Marlène Schiappa’s statements have revived the debate around episiotomies. A working group of obstetrician-gynecologists is considering its indications.
The numbers are wrong, but the concerns are real. During her speech to the Senate, the Secretary of State for Gender Equality addressed the issue of episiotomy. A report has been commissioned on the relevance of this incision of the perineum during childbirth, which is the subject of both social and scientific controversy.
And Marlène Schiappa’s statements only added fuel to the fire. At the Luxembourg Palace, the Secretary of State mentioned “a rate of episiotomies at 75%, while the WHO recommends being around 20-25%”. An estimate that caused an uproar on the side of obstetrician-gynecologists and the learned societies that represent them.
But behind the statistics lies a reality. Not all establishments are equal when it comes to episiotomy. Two are distinguished by a particularly low rate of recourse to this surgical procedure, the CHUs of Poitiers (Vienne) and Besançon (Doubs). Which begs a question: Are episiotomies performed in hospitals still useful?
At the National College of French Obstetricians and Gynecologists (CNGOF), a working group is trying to answer this question. Professor Xavier Fritel, gynecologist-obstetrician at the Poitiers University Hospital, is one of them.
Why is an episiotomy performed?
Prof. Xavier Fritel : During a normal delivery, serious tears can occur, namely a tear of the anal sphincter – also called the complete perineum. This can cause, later, a risk of anal or fecal incontinence. It is not common but it can occur in 1 to 5% of first deliveries. The aim of the birth attendant is therefore to avoid them.
How to identify the women who will need it?
Prof. Xavier Fritel : The main factors are a first delivery, an instrumental delivery – using forceps or a suction cup – or the presence of a heavy baby. The discussion focuses on the cases that would need it. This debate is not settled since we lack the predictive factors of the serious tear, and we do not know much about them. The predictive value of the factors that we know remains poor.
In other words, it is difficult to identify before the end of childbirth which woman will have a tear, and which will not. Depending on the maternity prevention wish, or its obstetrical policy, there will be a lot of episiotomies or very few. I cannot scientifically and medically say who is right or wrong.
Is the usefulness of episiotomy proven?
Prof. Xavier Fritel : There is a controversy in the scientific community on the benefit provided by episiotomy. The debate around systematic episiotomy took place in the 1990s. The current consensus is that in the majority of cases you do not need to do an episiotomy. Current rates reflect this, and they have fallen significantly since the 1990s. The current debate is about unsafe childbirth.
We need to make progress in the area of predictive medicine, and particularly in preventing serious tears. The progress to be made is real. This may explain why opinions diverge. At present, it is difficult to predict this accident, and not everyone is convinced by the preventive role of episiotomy.
Can the opinion of the working group change this?
Prof. Xavier Fritel : Recommendations can change practices. But the main goal is to take stock of the science, to say what the existing proofs are. The question put to the task force is whether there is any evidence that would allow us to make recommendations. I don’t have the answer yet.
For my part, I work in an establishment that does very few episiotomies. But we wonder about the right indications, in particular during an instrumental extraction. The question arises of doing differently in this case. Scandinavian studies have observed, since the 90s, a very significant decrease in their rate of episiotomies but also a significant increase in the number of serious tears. This raises the question of the limit.
Can the debate change practices?
Prof. Xavier Fritel : I think it’s not productive. I saw this controversy as anathema against obstetricians. It was more accusatory than anything else. Doctors lead a scientific debate within learned societies. The work started with the professionals, and was scheduled before the Secretary of State spoke. We also have a debate with the patients, since the subject is discussed with pregnant women. They may ask not to have an episiotomy, we will explain to them why we may have to perform one. Generally, we are understood about our prevention approach.
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