Atraumatic childbirth: is it a utopia?

Excerpt

As reported by the Royal College of Obstetrician and Gynecologists (RCOG) Guidelines in the UK, it is estimated that > 85% of women who have a vaginal birth will sustain some degree of perineal trauma, and of these 60–70% will experience suturing. Obstetric Anal Sphincter Injuries (OASIs) represent the most severe form of perineal tears [1‐3]. An alarming fact is that the incidence of OASIs in the UK and other Europeans Countries has tripled (from 1.8 to 5.9%) in the last decade, with inevitable consequences for women’s health and quality of life [4, 5]. Certainly, this rising rate could be explained by better recognition of OASIs, although the increasing recourse to instrumental delivery and the use of a “hands-off” approach at delivery have played an important role in this growth. In this scenario, the questions are: Can we deliver better? Is perineal trauma inevitable during vaginal delivery? Unfortunately, complete perineum protection during vaginal childbirth remains an ideal. However, it is possible to act on the preventable risk factors for perineal trauma, especially those related to the second stage of labor. This moment is crucial for the onset of pelvic floor dysfunctions (PFDs). Care should be taken following good obstetric practice regarding times and modalities. But what does good obstetric practice mean? It has been widely demonstrated that operative vaginal delivery (OVD) is associated with significantly higher risk of OASIs, resulting in long-lasting PFDs, such as anal incontinence and pelvic organ prolapse. In case of obstetric emergencies and fetal distress, when OVD is unavoidable, a mediolateral episiotomy (MLE) 60° to the midline should be considered. In fact, it has been reported that the use of MLE is associated with a five- to tenfold reduction in the rate of OASIs in both primi- and multiparous women [5‐7]. …