particular order that I believe help us with the
> low perineal damage rate are
> 1. Docs use vacuum over forceps
> 2. No routine epis for operative vag birth
> 3. Antenatal perineal massage encouraged
> 4. Low ( but climbing) epidural rate (10-15%)
> 5. Midwives catch most of the babies (but own doctor present)
> 6. No time limit in second stage (but listen after every contraction)
> 7. I always consider ppposition change than vacuum or post-anal pressure
> rather than epis if head very low and worrying FH
> 8. I could add - discourage the stranded beetle position. I'm sure the
> upright position encourages spont birth but I suspect it may encourage the
> head to sometimes "blast" out with a larger tear.
>
> Have a culture of (mostly) directed pushing which is probably not helpful.
> Also, I agree too much peri watching is unlikely to be helpful, and must
> certainly be a bit demeaning. We have almost no waterbirth - again
probably
> more a cultural thing than any specific directive against it.
>
> In regard to number 2, using 99 Victorian figures, if selective epis (lets
> say 10%) was used for operative vaginal birth, the episiotomy rate (+/-
> tear) in Vic would drop from 23.3% to 11.9%.
> The rcog website has great evidence-based guideline on perineal trauma and
> repair
> http://www.rcog.org.uk/guidelines/guideline29.html
> http://www.rcog.org.uk/guidelines/perineal.html
>
> David
>
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