EPISIOTOMÍA - PROCEDIMIENTOS Y TÉCNICAS DE REPARACIÓN

The first use of an episiotomy to facilitate the delivery of an infant is lost in the past. Whether ancient midwives or birth attendants used primitive knives has been questioned for years. Perhaps they did or perhaps they did not. What is known, however, is that intentional incision of the perineum was not practiced as a routine procedure until the 20th century.

Treatises o n management o f the perineum as the fetal head emerges at the time o f delivery focused o n protecting against tears and lacerations. In the 1700s, the usual description o f a delivery o f the infant’s head concentrated o n preserving the intact perineum by allowing a slow, controlled dilation and delivery by exerting pressure o n the perineum (1).

In 1828, Ferdinand von Ritgen described a similar maneuver for easing the head over an intact perineum (2). His procedure, which he modified to use extension rather than flexion of the head, also was designed to prevent trauma to the perineum while facilitating the delivery (3). This was accomplished by placing the examiner’s fingers on the perineal body and gently pushing the head from flexion to extension.

This maneuver is still performed in deliveries today and is known as the Ritgen maneuver. Although procedures for increasing the size of the vaginal outlet may have been used in the United States by Native Americans, immigrant midwives, or others, the first reported use was in Virginia in 1852 (4). However, there is little evidence that it gained any regional or widespread acceptance as part of a vaginal delivery.

In 1893, Karl August Schuchardt, preparing to perform a vaginal  approach to excision of a large cervical cancer, performed a medilateral incision of the perineum to obtain additional exposure (5). He reported on this procedure to increase exposure in the same year. In his report, he described incision in the mediolateral tissue and muscles with much the same anatomical detail we would use today. Although he never used the word “episiotomy,” the procedure would be called

gynecologic episiotomy today.

J. B. Delee usually is credited with popularizing the use of the episiotomy when he became the champion for the use of forceps to protect the fetal head during delivery (6). He felt strongly that use of the forceps always should be accompanied by an episiotomy to prevent damage to the pelvic floor. Because of Delee’s stature in the field of obstetrics, his premise rapidly became accepted by U.S. obstetricians. 

As more and more women gave birth in hospitals rather than homes, episiotomy became the rule rather than the exception. The  lithotomy position, especially if extreme, actually accentuated the tightening of the perineal opening and further contributed to the perceived need for a surgical approach to increase the vaginal opening. This procedure, which began as a mediolateral approach, slowly evolved in the United States during the 1950s and 1960s to predominantly a midline procedure.

The purpose of the procedure, which was explained to residents year after year, was to facilitate the second stage of labor. It also was reported to reduce perianal trauma, pelvic floor dysfunction and prolapse, urinary and fecal incontinence, and sexual dysfunction. Benefits to the fetus were a shortened second stage and less potential trauma to the fetal head. 

In the 1970s and 1980s, however, obstetricians began to question the validity of the concept of protecting the perineum and the benefits related to “routine episiotomy.” In 1981, the National Childbirth Trust in London published a study that questioned the use of episiotomy asa routine  procedure (7). This led to further review and questioning of routine use of episiotomy for vaginal delivery given that there was little evidence to support the reported benefits. Today, episiotomy is still the most common surgical procedure performed by most obstetricians; however, it is much less common  than in the 20th century. In 2003, 716,000 episiotomies were performed in the United States, whereas 11 years earlier, more than 1.6 million episiotomies were performed (8, 9) (see table). It most often is used in women who are having their first child and less frequently used with later children.

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Edición: 2007
Idioma: Ingles

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