Discouraged by experts, episiotomies still common in some hospitals
Since it was uploaded to YouTube, the video of Kimberly Turbin's 2013 episiotomy has been viewed more than 430,000 times. In the video, Turbin lies on her back in a hospital bed. Her knees are bent, her legs and feet are elevated above her in stirrups. She is trying to push the baby out.
"Push, push, push. Go, go, go," the nurse says.
A doctor walks into her room in Providence Tarzana Medical Center in California's San Fernando Valley. He pulls out a pair of sharp scissors.
"What are you doing?" Turbin asks, breathless, between contractions.
He tells her he is going to cut her perineum, a procedure known as an episiotomy.
"What? Why? We haven't even tried," Turbin cries. "No, don't cut me!"
"What do you mean, 'Why?'" the doctor responds, sounding increasingly irritated as Turbin continues to protest. "That's my reason. Listen: I am the expert here."
"You cannot fight with the doctor," Turbin's mother tells her daughter. "Just do it, doctor. Don't worry."
Then comes the audible sound of him snipping Turbin's flesh.
Episiotomy, a once-common childbirth procedure that involves cutting tissue between the vagina and anus to enlarge the vaginal opening, has been officially discouraged in most cases for a decade. Yet it is still being performed at much higher than recommended rates in certain hospitals and by certain doctors.
In 2006, the American College of Obstetricians and Gynecologists released a recommendation against routine use of episiotomy, finding that it benefited neither mothers nor babies. In 2008, the National Quality Forum also endorsed limiting the routine use of episiotomies. The procedure is still supported for use in certain emergency situations.
Nationally, and throughout California, the use of episiotomies has dropped significantly since the official recommendations came out - from 21 percent of all vaginal births in the state in 2005 to less than 12 percent in 2014.
That overall drop masks some giant disparities. A majority of the state's hospitals now have rates under 10 percent, according to state data. But a few, including Whittier Hospital Medical Center and Beverly Hospital, in Los Angeles, are performing the procedure in more than 60 percent of vaginal births. Neither hospital returned calls for comment.
"If you perform an episiotomy, you're more likely than not going to cause more postpartum pain and discomfort," said Dr. Alexander Friedman, an assistant clinical professor of obstetrics and gynecology at Columbia University Medical Center.
Friedman was the lead author of a 2015 JAMA report about the variation in episiotomy rates among hospitals nationally. While it's difficult to determine precisely what that rate should be, he said, it should likely be less than 10 percent.
As recently as the late 1970s, episiotomy was used in more than 60 percent of vaginal deliveries because doctors believed a clean incision made it easier to stitch up a woman and prevented overstretching of the muscles surrounding the vagina. In the past few decades, though, research began showing that the cuts were sometimes causing serious pain and injuries, including third- and fourth-degree lacerations, incontinence and sexual dysfunction. The cuts often proved slower to heal than a natural tear.
Armed with this information, many pregnant women started refusing the procedure, and most obstetricians stopped doing it routinely.
But some doctors are going against that trend.
Dr. Emiliano Chavira, a maternal and fetal medicine specialist at Dignity Health's California Hospital Medical Center in Los Angeles, lists three main reasons why he suspects some providers continue to perform routine episiotomies: They've always done them, they lack awareness of best practices or they want to speed up deliveries.
"Certain segments of the obstetric community are very slow to modernize the practice," he said. "They're very slow to abandon procedures that are not a benefit and, in fact, may be harmful. And it's really disappointing."
Such variation exists not only among providers, but among hospitals. Case in point: The Los Angeles hospital chain AHMC Healthcare Inc. Each of its six hospitals has continued to do episiotomies in more than 29 percent of vaginal births, according to state data. Two of them - Garfield Medical Center and Whittier Hospital Medical Center - have episiotomy rates close to 60 percent. Representatives of the chain and its hospitals did not return repeated calls and emails requesting comment.
By contrast, Kaiser hospitals have seen huge reductions in use of the procedure since the Oakland-based managed care organization undertook an intentional effort to address overuse.
Dr. Tracy Flanagan, director of women's health and maternity at Kaiser Permanente in Northern California, said her office began examining episiotomy rates at different hospitals four or five years ago. It first looked at rates at the hospital level, then at the physician level, she said.
"When we generated the data, we saw a lot of the variation and got to work on it," she said.
They sent the data to the individual hospitals. Then, doctors at each hospital who rarely performed episiotomies educated their colleagues about the appropriate use and risks.
Physicians tend to respond best if other physicians present them with a compelling argument to change their practices, Flanagan said. Reliable data, transparency and peer-to-peer education is a good recipe for narrowing variation, she said.
The average episiotomy rate for the Northern California Kaiser hospitals is now about 3 percent, she said. Zero percent would be too low, she added, since there are some cases where the procedure's use is indicated - if a baby's shoulder is stuck, if a baby's heart rate drops, or if the mother is exhausted and wants an episiotomy, for instance.
Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative at Stanford University, says the episiotomy data offer a lesson on how quickly practices can change. It also highlights the hospitals where doctors refuse to alter their ways, he said.
In the case of C-sections, doctors may be motivated to perform the procedures because they allow for faster deliveries or better pay, he said. But the main reason most doctors still perform episiotomies is because they always have done so, he said.
"It is always hard for people to relearn," Main said.
His organization is leading an effort to provide doctors and hospitals with data on certain childbirth practices to show them how they compare with their peers around the state. Beginning in 2010, they partnered with the March of Dimes to educate providers about the dangers of elective delivery prior to 39 weeks. Within three years, that practice had dropped off rapidly, he said. They are currently undertaking similar efforts related to C-sections.
Chavira, the maternal and fetal medicine specialist at California Hospital in Los Angeles, said he would like to see similar transparency with episiotomies.
"If you have a hospital where people are doing 5 percent episiotomies and one guy is doing 60 percent episiotomies, all of a sudden he sticks out like a sore thumb," he said.
A lot of women don't want the procedure, he noted, and doctors are supposed to honor their patients' wishes.
Turbin, a 29-year-old dental assistant who now lives in Stockton, is suing her former doctor, Alex Abassi, for assault and battery. In June, a judge ruled that the case could go to trial this fall. Citing cognitive impairment, Abassi surrendered his medical license last year. The executive director of the attorney's office representing Abassi declined to comment.
Since the episiotomy, Turbin said, "I had major, major, major, major pain."
She's afraid to go to the doctor now, she said, and she's terrified of getting pregnant again.
"If I go back to that day, there's nothing I could have done," she said. "That doctor was going to cut me no matter what."
©2016 Kaiser Health News
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