Episiotomy: a medicolegal vicious cycle.

The present study aimed to analyze the litigation trends and ensuing compensatory damages brought about by the use of episiotomy, in order to outline a set of cautionary rules meant to limit the scope of legreal aftermath for both doctors and health care facilities. The authors have set out to gain an insight into the controversial practice of episiotomy, in light of available research data and official positions of various scientific and medical associations, with a close focus on the legal and medical viability of the procedure itself. Court data and trial records have been taken into account as well, via searches into legal databases and search engines (Justia, Lexis, Jurist.org, Venice Courthouse, etc.). This review showed that most episiotomy-related lawsuits stemmed from a routine use of that procedure, which is almost universally advised against, and without valid informed consent having been gained. Ultimately, authors have seen fit to underscore the need for patients potentially eligible for an episiotomy (selective episiotomy) to receive thorough and understandable information in a timely fashion including the necessity and the effectiveness of the procedure as well as the risks involved, so that a well-informed decision can be made based on factual data.

Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury?

PURPOSE: Our main objective was to investigate whether the implementation of a restrictive episiotomy policy in operative deliveries changes the incidence of obstetric anal sphincter injury (OASI). METHODS: This is an observational study over an 11-year period in Poitiers University Maternity, France. We included women with vaginal operative deliveries after 34 gestational weeks for singleton births in cephalic presentation. We collected data on the mother and operative delivery characteristics: indication, instrument, epidural analgesia, labor length, episiotomy, OASI, and birthweight. We investigated the changes in the mediolateral episiotomy (MLE) and OASI rates and the association between MLE and OASI. The primary outcome was the evolution of the OASI and MLE rates. The secondary outcome was the occurrence of OASI during operative delivery with or without MLE. RESULTS: In total, 2357 operative deliveries were assessed, including 847 vacuum-, 1350 forceps- and 160 spatula-assisted deliveries. Of these, 950 were performed with MLE and 1407 without; 37 OASIs (3.9%) occurred in the MLE group, and 137 (9.7%) in the no-MLE group. Between 2005 and 2015, MLE use decreased from 78.5 to 16.2% and OASI occurrence increased from 3.1 to 12.7%. The increase in OASI occurrence was significant for forceps deliveries, but not for vacuum or spatula deliveries. Operative delivery with MLE was associated with a three times lower OASI occurrence than that without MLE (adjusted OR = 0.29, 95% CI [0.20-0.43]). CONCLUSIONS: Implementation of a restrictive MLE policy for operative delivery seems to be associated with an increase in OASI incidence with forceps, but not with vacuum.

Does episiotomy always equate violence in obstetrics? Routine and selective episiotomy in obstetric practice and legal questions.

OBJECTIVE: The study's main goal is to figure out whether episiotomy, a widely applied invasive procedure, may constitute a determining factor of liability for practitioners according to the standards of obstetric violence. MATERIALS AND METHODS: The authors have aimed to analyze laws and documentation issued on the matter by sovereign states, statements and remarks from International health organizations, in addition to scientific article available on the main search engines (PubMed, Scopus, Google Scholar) and legal databases (Lexis, Justia). RESULTS: The body of research has highlighted the existence of a wide-ranging agreement as to routine episiotomy, deemed to be a scientifically unfounded procedure, and which should, therefore, be avoided. By virtue of that, routine episiotomy might easily give rise to charges and liability for doctors and midwives alike; likewise to claims may stem from a failure to perform an episiotomy when it was actually needed. CONCLUSIONS: Unlike routine episiotomy, selective episiotomy is far more unlikely to cause charges of obstetric violence against operators. Unfortunately, the criteria in order to establish when a selective episiotomy is indicated are far from consistent and would require an additional effort on the part of scientific societies towards a more clearly defined and shared description.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.

Is the policy of restrictive episiotomy generalisable? A prospective observational study.

OBJECTIVE: To assess whether the policy of restrictive episiotomy could be safely implemented in Chinese population, and whether perineal length was related to risk of perineal tear during spontaneous vaginal delivery. METHODS: A prospective observational study was conducted between November 2007 and February 2008. A restrictive approach of episiotomy was implemented in those Chinese women who carried an uncomplicated singleton cephalic presenting pregnancy in labour. Perineal length (PL) was measured at three time points: (A) at early first stage of labour; (B) at the beginning of the second stage; (C) at crowning. Women with and without perineal tears were compared with reference to PL measured at different stages and its stretching performance (defined by the change in PL between different stages). RESULTS: Among the 429 women recruited, mean PL at point A, B and C was 38.8 mm (+/-7.9), 49.4 mm (+/-8.1) and 59.4 mm (+/-9.4), respectively, which were similar to those reported in other countries. Episiotomy rate reduced from 73.3 to 26.8%. Among the non-episiotomy group, 13.7% had no perineal tear, 86.3% had minor (first or second degree) tears but none had major tears, whilst 3.5% and 0.9% of episiotomy group had minor and major tears, respectively. PL was not associated with the risk of perineal tear. CONCLUSIONS: Restrictive episiotomy reduces the episiotomy rate without compromising the perineal safety. Chinese women's PL is not shorter than other races, or is predictive of perineal tears.