Nevada Journal of Public Health Volume 4 Issue 1 Article 1 2007 Episiotomy and Obstetric Trauma in Nevada: Evidence from Linked Hospital Discharge and Birth Data Gulzar H. Shah National Association of Health Data Organizations, [email protected] Joseph A. Greenway University of Nevada, Las Vegas, [email protected] Wei Yang University of Nevada, Reno, [email protected] Follow this and additional works at: https://digitalscholarship.unlv.edu/njph Part of the Community-Based Research Commons, Medicine and Health Commons, Obstetrics and Gynecology Commons, and the Public Health Commons Recommended Citation Shah, Gulzar H.; Greenway, Joseph A.; and Yang, Wei (2007) "Episiotomy and Obstetric Trauma in Nevada: Evidence from Linked Hospital Discharge and Birth Data," Nevada Journal of Public Health: Vol. 4 : Iss. 1 , Article 1. Available at: https://digitalscholarship.unlv.edu/njph/vol4/iss1/1 This Article is protected by copyright and/or related rights. 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We wish to acknowledge Wu Xu, PhD, and Pamela Clarkson Freeman, PhD of Utah Department of Health, and Denise Love, MBA, BSN, Executive Director NAHDO, for their valuable guidance and contribution on design and other aspects of this study. This article is available in Nevada Journal of Public Health: https://digitalscholarship.unlv.edu/njph/vol4/iss1/1 Journal of the Nevada Public Health Association, Vol. 4, Issue 1, Shah et al. 1 Episiotomy and Obstetric Trauma in Nevada: prevent tears of the perineal muscles. The notion that Evidence from Linked Hospital Discharge and episiotomies prevent third and/or fourth degree tears Birth Data of the perineum, or protect the pelvic floor, has been repeatedly questioned. Previous research shows that Gulzar H. Shah, M. Stat, M.S.S., Ph.D. although episiotomy may prevent lacerations and Joseph A. Greenway trauma in certain cases, the procedure is performed Wei Yang, M.D., Ph.D unnecessarily in many cases, doing more harm than good (Eason, Labrecque, Wells & Feldman, 2000; Abstract Woolley, 1995). Based on the perception that episiotomy This research examines the relationship prevents obstetric trauma, the procedure is liberally between episiotomy and birth trauma. Obstetric performed in U.S. Hospitals. Using linked Nevada trauma was defined as third or fourth degree Birth Registry and Nevada Impatient Hospital lacerations as proposed by the Agency for Healthcare Discharges (2000 to 2005), we applied descriptive Quality and Research’s (AHRQ) Patient Safety analyses and logistic regression to examine the status Indicators (PSIs) 18 and 19. While a laceration is of Nevada episiotomy practice and its impact on birth defined as “a cut, tear, or ragged opening in the skin trauma for mothers. Of 106,461 vaginal live births, caused by an injury or trauma”, (Yale Medical rd th 26,383 (24.8%) episiotomies were conducted. Group, 2007) the 3 and 4 degree lacerations in our Obstetric trauma rate declined from 5.2% of vaginal study refer to more serious tears including those in deliveries in 2000 to 4.4% in 2005. After statistically the soft tissue, defined by ICD-9-CM codes in 1 controlling for the effect of other risk factors, zero hospital discharge data (Agency for Healthcare parity, episiotomy, other instrument assisted Research and Quality, 2007). The primary purpose of deliveries, non-MDs as birth attendants, rural this research was to test the research hypothesis that hospitals, urban county residences, and non-teaching Episiotomy does not necessarily prevent obstetric hospitals are associated with an elevated risk trauma; instead, it is associated with increased risk of obstetric trauma. We conclude that Nevada is on par obstetric trauma, measured by 3rd or 4th degree with the year over year decline in national episiotomy lacerations during child birth. The questions of rates. interest were, “What are some factors explaining Key words: Episiotomy, obstetric trauma, variation in episiotomy in Nevada hospitals, and how lacerations, Nevada Inpatient Hospital Discharge do episiotomies and other characteristics of hospitals Data and births impact obstetric and trauma?” Author Information RELATIONSHIP BETWEEN EPISIOTOMY Gulzar H. Shah, M. Stat, M.S.S., Ph.D. is Director AND OBSTETRIC TRAUMA of Research at the National Association of Health An episiotomy is generally performed to Data Organizations (NAHDO), 448 E, 400 S, Ste prevent tears of the perineal muscles. For most of the 301, Slat Lake City, Utah, 84111, Phone: 801-532 twentieth century, the routine use of episiotomy was 2282; email [email protected]; [email protected] believed to have multiple benefits for both mother Joseph A. Greenway, is Director, Center for Health and infant. The earlier literature available on this Information Analysis, University of Nevada at Las subject, though not empirically sound, supported the Vegas. use of universal episiotomy at delivery as the method Wei Yang, M.D., Ph.D. is Professor of Epidemiology for preserving perineal function (see, e.g., Pomeroy, and Biostatistics, School of Public Health, University 1918; DeLee, 1920; Gainey, 1943). Episiotomy is of Nevada, Reno justified on several grounds, most of which has been challenged recently. First, it is believed to prevent Acknowledgements pelvic floor function (Klein, 1994), but studies have This research was funded by Agency for Healthcare shown that in this regard, episiotomy itself is a major Research and Quality (AHRQ) grant # R24 HS11844-05 “Intermountain BRIC Consortium”. We 1 wish to acknowledge Wu Xu, PhD, and Pamela The definition of 3rd and 4th degree obstetric lacerations Clarkson Freeman, PhD of Utah Department of proposed by AHRQ and used in this research include: ICD- Health, and Denise Love, MBA, BSN, Executive 9: 66420,1,4 and 66430,1,4 (TRAUMA TO PERINEUM AND Director NAHDO, for their valuable guidance and VULVA DURING DELIVERY, THIRD DEGREE PERINEAL LACERATION); and (TRAUMA TO PERINEUM AND VULVA contribution on design and other aspects of this study. DURING DELIVERY, FOURTH DEGREE PERINEAL Introduction LACERATION) Episiotomy, a surgical incision of the mother’s perineum performed at birth, is perceived to 1 Journal of the Nevada Public Health Association, Vol. 4, Issue 1, Shah et al. 2 source of injury in that it cuts muscles and nerves of pelvic relaxation, most notably stress incontinence, (Signorello, et al., 2000; Signorello, Harlow, Chekos based on perineal condition following childbirth. & Repke, 2001). Here, the ‘pelvic floor function’ In a comprehensive review of literature refers to the ability of muscles supporting the pelvic conducted since 1980, Woolley (1995) concluded organs to perform activities such as urinating, having that there was no evidence that episiotomy reduces bowel movements, and sexual intercourse, in the normal loss of pelvic floor muscle strength coordination with bladder and rectum muscles. usually experienced after vaginal delivery. Studies Secondly, episiotomies are supposed to reduce since then have shown that episiotomy is actually delivery-related pain but a recent systematic review perilous in that it increases the rate of perineal of major studies of episiotomy from 1950 to 2004 infection, blood loss, pain during healing, and risk of rejects that claim (Viswanathan, Hartmann, Palmieri, injury to the anal sphincter. It is argued that allowing 2005). Third, some episiotomies are done for the perineum to tear on its own results in less pain facilitating the healing & recovery process. However after childbirth than an episiotomy, and that women research shows that deep tears caused by who don’t tear, or who tear naturally, resume sexual episiotomies are actually more difficult to repair than relations sooner than women with episiotomies the minor ones that may occur when no episiotomy is (Rockner, Henningsson, Wahlberg & Olund, 1988; done (McGuiness, Norr & Nacion, 1991). Fourth, Simpson, Thorman, 2005). episiotomy before operative vaginal delivery is In 2005, a major government review of advocated for facilitating instrument assisted episiotomy concluded that the benefits of the deliveries, in particular with forceps (Ecker, 1997; procedure don’t outweigh the harm (Viswanathan, Helwig, Thorp & Bowes, 1993; Thompson, 1987). Hartmann & Palmieri, 2005). Nonetheless, Yet the use of episiotomy in cases of vacuum episiotomy is still routinely performed, with 716,000 extraction also increases the likelihood of severe performed in 2003 in the United States (National perineal trauma (Robinson, Norwitz, Cohen, Hospital Discharge Survey, 2003). While some McElrath & Lieberman, 1999). Fifth, the use of episiotomies may still be medically necessary, the episiotomy is usually recommended when shoulder