THE PRACTICE OF EPISIOTOMY: A QUALITATIVE DESCRIPTIVE STUDY ON PERCEPTIONS OF A GROUP OF WOMEN

Chang Yi Wey1, Natália Rejane Salim2, Hudson Pires de Oliveira Santos Junior3, Dulce Maria Rosa Gualda4

1. Hospital Universitário, Universidade de São Paulo
2,3,4. Escola de Enfermagem, Universidade de São Paulo

ABSTRACT:

This study set out to understand the experiences and perceptions of women from the practices of episiotomy during labor. This is a qualitative descriptive approach, performed in a school hospital in São Paulo, which data were collected through interviews with the participation of 35 women, who experienced and not episiotomy in labor. The thematic analysis shows these categories: Depends the size of the baby facilitates the childbirth; Depends each woman; The woman is not open; and Episiotomy is not necessary. The results allowed that there is lack of clarification and knowledge regarding this practice, which makes the role of decision ends up in the professionals’ hands. To sum up, it is important to the professional knowledge about scientific evidences; awareness linked to the rights of users and respects their individuality.

Keywords: episiotomy; delivery of health care; obstetrical nursing.

INTRODUCTION

Throughout the different historical moments of care assistance, the practices of care for women in labor have been changing. The institutionalization of labor in the last century brought about a range of routine procedures, which resulted in the medicalization of the birth process.

The indescribable picture of the use of these procedures and the large number of unnecessary interventions with a negative impact on perinatal morbimortality has led to the reflection on the obstetrical practice from the perspective of evidence-based medicine, which proposes judicious, conscious and explicit use of successful practices in order to guide the decisions taken in individual services^(1-2).

In Brazil, the Ministry of Health's recommendations seek to promote evidence-based obstetric practice as a professional and necessary commitment to health promotion⁽³⁾, whose guidelines are in accordance with the recommendations of the World Health Organization (WHO), among which the guide "Care in Normal Labor: a practical guide"⁽¹⁾.

This publication presents a set of practices aimed at promoting healthy labor and delivery and also the prevention of maternal and perinatal mortality. Care practices are categorized into the following groups: A) relating to practices that are currently used and should be encouraged; B) practices considered ineffective that should be abandoned; C) practices that are currently used, but need to be more deeply studied and thus should be used with caution; and D) practices that are used frequently but considered inappropriate⁽¹⁾. Among the items that constitute this last category, we highlight the item "Routine use of episiotomy," which is the object of this study. 

Episiotomy is characterized by a perineal incision, in order to enlarge the vulva, establishing itself as a practice of routine used in childbirth. The recommendation of the World Health Organization is a restricted use of episiotomy, without exceeding the rate of 10% of cases, and being only indicated in cases of signs of fetal distress; insufficient labor progress; the threat of third-degree tear (including third degree laceration in previous delivery) ⁽¹⁾.

Scientific evidences show that the routine use of episiotomy is associated with several side effects such as section or extension of the section to the anal sphincter, unsatisfactory anatomic results, vaginal prolapse, rectal vaginal fistula, increase in blood loss and bruising, pain and swelling, infection and dehiscence and sexual dysfunction. Nevertheless, proper and restrict use presents good results such as lower risk of vaginal and perineal trauma, less healing complications, urinary incontinence, dyspareunia and others⁽¹⁾. 

However, the use of episiotomy without clinical recommendation is still a common practice. Studies show that health professionals remain rooted in concepts that differ from scientific evidence-based results. What’s more, the professionals don’t explain the medical procedures to the women and their families, which shows disrespect for citizenship, for without knowing the implications and the scientific evidence supporting each procedure, women are unable to decide on clinical management and become dependent on the professional decision⁽⁴⁾. 

Thus, the importance of integration between research evidence and clinical experience along with the professional and the patient's values⁽²⁾ led us to conduct this study in order to understand women's perceptions about the episiotomy, so as to deepen awareness of the care assistance process, promoting the elimination of barriers to the implementation of an adequate scientific and humanistic care.

METODOLOGY

A qualitative descriptive approach was preferred because it enables not only to capture the way people think and react to the issues aforementioned, but also to know people's experiences, the meaning, description and interpretation given to their experiences in a particular process and context. 

This research was carried out in the Rooming-in section (AC) of the Hospital of the University of São Paulo (HU-USP), which is included in the Brazilian Unified Health System (SUS), and is considered an institution of excellence for the basic health units belonging to the Coordination Health of the sub-city hall of Butantã, in the west zone of São Paulo. 

Inclusion criteria for participants were established as followed: women who had vaginal child delivery in the HU-USP and underwent episiotomy procedure. The exclusion criteria adopted were: women with postpartum complications and lack of willingness to participate in the study. To compose the group of participants, the researchers first checked the list of women in the maternity hospital who had had vaginal deliveries. On the process of checking the records, it was found that these women had had vaginal delivery with episiotomy in current or previous childbirth, and this fact was also personally confirmed by the mothers. 

The group of participants in this study consisted of 35 women, identified under the symbols E1 to E35 in the body of the text so as to ensure anonymity. Of the 35 participants, 24 had undergone episiotomy in the previous delivery and 08 respondents had undergone this intervention in the current hospitalization, concurrently with the period of data collection in this study. The contributors’ age ranged from 22 to 41 years. The level of education ranges from elementary school to high school. Regarding marital status, most of participants answered that they were living in a consensual union. Regarding occupation, the majority of the respondents were working as professional housekeepers and sellers. 

Data were collected through interviews; the site used to carry out the interviews was a private room at the same AC, for it was a private place where the participants could freely express themselves. The interviews lasted an average of 40 minutes and were conducted by guiding questions, namely: Could you tell me how your child delivery was? Was it necessary to have to get cut down there (episiotomy)? In your opinion, what is this cut for? Who made the decision to make the cut? What did you think of this? Comparing to your previous childbirths, did you noticed any difference in terms of professional assistance service related to this procedure? 

After the transcription and re-reading the interviews’ content, they were analyzed in the light of the method of content analysis, thematic modality. The analysis identified several themes, among which are those related to the perception of the procedure of episiotomy. 

Regarding ethical criteria, the project was approved by the Ethics Committee in  Research  of  the  HU-USP, protocol No. 639/ 06, and complied  with the rules of

Resolution 196/96 and the Declaration of Helsinki.

RESULTS 

Data analysis allowed it to be grouped in four themes related to the practice of episiotomy, as follows: Depending on the size of the baby, it facilitates the delivery; depends on each woman; the woman doesn’t remain open; and, the episiotomy is not necessary. 

Depending on the size of the baby, it facilitates the delivery

Women relate the need to perform an episiotomy to the size of the baby: 

I think it depends on the baby, when it’s big, you have to have it cut, but when it’s small, there is no need to cut. I think this way! (E30).

Women associate the baby's size with possible difficulties at the moment of the baby expulsion; therefore believe that episiotomy enlarges the passage. 

In my viewpoint, the cut is there to help, to avoid the risk of the baby being too big to come out, or not having passage [...]. I do not know, I think that (E29). Depends on the size of the child, the way it lies down there, my baby was big, was born with 4.095gramas [...] (E34). 

Accordingly, there was a perception that the delivery without episiotomy imposes greater suffering to women. Child delivery without episiotomy is seen as an aggravating factor. 

I think it helps because it would be much harder if the woman had to do all the strength to push the baby out on her own, I tried to do it without having it cut down there, I was not enduring the pain and she wouldn’t come out. (E1) 

The performance of episiotomy was perceived as a good factor. Sometimes, due to fast labor, there isn’t enough time to perform this procedure and this fact creates fear in the mother.

I had it done in my first delivery, but in the second, we didn’t have time for anything. I thought it was good in my first childbirth. The cut must give a nice help! The second went very fast and mess it up a little bit, then the doctor had to use anesthesia and suture. In this case, I agree that the procedure should be done if necessary. I think having it cut helps. (E26) 

Depends on each woman 

The performance of episiotomy was perceived as a necessary intervention by some women, but not by others. 

I had it done in all my deliveries, I think there are some women who need the cut. And there're some that do not.  It depends on each woman. (E11)

I think some women do not need stitches; it will vary from each one. (E22)

Despite considering that is the woman's body what determines whether or not the episiotomy should be done, some participants said that the decision is in the hands of the professional. So, it’s the professional who evaluates and decides on the need for an episiotomy, justified by the belief that it would help speed up the delivery process.  Women have doubts about the need for episiotomy and remember that this procedure was not performed in the past. 

If they think it’s the best thing to do, they should do; it depends on the doctor. If he thinks the passage isn’t large enough, then he should cut it. It is the doctor who decides because when we are in pain, we can’t decide anything. Sometimes I think of the fact that nobody needed stitches before. Some women don’t need stitches because they have enough passage, but some need it because they don’t have passage. (E13)   

Another participant reported that she couldn’t understand why her friend had no need for episiotomy. Episiotomy was seen as an intervention that helped at the moment of delivery and, in the perception of this participant, it is done only in necessary situations. 

It's good to have it cut down there, it gives a little help. I have a friend who had four children, all under normal delivery and she needed no stitches, so I can’t explain the reason for that. I had 3 children and needed stitches and don’t know how someone has a normal delivery and still doesn’t need any stitches. She said it came out, and the body pain was over immediately after, she had just the normal bleeding. I think it’s done when it’s needed. Imagine if it wasn’t necessary at all? No one would do it then. That’s my opinion: if it’s necessary, then it should be done; if it is not, then it shouldn’t be done. (E16)                              

The justification given by professionals to perform the episiotomy was that the baby would not come out without this procedure. Discomfort and  impossibility of a faster recovery due to the realization of episiotomy was mentioned. 

I don’t like, I had less stitches in my first baby delivery, but this time the doctor said: "I will need to cut, it is necessary, otherwise it won’t pass through." It was bad, but if needed, it has to be done [...], it brings much discomfort and it takes long to heal. (E3) 

The woman doesn’t remain open

The women reported that the need for any kind of suture on the perineal region was always present, whether due to the episiotomy or to disruptions caused by the passing of the baby. The fact that a delivery doesn’t require any sutures caused surprise amongst the women due to the general belief in the impossibility of a baby delivery without any kind of rupture or tear in the mother’s perineum. The culture of episiotomy was so deeply rooted in these women’s mind that when a baby delivery occurs without the need for sutures, this is seen as an exception. 

I had 3 baby deliveries and needed stitches in all of them. Some women told me that they didn’t need stitches, I find a bit weird, because the fact is that the passing of the baby tears the mother. Are you going to remain with that open? I find a bit weird, can you imagine, a huge hole!! (E2) 

The belief that the woman "become enlarged" if there is no suture of the perineum after the delivery is also present. The absence of suture was seen as a possible problem in the future, due to multiparity. 

I think the cut helps. People from up North say that women who had children and had no sutures become enlarged, I don’t know how it happens [...]. A woman who has a lot of children and has a lowered womb became this way because she had no sutures. That’s way I think it’s a good thing to have sutures. (E9) 

Episiotomy is not necessary

In this category, in contrast to the perceptions presented so far, participants reported the practice of episiotomy as being unnecessary, claiming that they’d rather have normal delivery without this procedure, but didn’t feel confident enough to ask it to their doctor. The discomfort and pain caused by the episiotomy was reported, pointing to the fact that the performance of episiotomy did not bring the benefits touted.

It's very bad afterwards, one suffers a lot. At first I thought it would be better to have it cut, that it would help. But I don’t think so, because I delivered this one without need for sutures [...].(E4)                
In my second delivery, I had it cut, but it wasn’t necessary this time. I think it's better not to cut. It hurts a lot, it’s very uncomfortable whenever you put pads on. (E7) 

As I didn’t need suture this time, I'm great, I’m able to walk and push, then everyone is happy when no stitches are needed. It is much less uncomfortable. (E10) 

This respondent claimed to be against episiotomy, for the well-being of women. In addition to the suffering resulted from the procedure, the consequences of the episiorrhaphy were reported, namely the fear of the first postpartum evacuation and the fear of being pressed by doctors on hygiene matters.

I think it hurts a lot. It's another source of pain, I think it shouldn’t be cut, in my opinion. When having stitches, one has a lot of fear, fear of sneezing, of going to the toilet, then the doctor put pressure that you should evacuate in the bathroom. Then, in addition to that fear, there is also this commitment you have with your doctor. A thousand times better without stitches . Well, it was in my case! (E25) 

Contrary to some other perceptions, participants reported that the pain during childbirth was not mitigated by episiotomy and postpartum recovery without episiotomy is better. 

I had [the cut] in all my deliveries, except in the last one. I don’t think it should be done. At the time of childbirth it ends up being the same, it hurts just the same. No cut is a better option because we don’t have to suffer afterwards. It’s much better without stitches as it doesn’t hurt afterwards. (E33) 

Discomfort due to the presence of stitches in the perineal region was claimed and, in some cases, it had some side effects such as irritation or increase in sensitivity.

This time it didn’t need anything, without stitches is much better. Stitches make it uncomfortable to walk, sit, to put pads on, I myself, until today, feel the place where the other stitches were done, depending on the moon phase it itches, hurts, it looks like pimples that are going to inflame, and depending on the sanitary pad, it can causes allergy, so I think we are better off without it. (E19) 

Another issue raised was the lack of clarification on the procedures that were done at the time of delivery. Some participants did not know whether an episiotomy was done or whether it was a spontaneous rupture of the perineum, and they only noticed a greater discomfort during suturing. 

I only felt it when it was being stitched after the delivery because it started to hurt and I told them it was hurting. I don’t know if it was a spontaneous tear or if they cut it themselves, because it’s full of stitches and it hurts a bit. (E34) 
I only had normal deliveries, but no one has ever come to me to say: ‘I’ll cut a little’. I’ve never experienced that. I remember them saying, ‘listen mom, I will put a few stitches in’, I don’t know how it works; if it is cut or tears by itself. (E10) 

DISCUSSION 

The practice of episiotomy in childbirth has spread among the medical field and reached its apex in the mid-twentieth century. Initially, this procedure had a selective therapeutic use. Over the years it became a prophylactic intervention until it reached the status of a routine procedure, indicated mainly in primiparae⁽⁵⁾. 

Due to questions raised from the results of current scientific evidence, the tendency is to restrict the use of episiotomy. In other words, it should only be suggested after clinical indication by proper professional assessment of the perineal condition of the woman. Feminist movements have also influenced this trend towards the restriction of the procedure, defending the women’s rights to a greater autonomy over the process of parturition, as well as a change of attitude and position of women at child delivery⁽⁵⁾. 

However, the practice of episiotomy, as presented in this study, is still deeply rooted in the cultural universe of both professionals and users of hospitals. A change in this reality requires a great deal of investment in health awareness and education programs, along with government actions towards the promotion of humanization of health care. 

Research conducted through retrospective survey on medical records of the Obstetric Center of the HU-USP, during the period between April 2001 and April 2002, found the rate of episiotomy performed in 1837 normal deliveries to be 91.5%⁽⁶⁾. The finding of a decrease in the frequency of episiotomies in the institution is shown in a second survey conducted in 2006, which found a frequency of episiotomies performed in 1774 normal deliveries to be 44,7% in that year⁽⁷⁾. These rates are still well above those recommended by WHO, which are of 10%⁽¹⁾. 

In a study that also found high rates of episiotomy, the authors relate the result to the fact that the place studied was a teaching hospital, where educational purposes justify the episiotomy, as well as the abusive use of labor induction methods and maternal position during the third stage (supine) ⁽⁸⁾. However, in spite of being an educational institution in which students need to experience the procedure for developing manual dexterity, one cannot lose sight of the practice of episiotomy as a specific procedure and not an institutional routine. 

When episiotomy is indicated for all the primiparae and the multiparae with previous episiotomy, the procedure becomes hospital routine, being done in all child deliveries, without a proper analysis performed for each mother individually⁽⁸⁾. 

The participants of this study associated the need for episiotomy with the baby's size, as a way of facilitating the delivery and preventing the baby from tearing the perineal region. The women’s speeches reveal their fear of the enlargement of the vulva and the possibility of remaining open after the passing of the baby and, for this reason, believe that episiotomy should be performed.

Other participants think this practice should be linked to the particularities of each woman, taking into account their bodily differences and the fact that some of them have enough passage and others don’t, which would justify the intervention. 

As mentioned, the realization of episiotomy and the need for suturing in normal deliveries are still deeply related to these women perception towards childbirth care. The lack of further knowledge of the process generated insecurity, which caused them to neither question nor stand up for their rights. 

Only a few women reported that the procedure is not necessary and could be abolished. This opinion is justified by perineal pain and discomfort caused by the stitches during the postpartum period. Other participants had no opinion on the need for episiotomy, which shows that this decision ends up in the hands of professionals. 

The pain and discomfort in the puerperium was important for women who had episiotomies, because it affects their lives in daily activities and simple actions such as sitting down and standing up. A study of sexuality in the postpartum period shows that women who had undergone episiotomy had felt pain, discomfort and difficulties in returning to an active sex life⁽⁹⁾. 

A qualitative study on women's view about the episiotomy identified that the participants were not given information about the episiotomy at any time before delivery. Those who reported having some previous information, said it was gathered from friends and relatives who had experienced it. Women showed lack of awareness of the procedure’s indications and of their own bodies. The study also showed that the professionals have mastery over the body of the mother, which reveals the necessity to recover the women’s autonomy in the childbirth process⁽⁴⁾. 

It is imperative that professionals have their practices supported by scientific evidence, analyzing each case individually. It is important to search for alternatives to prevent perineal trauma, such as lateral position during the baby expulsion; spontaneous pushing as opposite to directed one; and reduction in the indiscriminate use of oxytocin⁽⁸⁾. 

In anthropology, theoretical aspects relating to the reports above have been widely discussed, under the name of authoritative knowledge. Derived from the biomedical model, the authoritative knowledge brings about the idea of superiority of the technical system, resulting in the standardization of professional conduct and discouraging any changes in ritualized rooted practices. These practices are communicated in meetings between professionals and their clients and are reinforced by the opinion which considers those people who don’t follow those practices to be ignorant, old-fashioned and also trouble makers⁽¹⁰⁾. 

This study has shown that some participants didn’t know whether they had undergone episiotomy, but only that they had been sutured. The lack of further information makes people trust the health professionals’ decisions, giving up their rights as users of health services. In addition to the lack of guidance throughout the care process, there is also the historical issue of the role expected from users of health services, which is to be the receiver of actions, not having any autonomy to decide on the conduction of their treatment. 

Technological development in childbirth care has increased throughout the world. The technical and scientific knowledge has brought advances to the woman health care field; however, there are abuses in the use of technology and devaluation of the beliefs of those who receive the intervention⁽⁵⁾. Current thoughts about decision making based on evidence have emphasized that the research evidence itself is not enough to guide appropriate action. Instead, professionals must apply their knowledge to assess the patient's problems, incorporating the results of research and patient preferences or values, so as to choose the best possible intervention.⁽²⁾                                                                                   

CONCLUSION

It is well known that the practices of the professionals who work directly in assisting child delivery must be supported by current scientific evidence. However, it is necessary to take into account the needs of each woman and to respect their wishes and their options in relation to the procedures to be carried out in the birth process. Thus, it is essential that women are well informed about best practices and feel empowered to participate in the process actively. It is important that professionals who work directly in obstetric assistance adopt the attitude of awareness promoters and disseminators of information. It comprises incorporating educational activities in professional practice; carrying out activities to assist the mother during prenatal care; being available to clarify their questions and helping them to become more aware of their bodies and thus, able to make their own choices.  

 Respect to physiology, promotion of safe child delivery and willingness to offer the woman a meaningful experience should be the bases of this care field. Changes in this scenario will only be possible if the health care users become aware of their rights, if professionals change their behavior and extensive information to the public about the physiological processes of childbirth become common practice. 

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Authors’ Contribution – The authors contributed to this study as follows: Chang Y. Wey (data collection, bibliographical research, conception and design, analysis and interpretation, article writing) Natália R. Salim e Hudson P.O. Santos Junior (analysis and interpretation and article), Dulce M.R. Gualda (conception and design, analysis and interpretation, article writing, critical review and final approval).