Introduction
Evidence base practice is crucial in the health care of the patient. In fact, establishing the quality of care depend totality on evidence. To insure the important of evidence in practice, many studies have been done over the years. The research done in these studies gave the world a view about the importance of evidence based practice. Globally, it should be used as a standard in care given to patients. From this point, each nurse should be aware of how to link between traditionally practiced medicine and evidence based medicine.
Evidence base practice (EBP) has been established since the 1900s. The nurse researcher who created EBP was Florence Nightingale (Brown and Schmidt). During the Crimean War, Nightingale started to identify factors related to morbidity and mortality rates of British solders (Brown and Schmidt). Although there was an improvement in the nursing care through her findings, it took forty years for the nursing research to become relevant to nursing practice (Brown and Schmidt).
Evidence base practice defined as "the conscientious use of current best evidence in making decisions about patient care" (Fineout and Melnyk). Also, it is defined as an answer to a clinical question that is related to care given to the patient depending on experience and the patient's values and preferences (Ammouri.a. et al).
The importance of EBP is to improve the quality of care given to the patient (Fineout and Melnyk). Nurses should be advocates for their patients; that can be established by improving the knowledge and practice of her nursing practice (Brown and Schmidt). Also, nurses must gather the skills and knowledge necessary to improve the care they will give to the patients to an acceptable standard as stated by Holland and Rees.
The last 20 years has shown a critical improvement in implementing EBP in patient care as stated in Ammouri.a. et al. Furthermore, EBP is dependent on nursing research. With research, nurses will generate new knowledge that influences nursing practice (Brown and Schmidt). On the other hand, without research in nursing, nursing practice will depend on tradition, authority, trial and error, personal experience and borrowed evidence as stated by Brown and Schmidt.
Assignment Topic
In Oman, EBP plays a very important role in patient care, as mentioned in Oman Nursing and Midwifery Council. All care delivered to the patient must base the best practice that is supported by evidence. Ministry of Health (MOH) and Sultan Qaboos University (SQU) established a program to improve the quality of EBP in Oman. Qualified trainers were brought from different countries to train medical and nursing staff about EBP and its importance to the patient care (Ammouri.a. et al).
Furthermore, the MOH established a program to insure the quality of care given to the patient through Quality Assurance Standards. In this program, each health facility should follow this standard to insure the quality of care. It focused on teaching, research, self-directing learning, and critical appraisal to improve practice and health care given to the patient (quality assurance standards).
Moreover, Oman has a health vision plan called Health Vision 2050. This plan focuses on health improvement and the quality of care given to the patients. In vision 4, the goal is to enhance health system research (health vision 2050).
Despite all of the programs that have been implemented, there are many nurses in our hospitals who practice medicine as a matter of routine instead of using EBP. One of these practices is performing an episiotomy during childbirth in most cases as a matter of routine rather than emergency intervention. "Episiotomy is a surgical incision made with scissors or a scalpel into perineum in order to increase the diameter of the vulval outlet and facilitate delivery” (Arulkumaran.S and Warren.R). An episiotomy is also defined as a cut to the perineum to facilitate a large space to the baby to emerge (Cuerden and Macdonald).
In fact, most nurses have the idea that an episiotomy prevents injuries to the patient and fetus in the second stage of labor. As a result of this belief, routine episiotomies are done just to end the second stage quickly and safely without considering the future impact the episiotomy may have on the patient.
The use of episiotomy during second stage labor should be according to special circumstances, not just for routine use. Also, the patient has the right to know when and why the episiotomy must be performed as stated by Cuerden and Macdonald. Moreover, the belief that said episiotomy can prevent the perineal from anal sphincter is denied by recent studies; also episiotomies can affect the pelvic muscle strength and causing perineal pain and dyspareunia (Arulkumaran.S and Warren.R).
On the other hand, there are times an episiotomy is necessary. The use of an episiotomy should be only in complicated cases, such as fetal distress, forcep deliveries and shoulder dystocia for the purpose of preventing perineal trauma (Arulkumaran.S and Warren.R).
In Oman, as observed from experience, the use of episiotomies is a matter of routine rather than a necessary procedure, especially in nulliparous women. No clear statistics could be found for my hospital, but as found in the Annual Health Report 2013, 3.7% of total spontaneous vaginal deliveries had an episiotomy performed.
The aim of this assignment is to evaluate and assess the use of routine episiotomy as studied in published articles and research and compare it with practical performing in our hospitals among the nurses. The main focused point is to improve the health care given to the patient with minimum harm to her with supported evidence.
PICO is a clinical question asked by researchers to enhance a good answer for the purpose of good practice in health facility that provide care to the patient as stated by Fineout.E and Melnyk.B.
For the purpose of this assignment, the PICO is: In normal pregnant women at birth, does non-performing episiotomy compared to performing episiotomy reduce the incidence of perineal trauma?
P: The patient population we will be looking at is women who enter into labor naturally and have vaginal births.
I: Many of these women have intervention in the form of an episiotomy during stage 2 labor.
C: We will be comparing the outcomes of non-performing vs performing an episiotomy on women during stage 2 labor.
O: In order to determine the benefits versus issues of performing an episiotomy on women in stage 2 labor, we must examine perineal trauma after child birth in women who have had or not had an episiotomy.
Review of Literature
In order to find solid evidence several journal databases were used. These databases include the Wiley Online Library, Research Gate, Elsevier, Pub Med, New England Journal of Medicine and The American Journal of Medicine. The literature was searched for evidence about the possibility of an advantage to not receiving an episiotomy versus receiving one without medical need. We will look at the following:
Evidence for the Use of Routine Episiotomies
Evidence for the Non-Use of Routine Episiotomies.
Current Practices
Evidence for the Use of Routine Episiotomies
Räisänen, Vehviläinen-Julkunen and Heinonen (2010) discovered that women who did not receive a routine episiotomy, especially those birthing for the first time, had higher incidents of vaginal, labia minora and urethra injuries. They also had more first and second degree perineal injuries. This would, at a minimum, indicate that routine episiotomies would benefit first time births.
Saxena et al. (2010) compared two groups of women. “In the control group 82 primiparas (96%) and 60 multiparas (48%) received an episiotomy. In the study group 37 primiparas (40%) and 22 multiparas (14%) delivered with an episiotomy” (Saxena et al., 2010). The primiparas in the control group experienced no tears while 13% of the primiparas in the study group experienced second-degree tears and 2% experienced severe perineal tears. Among the multiparas, 1.6% of the control group had second-degree tears versus the study group in which 10% had second-degree tears. This indicates that receiving an episiotomy reduces a women’s risk of second-degree and higher perineal tears. Carroli and Mignini (2009) had similar findings.
Handa et al. (2013) studied women with pelvic floor disorders and found that episiotomies were not associated with pelvic floor disorders, while forceps deliveries and perineal lacerations were. This is indicative that episiotomies could be beneficial in preventing pelvic floor disorders.
Evidence for the Non-Use of Routine Episiotomies
One of the reasoning’s behind routine episiotomies is the idea that they will prevent future issues such as urinary and anal incontinence. Fritel et al. (2007) performed a study comparing women who received routine episiotomies to those who received them as a necessity or did not receive them at all. The study found that there was no difference between the amounts of urinary incontinence, perineal pain, and pain during intercourse. There was an increase in anal incontinence in those who received routine episiotomies. Although the differences were non-existent in most post-birth issues between those who had routine episiotomies and those who did not, the fact that the group who had routine episiotomies had a higher instance of anal incontinence indicates that episiotomies should not be used indiscriminately.
A study done in 2008 by Murphy et al. had similar findings to Fritel et al. This study went further and also showed that neonatal trauma was similar in groups of women who had restrictive episiotomies and groups who had routine episiotomies.
Shahraki et al. (2011) found that restrictive use of episiotomies results in low maternal complications. By not using episiotomies, there would be an increase in intact perineal and minor perineal trauma; it would also reduce the amount of pain post-delivery. Since the research found that restrictive episiotomies does not increase maternal or neonatal morbidities, routine episiotomies are unnecessary. Golmakani et al. (2008) had the same findings. Patterson, Winslow and Matus (2008) does make the claim that episiotomies increase infant morbidity. While it asserts this claim, there is little evidence to back it up and other literature contradicts their findings. Perhaps they are mistaken in their assertions, or perhaps further research needs to be done to determine if episiotomies are a cause of higher infant morbidity rates during childbirth.
Rodriguez et al. (2008) studied 223 women who underwent routine episiotomies and compared them to 222 women who had selective episiotomies. In the first group, 14.3% had third or fourth degree perineal lacerations, compared to 6.8% in the second group. Selective perineal episotomies reduce the risk of third degree perineal lacerations in patients.
Another aspect to restricting the use of episiotomies is highlighted in the 2013 study by Manzanares et al and the 2012 study by Lurie et al. The study shows that women who receive an episiotomy during their first childbirth are at increased risk of a perineal tear or another episiotomy during their second childbirth. Once again, unrestricted use of episiotomies have long term effects on women, even carrying into their subsequent child births.
Another issue with episiotomies that affects women long term is how they effect a women’s sexual life. Ejegard, Ryding and Sjogren (2008) found that episiotomies may affect the sexual life of a women in the second post-partum year, causing more pain and vaginal dryness during intercourse.
Current Practices
In 2008, Gossett and Dunsmoor published a study that evaluated 2,959 deliveries by 17 practitioners. Increased episiotomy rates were shown in providers with a greater number of years on practice and physicians who were not the outpatient physician. Episiotomies rates ranged from 2-43%, indicating a need for educating the physicians on evidence based care.
While routine episiotomies may be unnecessary, they have their place in assisted deliveries. de Leeuw et al. (2008) looked at anal sphincter injury occurrence in forceps and vacuum extractions. Mediolateral episiotomies have a significant impact on the reduction of anal sphincter injuries when the use of forceps or vacuum becomes necessary. While an episiotomy should not be used in every case, it is of utmost importance that they be considered on a case by case basis.
In the United States current practices have drastically changed in regards to episiotomies. According to Frankman et al. (2010), in 1979 the episiotomy rate was 60.9%. In 2004 it had reduced to 24.5%. This is in a large part to the recognition of evidence based practices in regards to episiotomies in the United States. On the other hand, rates of caesarean sections have increased from 8.3 in 1979 to 17.2 in 2004 per thousand women. This may indicate that more challenging births are dealt with using caesarean section versus episiotomies as part of current practices.
Summary
While some evidence exists for the positive aspects of routine episiotomies, it is not overwhelming. Also, it is far outweighed by the benefits of using evidence based practice to determine if an episiotomy is needed in each individual case. Further looking at the studies also reveals that many younger medicine practitioners have implemented evidence based practices in regards to episiotomies, while older medicine practitioners are more likely to routinely use them. This is indicative for the need to retrain older practitioners to the use of evidence based practice versus how they were taught to use episiotomies.
Local Evidence
Although great strides have been taken to implement evidence based care in Oman, it is slow to uptake. The routine use of episiotomies is still common practice among nurses in Oman hospitals. According to Al-Khasawneh et al. (2015), the rate of episiotomies in Oman is 66% which is very high. Regional Hospitals are more likely to engage in the practice of routine episiotomies than tertiary hospitals. This is despite efforts to teach evidence based medicine.
Recommendations
Considering that the routine use of episiotomies differs greatly with the medical evidence, there are several recommendations I would make. These recommendations do have some unique hurdles to overcome, as the common belief in Oman is that episiotomies help reduce birth trauma. Also, differing hospital environments may be more or less open to changes suggested.
My recommendations include:
Implementation of standard evidence based practices in regards to the use of episiotomies during child birth.
Establishing acceptable episiotomy rates, and holding hospital staff to these rates.
Educate pregnant women on episiotomies and their use so they can speak out for themselves during childbirth.
Action Plan
The first portion of the action plan includes retraining of current medical staff, and implementing new information in schools that are training future medical staff. It is important that the evidence be presented in such a manner where currently trained medical staff understand the importance of ceasing to use routine episiotomies. It is during these classes basic standards for deciding whether or not to perform an episiotomy can be taught.
Another important point will be to decide what an appropriate number of episiotomies performed per doctor or nurse is. This standard must be upheld by keeping track of each nurse and doctor, and coaching them if they go over the acceptable number.
Since the practice of routine episiotomies is so ingrained in Oman, despite the training in evidence based medicine, it can be expected that implementing this new training will reach certain speed bumps along the way. There will need to be support from upper management and a united front while implementing this new practice in order to counterbalance any negative attitudes surrounding the change.
Although there may be hurdles to overcome in training, it will be worth the effort. Ho et al. (2010) “examine(d) episiotomy practices before and after a multi-component intervention designed to support the use and generation of research evidence in maternal and neonatal health care.” They found that this intervention and retraining led to a decrease in routine episiotomies and, “An intervention based on understanding and using the best available evidence can result in significant improvements in care and health outcomes.”
Also, part of birthing classes should educate women as to the use of episiotomies. This will allow them and their partner to better advocate for themselves during the child birth process should the need for an episiotomy come up.
Conclusion
Evidence Based Practice is so important to use in determining the best way to deal with p-patients in their various ailments. By using EBP, unnecessary procedures can be eradicated, unnecessary medications can be skipped and so much more. In the specific case of the routine use of episiotomies, EBP shows that it is unnecessary. This will help women who go through childbirth receive better care, and therefore suffer less long term consequences related to child birthing. Since this assignment was about finding the best way to care for women who are giving birth in regards to episiotomies, I feel that it had been a success.
Also, by purposefully looking at a specific subject and applying EBP to that subject, I have a greater understanding in how to use EBP. I also have a greater understanding of the importance of EBP to the practice of medicine and to being a successful medicine practitioner of any kind.
References
Al-Khasawneh, E., Al-Ghammari, K., Al-Riyami, Z., Al-Moqbali, M., Al-Marjabi, F., Al- Mahrouqi, B. and Al-Khatri, A. (2015). Predictors of routine episiotomy in primigravida women in Oman. Applied Nursing Research.
Carroli, G. and Mignini, L. (2009). Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews, (1).
de Leeuw, J., de Wit, C., Kuijken, J. and Bruinse, H. (2008). Mediolateral Episiotomy Reduces the Risk for Anal Sphincter Injury During Operative Vaginal Delivery. Obstetrical & Gynecological Survey, 63(5), pp.287-289.
Ejegard, H., Ryding, E. and Sjogren, B. (2008). Sexuality after Delivery with Episiotomy: A Long-Term Follow-Up. Gynecol Obstet Invest, 66(1), pp.1-7.
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Fritel, X., Schaal, J., Fauconnier, A., Bertrand, V., Levet, C. and Pigné, A. (2007). Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG: An International Journal of Obstetrics & Gynaecology, 115(2), pp.247-252.
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Saxena, R., Sandhu, G., Babu, K., Bandol, H. and Sharma, G. (2010). Restricted use of episiotomy. J Obstet Gynecol India, 60(5), pp.408-412.
Shahraki, A., Aram, S., Pourkabirian, S., Khodaee, S. and Choupannejad, S. (2011). A comparison between early maternal and neonatal complications of restrictive episiotomy and routine episiotomy in primiparous vaginal delivery. Journal of Research in Medical Sciences, 16(12).
