Rather than using routine episiotomy , obstetrician-gynecologists should take steps to lower the risk for obstetric lacerations during vaginal delivery , according to a new practice bulletin released by the American College of Obstetricians and Gynecologists. According to the American College of Obstetricians and Gynecologists ACOG , perineal massage, either antepartum or during the second stage of labor, can decrease muscular resistance and reduce the likelihood of laceration. The bulletin also recommends the use of warm compresses on the perineum during pushing to reduce third- and fourth-degree lacerations. The guidelines also note that such prophylactic interventions may also be beneficial for women with previous OASIS during future pregnancies. The bulletin also provides recommendations on the diagnosis of lacerations, preferred suturing technique, the use of antibiotics at the time of OASIS repair, pelvic floor exercises and long-term monitoring.
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Both of these recommendations have been classified as Level A based on good and consistent scientific evidence. This is an update from a prior practice bulletin, which had previously only focused on episiotomy, co-author Sara Cichowski, MD , told MedPage Today. A meta-analysis found significantly reduced third-degree and fourth-degree lacerations relative risk 0. The authors note that warm compresses "have been shown to be acceptable to patients. Perineal massage during the second stage of labor was also linked with a reduced risk of third-degree and fourth-degree tears compared with "hands off" the perineum, the authors wrote RR 0.
Studies on birthing positions had mixed results , with no clear consensus on any birthing position being associated with a reduced risk of lacerations or episiotomy. Similar results were seen for studies examining delayed pushing between 1 hour and 3 hours of full dilation. Restricted use of episiotomy is still recommended over routine use of episiotomy. Cichowski said that while overall rates of this procedure have fallen, there are some data to indicate there are regional differences, where some individual practitioners will routinely perform episiotomy.
Cichowski added that even in patients who have severe lacerations, such as obstetric anal sphincter injury, the vast majority could have a vaginal delivery in subsequent pregnancies.
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Although episiotomy is performed in approximately one third of vaginal births in the United States, prophylactic use of the procedure does not result in maternal or fetal benefit and should be restricted, according to a practice bulletin from the American College of Obstetricians and Gynecologists ACOG. Historically, the purpose of episiotomy was to facilitate completion of the second stage of labor to improve maternal and neonatal outcomes. Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor caused by a more rapid spontaneous delivery or from instrumented vaginal delivery.
ACOG Recommends Restricted Use of Episiotomies
Read terms. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes. Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth. The purpose of this document is to provide evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy. ACOG Clinical is designed for easy and convenient access to the latest clinical guidance for patient care. Figure 1.
ACOG: New Guidance to Prevent Vaginal Tearing During Delivery
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