Christiana Care is taking a leading role in developing national guidelines for the obstetrical practice of episiotomy, which is a surgical incision to enlarge the vaginal opening during childbirth in order to aid delivery and prevent tissue damage.
“Establishing national standards will benefit patients across the country,” says Matthew Hoffman, M.D., MPH, director of OB/GYN Education & Research at Christiana Care, one of the nation’s highest-volume health systems for delivering babies. “At the very least, episiotomy causes pain for mothers—and most of the time that pain is unnecessary.”
Under current guidelines in obstetrics, episiotomy is a routine practice. On Nov. 30, the National Quality Forum endorsed Christiana Care’s petition to consider the incidence of episiotomy as a performance measure in evaluating the quality of perinatal services. The National Quality Forum is a nonprofit organization that endorses national consensus standards for measuring and publicly reporting on health care performance. National Quality Forum endorsement takes the standard of low episiotomy rates a step closer to becoming adopted by the Joint Commission, the independent, not-for-profit organization that accredits and certifies health care systems.
Episiotomy was routine for decades and was a standard part of training for most obstetricians practicing today, Dr. Hoffman says. In theory, the procedure prevented more serious vaginal tears, as well as reduced the patient’s risk of incontinence. But over time, the evidence didn’t support that theory. In fact, data shows that episiotomy increases the risk of serious lacerations. The procedure also can contribute to incontinence of stool.
The petition to the National Quality Forum by Christiana Care and the National Perinatal Information Center (NPIC) is part of the health care system’s ongoing commitment to providing quality care. To support the goal of establishing episiotomy rate as an indicator of quality, Christiana Care launched an educational program for providers of OB/GYN services on the procedure and the lack of benefit to patients, starting in October 2008.
“We also began tracking and presenting how we are doing with our episiotomy rate every month at our OB/GYN business meeting,” says Linda Daniel, director, Performance Improvement/Care Management, Women and Children. Between the fiscal years 2008–2010, the rate of episiotomy declined 55 percent at Christiana Care. In 2010, only 1 percent of obstetricians in the health care system had an episiotomy rate of more than 20 percent, compared to 25 percent of physicians in 2004.
Overall, the episiotomy rate at Christiana Care is currently about 2 percent. There is an exclusion for shoulder dystocia, a rare and dangerous condition that occurs when a baby’s anterior shoulder cannot pass beneath the joint that connects the mother’s pubic bones after the baby’s head has been delivered.
“In theory, the doctor might need additional room to perform the manipulations required to deliver the baby safely,” Daniel says.
The measure was tested with the help of NPIC, as well as Christiana Care’s fellow members of the Counsel of Women and Infant Specialty Hospitals (CWISH) to validate the measure’s reliability, feasibility and usability. Episiotomy rates from NPIC’s database were far higher than those at Christiana Care, averaging 12.9 percent. CWISH rates averaged 16.2 percent.
“In the future, hospitals will be judged on their episiotomy rates as a quality marker,” Dr. Hoffman says. “Christiana Care is already there.”