book form. The bulk of the material is an in-depthhistorical review reflecting the changing opinions of birthattendants on the use of episiotomy over the past 250years. The book describes the use of episiotomy worldwide but focuses on the comparison of use in the UnitedStates and the United Kingdom. Although the writingstyle and vocabulary can be easily interpreted by the highschool graduate, this book is clearly written for thewoman’s health professional. The book is written toprovide a guide to effecting change in obstetric practiceusing the history of episiotomy as a model.

The author does a thorough job of reporting opinionson episiotomy as well as birth in general dating from thelate 1700s. As a result of this thoroughness, manypassages are followed by lengthy citations that interruptthe ease of reading; however, this extensive researchresulted in a comprehensive reference list, of whichmany entries piqued this reviewer’s interest.

Graham favors the description of birth as a physiologicevent. He thus reports the emergence of routine episiot-omy as part of the “cascade of intervention” that resultedwhen obstetrics moved from the home to the hospital.He identifies a list of advantages to episiotomy thatpromoted its prophylactic use for almost “100% ofnulliparas.” The author reports several interesting “ben-efits” of episiotomy. One benefit often cited is preven-tion of perineal laceration, but it is also reported that thisprocedure will prevent urinary incontinence, promotesexual satisfaction of both partners, and further preventbrain damage to the fetus. Most significantly, he relaysthat no sound scientific evidence supports these claimsabout episiotomy; its use became a standard of carebased on the testimony of experts.

The author notes that the United Kingdom acceptedroutine episiotomy at a much later date than did theUnited States. He describes the dilemma that Britishmidwives faced with this adaptation. He provides testi-mony as to how mandated episiotomy weakened theskills of the midwife, who had previously been forbiddenby law from cutting the perineum. He also reports thenegative impacts the episiotomy had on a woman’s birthexperience; although the British midwife was given theprivilege of cutting, the sewing was left to a trainedsurgeon. Sometimes several hours would pass before thesuturing could be done.

Despite the lack of scientific knowledge base and thenegative connotations associated with episiotomy, theauthor finds that the medical community did little tochallenge its use until the women themselves began toprotest. The growing women’s movement and increasedconsumerism of the 1970s fueled dissent with the “en-gineered” birth experience. The author points out that inthe United Kingdom a strong leader was found in birtheducator Sheila Kitzinger, who subsequently led theforces that pressured reform. Once the consumer began

to protest, the scientific studies were set into motion.Interestingly, the author reports that those in the UnitedStates who opposed the mainstream simply sought outhome birth. Graham attributes this and the significantlysmaller proportion of births attended by midwives asfactors that delayed the scientific review of episiotomy inthe United States.

Graham reports that in the United States the nurse-midwives were instrumental in providing scientific datathat disproved the theories about the benefits of episiot-omy; however, as with the movement to increase its use,the use of episiotomy was reduced before the availabilityof scientific data. The author provides graphs that sub-stantiate this fact.

The final chapters of this book are devoted to theprocess of change. The author identifies the barriers andchange agents that led to both the adoption and retrac-tion of routine episiotomy. He identifies the medicaldevelopments and desires of the consumer that led to thechanges undertaken. He defines what scientific dataexemplifies weak evidence as opposed to strong evi-dence and encourages questioning routines in individualpractices. He provides insight into where to find evi-dence.

This reviewer found many appealing features to thisvolume. Specifically, the book provides an in-depthhistory of the use of episiotomy and related birth prac-tices. The method in which the history is presented isscientifically based yet easily read. The author includesthe opinions of midwives and weighs them equally withthose of obstetricians. The book is written with a focuson positive outcomes for women. Because the book iswritten from the view point of a sociologist, there is lesstendency for the reader to assume bias when the authoris presenting the facts. Finally, this book encouragesevidence-based change in the practice of obstetrics andprovides encouragement for practitioners seekingchange.

Perimenopause—Changes in Women’s Health After35. By James E. Huston, MD and L. Darlene Lanka, MD.Oakland (CA): New Harbinger Publications, Inc, 1997.394 pages. $13.95, softcover.

Reviewed by: Karen Burgin, CNM, MA. Nurse-MidwiferyAssociates, Brooklyn, New York.

Dr. James Huston and Dr. Darlene Lanka, ob/gynphysician colleagues, have drawn upon their extensiveclinical experience to address the education and infor-mation needs of the 38 million “baby boomer” womenin the United States who must now navigate the ups anddowns of the perimenopausal years.

In many ways the authors have produced a helpfulguide, citing an admirable number of professional refer-ences and quoting liberally from many popular books on

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women’s health. They write in a literate, educated, andinformative style with touches of humor, and consistentlyaddress the reader personally in the second person. The394 pages undertake to cover a wide range of territory—not only hormonal and reproductive changes but manyother health problems and concerns of perimenopausalwomen as well: cardiovascular disease, thyroid disorders,cancer, urinary incontinence, osteoporosis, psychosex-ual dysfunction, substance abuse, skin and hair changes,cosmetic issues, poor nutrition, weight issues, and stress.An extensive final chapter covers many types of gyne-cologic problems and the surgical means of correctingthem; one of the authors is credited in the physician-authored foreword as being “a great gynecological sur-geon.”

Discerning JNM readers of that foreword may wellanticipate the book’s major flaw: the physician authorspredictably favor medical and surgical solutions for prob-lems that alternative providers know can also be man-aged differently with more holistic approaches. Theauthors cannot be accused of being exclusively medicalas they do make an effort to include newer therapies andmodalities that have recently found their place in wom-en’s health care. But to scratch the surface is to unearththe authors’ medical preferences and convictions. Forexample, 30 pages are devoted to the detailed chapterentitled “You Can Change Your Hormones: the Case forHormone Replacement Therapy.” This is followed by a10-page chapter on “Alternative Medical Disciplines—Are They a Good Choice for You?” in which the readeris briefly provided with general information about Chi-nese medicine, homeopathy, holistic medicine, herbs,homeopathy, and mind-body medicine.

An introductory chapter, “Changes in Fertility: Preg-nancy, Infertility, and Contraception,” surprised thisreviewer with the statement, “If you have small fibroids,heavy periods, menstrual cramps, prolapse (sagginguterus), or stress incontinence, you will benefit from avaginal hysterectomy.” The reader is then informed thatwithout that uterus, she can take estrogen alone whenshe reaches menopause and won’t need combinationtherapy. This precedes the thorough discussions of bothhysterectomy and hormone replacement therapy (HRT)placed later in the book, and serves as an example of thebook’s underlying tacit assumption that even thoughalternatives exist, the educated reader will want tochoose medical and surgical approaches. In contrast,however, the last chapter, covering hysterectomy inmore detail, lists only valid indications for the surgeryand informs the reader that only about one fifth offibroids cause symptoms and that surgery should bereserved for those who are symptomatic. This is some-what puzzling in light of the earlier statement, raising thequestion of whether the authors were of one mind in

their collaboration, and whether the book could havebeen more carefully edited.

This last chapter also subtly encourages women tochoose elective oophorectomy when hysterectomy isindicated, using the rationale of protection from ovariancancer. Absent are clear statistics about just how manywomen who opted to preserve their ovaries fell victim tothis cancer; an earlier chapter concedes that the lifetimerisk of developing it is 1 in 70 women from the generalpopulation. Encouragement to go ahead and have thatrecommended hysterectomy is backed up by two studiesthat showed that “women who opted for hysterectomywere more satisfied with the outcome than womenchoosing other forms of alternative therapy.” This chap-ter also states categorically that oophorectomizedwomen require HRT, reflecting the more subtle pro-HRT opinions that crop up throughout the book.

JNM readers, forewarned and prepared from theauthors’ slant, can nonetheless learn a great deal fromthis book and can recommend it to discriminating,intelligent clients. Especially useful is the information onthyroid function, nutrition, weight control, substanceabuse, plastic surgery, and urinary incontinence. Ingeneral, the authors have done their homework andhave made a useful contribution to women’s self-helphealth literature.

Assessing and Managing Common Signs and Symp-toms: A Decision-making Approach for Health CareProviders. By Lisa L. Lommel and Patricia L. Jackson.San Francisco: The Regents, University of California,1997. 453 pages. $54.95, paperback.

Reviewed by: Cathy Buiten, RN, SFNP, The University ofMichigan, Lansing, Michigan.

This text was first developed for a course in commondisease management taught to advanced practice nursesat the University of California, San Francisco. Its statedpurpose is “first, to introduce advanced practice studentsto the inductive assessment and management of com-mon signs and symptoms. Secondly, the book is in-tended to provide a framework for a systematic decision-making model.” It accomplishes both of these purposeswell.

The book is divided into eleven chapters according tobody systems. Each chapter is then further divided bypresenting symptoms, specific objective criteria, anddifferential diagnoses followed by a management plan.One example is the chapter on musculoskeletal pain.The chapter is divided into the common complaints ofnonarticular pain and neck and back pain. Twenty-sevendiagnoses form the differential for this section. Bothpediatric and geriatric diagnoses are given, for example,developmental dysplasia of the hip and hip bursitis. Theinclusion of all age groups and both male and female

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