String of ACOG press releases support normal birth.
ACOG News Release March 31, 2006
ACOG Recommends Restricted Use of Episiotomies
Washington, DC -- The use of episiotomy during labor should be restricted, with physicians encouraged to use clinical judgment to decide when the procedure is necessary, according to a new Practice Bulletin published by The American College of Obstetricians and Gynecologists (ACOG) in the April issue of Obstetrics & Gynecology. According to ACOG, "The best available data do not support the liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries."
Episiotomy is a surgical incision made into the perineum--the region between the vagina and the anus--to widen the vaginal opening for delivery. Episiotomy was performed in more than one-fourth of all vaginal deliveries in 2002. Although rates of episiotomy have decreased in recent years, it is still one of the most commonly performed procedures in obstetrics.
Recent studies show that common indications for episiotomy were based on limited data. Additionally, there was a general underestimation of potential adverse consequences associated with the procedure, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and painful sex. Data suggest that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one. Without sufficient data to develop evidence-based criteria for performing episiotomies, clinical judgment remains the best guide to determine when its use is warranted, according to ACOG.
Historically, the procedure has been indicated in circumstances such as abnormal labor progression, non-reassuring fetal heart rate pattern, vacuum- or forceps-assisted vaginal delivery, and shoulder dystocia. It also was believed to hasten the second stage of labor and reduce the risk of spontaneous perineal tearing, subsequent pelvic floor dysfunction, urinary and fecal incontinence, and sexual dysfunction.
"In the case of episiotomy, as with all medical and surgical therapies, we need to continually evaluate what we do and make appropriate changes based on the best and most current evidence available," said the document's author, ACOG Fellow John T. Repke, MD. "We should avoid the pitfall of letting anything in medicine become 'routine' and therefore, outside the realm of review and critical analysis."
Practice Bulletin #71, "Episiotomy," is published in the April 2006 issue of Obstetrics & Gynecology.
ACOG News Release November 30, 2005
Vaginal Birth Not Associated With Incontinence Later in Life
Washington, DC -- Contrary to the belief held by some, vaginal birth does not appear to be associated with incontinence later in life, a new study has found. The study, published in the December 2005 issue of Obstetrics & Gynecology, found that incontinence was more strongly related with family history.
An estimated 30-50% of adult women suffer from urinary incontinence, and vaginal delivery is often considered to be the major risk factor for stress urinary incontinence. While 62% of urogynecologists previously surveyed would support performing elective cesarean deliveries to prevent incontinence in the long term, the benefit of this practice has not been proven. Risk factors for incontinence include body mass index, hypertension, and integrity of the pelvic floor, all of which tend to run in families.
Researchers from the University of Rochester Medical Center in New York studied 143 pairs of biological sisters. All of the women were at least 45 years old and postmenopausal. All but two pairs of sisters were Caucasian. However, one sister of each pair was nulliparous (no deliveries) and one was parous (at least one vaginal delivery). The women answered questionnaires and underwent clinical testing to measure incontinence.
The researchers found that the rate of incontinence was 47.6% for nulliparous women and 49.7% for parous women, a statistically insignificant difference. They did discover, however, that 63% of the pairs shared continence status (i.e. either both were continent or both were incontinent). The researchers say that their findings run contrary to the conventional wisdom that nulliparity protects against incontinence and are similar to findings from their earlier study of nuns who had never given birth and yet still had high rates of postmenopausal incontinence.
While further research is needed to determine if there is a genetic component to incontinence, the researchers say that this study indicates that family history is more strongly associated with incontinence than a history of vaginal delivery.
ACOG New Release November 30, 2005
Research Finds 40% of Pregnancy-Related Deaths Potentially Preventable
Washington, DC -- The overall maternal mortality rate in the US is not as low as it could be, according to a review of pregnancy-related deaths published in the December issue of Obstetrics & Gynecology. The review found that 40% of all pregnancy-related deaths in North Carolina from 1995-1999 were potentially preventable. Worldwide, complications of pregnancy are a major source of mortality among women. Although the US saw a 99% reduction in maternal death during the 20th century, 29 developed nations still have lower maternal mortality rates.
The North Carolina Pregnancy-Related Mortality Review Committee examined 108 cases in which death occurred within one year of the end of the pregnancy and was caused by the pregnancy or its treatment. The study found that 41 of these deaths may have been averted by one or more changes in the health care or counseling provided or by changes in patient actions. Results suggest that lack of preconception care, patient actions, failures in the health care system, and a substandard quality of care were the four main contributors in the preventable deaths.
In cases involving lack of preconception care, there was no evidence that women with serious medical conditions were counseled about the risks of pregnancy before becoming pregnant. Patient actions contributed to mortality when women did not follow medical advice, failed to follow up with care or recommended therapies, or failed to seek care in a timely fashion. In some instances, failures in the health care system led to inadequate planning for patient follow-up or transfer. Quality of care contributed to mortality when the care provided was below expectations for the level of facility in question.
Preventable causes included hemorrhage, pregnancy-induced hypertension, and complications of chronic disease (e.g. cardiovascular disease). Deaths from conditions such as amniotic fluid embolism were not considered preventable. Researchers suggest more comprehensive study of maternal mortality cases and an open dialogue among clinicians to develop strategies that will continue to make pregnancy even safer for US women.