Monday, May 03, 2010

From routine episiotomy to routine caesarean

It's not easy to challenge accepted culture.

Dr Michael C Klein is a Canadian family physician who has challenged the accepted culture of routine episiotomy. I heard him speak on the topic at the Women's in Melbourne, probably 10 or more years ago. Recently Klein has published an article with the title From routine episiotomy to routine cesarean section: HOW SOCIETY CAME FROM REJECTING ONE TO EMBRACING ANOTHER. The link will take you to the article. Here are a few excerpts.

Klein writes:
"My views about episiotomy were formed by an experience in the early 1960s in Ethiopia, where I worked with midwives who attended births without routine use of episiotomy. Twenty years later while on sabbatical at Oxford University, I collaborated with midwives who rarely employed episiotomy yet obtained good results. Back in my usual setting in Montreal, our family practice maternity group employed the techniques and approaches that I had learned in England.
Our episiotomy rate was less than twenty-percent while the institutional rate was in excess of sixty-percent overall and greater than eighty-percent among women experiencing their first birth."
...
"In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment. The place of episiotomy in this model was clear. In fact, labour can be slightly shortened by employing episiotomy. Those who felt this procedure was important often expressed concern about the negative effects of birth without episiotomy. In the absence of episiotomy, they were concerned about pressure on the fetal brain, maternal soft tissue support, and subsequent pelvic floor function, including delayed morbidity–such as urinary incontinence. Keep in mind that such thinking characterizes the thinking of the current proponents of elective Cesarean section."
...
"It turned out that episiotomy caused the very trauma that it was supposed to prevent, and those practitioners with the highest episiotomy rates had the highest rates of virtually all other procedures as well."
...
"Reconciliation of differing and often confusing views about normal childbirth among the maternity care disciplines and women is essential for the benefit of women and their families."
...
"Next Steps: At the age of almost seventy-two, I have now decided, along with my multidisciplinary colleagues, that we know pretty much what is going on in practice, education and training. And to correct the faults that have led to many of the problems uncovered will not be easy.
We cannot fiddle with such a flawed system and expect to improve it. But in the next few years, the dearth of obstetricians, family physicians and midwives available to serve pregnant and laboring women, will make it necessary to come up with major creative solutions. This will need to include new collaborative models of care, new interdisciplinary practice and teaching models, new financial arrangements and a whole new way of helping us partner with pregnant women in a way that supports and honors rather than frightens them. And of course we will have to control our own fears and anxieties or we will be unable to make the needed changes in a system that is poised to collapse.
Governments, policy-makers and educators will have to be helped to appreciate the ultimate financial and human costs to which the current path leads. It is rare to be able to help make a change that is both the right thing to do while also saving money for the system.
Hopefully we will not only study change but help make the changes that we will study."

1 comment:

Joy Johnston said...

I wonder if other readers raised their critical eyebrows at the statement "In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment."

That pretty welll describes the majority of professional maternity care providers (doctors and midwives) in Australia today. The skill of working in harmony with our bodies' natural processes in childbearing is almost a lost art in midwifery, and I doubt it is even recognised as useful in obstetrics.

I wonder if the mainstream birthing culture has changed in Canada since the 1980s?