This case involves a female patient who had been bought to the hospital after going into labor with her second child. During delivery, multiple maneuvers had to be made to deliver the the child, and a large episiotomy was done to deliver the head with extensive tearing. The mother underwent multiple reconstructive surgeries for the tearing, but still had poor function of her pelvic floor. She underwent extensive and on-going physical therapy for pelvic floor dysfunction, but continued to be limited in walking, sitting, and bowel function due to damage from the episiotomy.
Question(s) For Expert Witness
- 1. How often do you perform episiotomies?
- 2. How close can the weight of a fetus be estimated and does the weight play a role in planning or performing a c-section?
- 3. What care is taken to avoid damage to the pelvic floor and to avoid the creation of fistulas when performing an episiotomy?
Expert Witness Response E-080405
I perform episiotomies in about 3-5% of deliveries that I’m personally involved in. The vast majority of episiotomies I perform are in the context of either an operative vaginal delivery with forceps, or to facilitate the delivery of the baby with shoulder dystocia. The estimation of the fetal weight can be generally be estimated within a 10-15% error, although occasionally our estimation might be off by a greater degree. Studies indicate the weight estimation can be done by either clinically (Leopold’s maneuvers) or by ultrasound. In a non-diabetic gravida, an estimation of 5 kilograms or more should prompt a discussion about cesarean delivery to avoid potential birth injury due to the large weight of the baby. To avoid damage to the pelvic floor and the creation of fistulae when performing an episiotomy, it requires surgeon’s knowledge and training of the female pelvic anatomy, performance and repair of the episiotomy, adequate analgesia/anesthesia, adequate exposure, assistance in retraction, careful surgical technique, and adequate post-op management.