PHYSICIANS BELIEFS AND BEHAVIOR DURING A RANDOMIZED CONTROLLED TRIAL OF EPISIOTOMY - CONSEQUENCES FOR WOMEN IN THEIR CARE

Objective: To evaluate whether physicians' beliefs concerning episioto my are related to their use of procedures and to differential outcomes in childbirth. Design: Post-hoc cohort analysis of physicians and pat ients involved in a randomized controlled trial of episiotomy. Setting : Two tertiary care hospitals and one community hospital in Montreal. Participants: Of the 703 women at low risk of medical or obstetric pro blems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by resid ents or nurses were excluded. Main outcome measures: Patients: intact perineum v. perineal trauma, length of labour, procedures used (instru mental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assignin g women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. Resu lts: Women attended by physicians who viewed episiotomy very unfavoura bly were more likely than women attended by the other physicians to ha ve an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours s horter for women attended by physicians who viewed episiotomy favourab ly than for women attended by physicians who viewed episiotomy very un favourably (p < 0.05 to < 0.01), and the former physicians were more l ikely to use oxytocin augmentation of labour. Physicians who viewed ep isiotomy more favourably failed more often than those who viewed the p rocedure very unfavourably to assign patients to a study arm late in l abour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that ''fetal distress'' or cesarean section necessitated exclusio n of the subject. They used the lithotomy position for birth more ofte n (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and p erineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourabl y and very favourably experienced less satisfaction with the birth exp erience (p < 0.01) than the patients of physicians who viewed the proc edure very unfavourably. Conclusions: Physicians with favourable views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.