ACOG Recommends That Physicians Restrict Episiotomy

Although episiotomy is performed in approximately one third of vaginal births in the United States, prophylactic use of the procedure does not result in maternal or fetal benefit and should be restricted, according to a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG). The recommendations were published in the April 2006 issue of Obstetrics & Gynecology.

Historically, the purpose of episiotomy was to facilitate completion of the second stage of labor to improve maternal and neonatal outcomes. Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor caused by a more rapid spontaneous delivery or from instrumented vaginal delivery. Despite limited data, this procedure became virtually routine, resulting in an underestimation of the potential adverse consequences, such as extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia.

The best available evidence does not support liberal or routine use of episiotomy. However, there still is a place for episiotomy for maternal or fetal indications (e.g., avoiding severe maternal lacerations, facilitating or expediting difficult deliveries). A systematic review comparing routine episiotomy with restrictive use reported that 72.7 percent of women in the routine-use group underwent episiotomy compared with 27.6 percent in the restricted-use group. The restricted-use group had significantly lower risks of posterior perineal trauma, suturing, and healing complications but a significant increase in anterior perineal trauma. No statistically significant differences were reported for severe vaginal or perineal trauma, dyspareunia, or urinary incontinence.

In general, two types of episiotomy have been described: the median (or midline or medial) episiotomy and the mediolateral episiotomy. The median episiotomy tends to be a simpler incision to repair and is the more commonly used procedure in the United States. However, median episiotomy is associated with a greater risk of extension to the anal sphincter (third-degree extension) or rectum (fourth-degree extension). Mediolateral episiotomy, an incision at least 45 degrees from the midline, maximizes perineal space for delivery while reducing the likelihood of third- or fourth-degree extension. Reported disadvantages of the mediolateral procedure include difficulty of repair, greater blood loss, and, possibly, more discomfort during the early postpartum period. Although the data are insufficient to determine the superiority of either approach, the procedures seem to have similar outcomes, including pain from the incision and time to resumption of intercourse.

Influenza Vaccination for Secondary Prevention in CVD

Influenza-related death is more common in patients with cardiovascular disease (CVD) than in patients with any other chronic condition. However, vaccination coverage levels in this population remain well below national goals and are marked by disparities across different age and ethnic groups. To help reverse this trend, the American Heart Association (AHA) and American College of Cardiology (ACC) recommend annual influenza immunization “with the same enthusiasm as control of cholesterol, blood pressure, and other modifiable risk factors,” according to an advisory published in the October 3, 2006, issue of Circulation (available at http://circ.ahajournals.org/cgi/content/full/114/14/1549).

Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against influenza prevents cardiovascular events and all-cause mortality in patients with cardiovascular conditions. Based on this evidence, the AHA and ACC recommend immunization with inactivated influenza vaccine (administered intramuscularly) as a component of secondary prevention for patients with coronary disease and other atherosclerotic vascular conditions. Live, attenuated vaccine (administered intranasally) is contraindicated for persons with cardiovascular conditions. Influenza vaccine should be administered to all persons with CVD unless they have a contraindication to receiving the vaccine.

One of the barriers to vaccination for patients with CVD is that cardiology practices often do not stock and administer influenza vaccine. Therefore, family physicians and other primary care physicians who treat patients with CVD can help improve inf luenza vaccination rates by providing and strongly recommending vaccination to their patients before and throughout the influenza season.

Self-study Course in Epidemiology Now Available Through CDC Web Site

The Centers for Disease Control and Prevention’s (CDC’s) introductory self-study course, Principles of Epidemiology in Public Health Practice, 3rd ed., is now available online. The course is designed for public health professionals at the state and local levels who are or expect to be responsible for outbreak investigations or public health surveillance.

The course provides an introduction to applied epidemiology and biostatistics. Continuing education credits are offered. The course is available at no charge at http://www2a.cdc.gov/phtnonline. A printed copy of the course can be ordered from the Public Health Foundation at http://bookstore.phf.org (telephone: 877–252–1200).

Meningococcal Vaccine Supply Increased; Deferral Request Lifted

The manufacturer of tetravalent meningococcal conjugate vaccine (MCV4; Menactra) reports that previous limitations in the vaccine supply have resolved. Therefore, the Centers for Disease Control and Prevention (CDC) recommends that physicians resume routine vaccination according to recommendations from the Advisory Committee on Immunization Practices. Groups that should be vaccinated include children 11 to 12 years of age, adolescents entering high school (if not previously vaccinated), and college freshmen living in dormitories. Because of problems with vaccine supply, the CDC recommended in May 2006 that physicians defer vaccination of children 11 to 12 years of age. The CDC now recommends that physicians recall these patients for vaccination, if possible.