Episiotomy

SmilingBluEyes · Jul 7, 2005

Here is something to contemplate, when you may be thinking an episiotomy is "better" than a "regular" laceration or tear:

Sometimes, cutting an episiotomy at the wrong time, or in a hurry, can make things worse. A midwife once gave me a good visual:

Get a piece of paper or paper towel and cut a tiny notch in it. Then, put pressure on the paper (not just the tear, but the whole paper) with your fist, while someone holds the paper at both ends. Look where it tears????

At the notch YOU CUT---and very widely and quickly, right?

You see, an epis. in some cases, can actually make what would be small tears, worse, if used indiscriminately or poorly. I actually saw MORE 4th degree lacerations (right into/through the anal sphincter!) when doctors cut episiotomies often ----in a place I used to work. 3rd and 4th degree tears were VERY common, even though most babies were not oversized! I thought it was pretty "normal" to see tears of such huge degree until I moved to a place where episiotomy was not done so often and cavalierly. I could not count the number of 4th degree's I had to take special care of! I was well-versed in 4th degree tearing and the pain that goes with it. (and it is just ugly the healing process these poor ladies endure----and a horrifying sight to behold).

Nowadays, I can count on ONE HAND the number of 4th-degree lacerations I have seen in a couple of years!

I learned the best pracitioners usually take a "wait and see" attitude and with a woman's perineum. Now, in the case where there is literally NO give, or a tight band, THEN they will go ahead and cut a small midline epis. Most don't l cut where I work, unless there is simply no other way around it, or in a case of SEVERE fetal distress/dystocia. And we see very few 3rd degree and even more rarely any 4th-degree tears as a result. Do 4th degree tears happen? Of course they do, but not nearly as often if you let nature take her course and ease into delivery the way nature intended.

SmilingBluEyes · Jul 7, 2005

Link to an article from Contemporary OB/GYN(September, 2004):

PREVENTING PERINEAL LACERATIONS

Preventing perineal lacerations during labor

By Jay Goldberg, MD, and Carmen Sultana, MD

Using a technique called super crowning, avoiding episiotomy, and reaching for a vacuum device rather than forceps during operative lady partsl deliveries are among the strategies that can help reduce the number of third- and fourth-degree lacerations. .......

see the rest of the article here:

http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=123812

SmilingBluEyes · Jul 7, 2005

okay, I'm not a nurse as of yet but here is a subject that I know a little something about. While I was having my second son (my first was c-sect), the doc just let me tear and let me tell you that was the worst experience of my life. I tore so bad she stitched me for an hour, I couldn't sit for a week without pain---would have much rather an episiotomy!!! Worst birth experience of all 3 of my children!!! Just my input!

I had an epis that extended to a 3rd degree tear. the healing process involved with that experience was much worse than that of my csection delivery of my daughter. I could not sit right for a week---walking was painful too. . It was horrible. Sex? For months, I could not even THINK about it. It hurt way too much each time we tried. In contrast, I was walking 2 or 3 miles a day 5 days after my csection. Without giving TMI, my husband and I were much happier much sooner postpartum, IYKWIM.

Yes, It hurt much worse to heal "down there" than in my abdomen, for sure.

I understand what you are saying here. I am saying, an episiotomy may not have been the right thing to do, either. It may have made it worse, believe it or not. Please see my posts above.

OUCH is right. Those tears take a LONG time to heal, don't they.

palesarah · Jul 7, 2005

I was wondering how others felt about the issue. I'm an lpn student, graduating this aug, currently in my ob rotation. I assisted in a lady partsl delivery today, and as soon as the head crowned, the Dr's did an epiosiotomy. I felt like they didn't even wait to see if it was necessary. Are dr's too quick to do this procedure nowadays? I feel like it's way too commonly done. I do a lot of reading up on the whole birthing process b/c I want to become a CNM.

where I work, I can count on one hand the number of labor patients I have had- in 2 years- who had episiotomies cut:3! and I can think of medically necessary reasons for all but one: a patient who abrupted partially shortly before delivery (and needed to be delivered emergently), and a patient who had been born with an some anomaly that required reconstructive-type surgery around her perineum and anal area got a very skillfull epis to prevent tearing into the scarred areas.

Our practitioners are not the type to cut to shorten a second stage, and they agree that tears heal better in their pts than episiotomies, and that cuts cause deeper tears. So it's a really uncommon procedure here.

babyktchr, BSN, RN · Jul 7, 2005

So many replies to reply to.......

MLE were the NORM when most older docs practiced in the beginning..so they continue on. I have one doc, bless his heart, that has scissors in hand each and every delivery, regardless if it will fit or not. I have fantasies of slapping them out of his hands...but that is another story.

MLE are usually cut in preemies to lessen trauma to the head, as these wee ones are more prone to brain bleeds. I know I still stand in horror when it is done, cause it is coming out ok..........(still want to slap the scissors)

I work with another doc who doesn't even wait till the area has become stretched before cutting....he cuts when it is thick and sounds like....oh my word....my perineum sucks in just thinking about it.

SmilingBluEyes · Jul 7, 2005

Preemies are another matter. Good point.

sddlnscp · Jul 7, 2005

Hmm - I am not even a nurse yet, but I did not have an episiotomy with either one of my chidren. I had a wonderful doctor though who fully believed in perenium massage - with my first child, I had one tiny itty-bitty tear that required all of one stitch and with my second child - nothing - I was ready to run a marathon within a couple of days. I have a friend who had two children and her doctor did episiotomies both times and it sounded to me as if that is routine for him - I felt so bad for her because she was in so much pain and sooo uncomfortable and there I was bouncing around and feeling great (just like a new mom should!). I do believe that some doctors preform episiotomies when they shouldn't - I am very thankful that mine is not one of them!

rastanursern, MSN · Jul 7, 2005

Here is something to contemplate, when you may be thinking an episiotomy is "better" than a "regular" laceration or tear:
Sometimes, cutting an episiotomy at the wrong time, or in a hurry, can make things worse. A midwife once gave me a good visual:
Get a piece of paper or paper towel and cut a tiny notch in it. Then, put pressure on the paper (not just the tear, but the whole paper) with your fist, while someone holds the paper at both ends. Look where it tears????
At the notch YOU CUT---and very widely and quickly, right?
You see, an epis. in some cases, can actually make what would be small tears, worse, if used indiscriminately or poorly. I actually saw MORE 4th degree lacerations (right into/through the anal sphincter!) when doctors cut episiotomies often ----in a place I used to work. 3rd and 4th degree tears were VERY common, even though most babies were not oversized! I thought it was pretty "normal" to see tears of such huge degree until I moved to a place where episiotomy was not done so often and cavalierly. I could not count the number of 4th degree's I had to take special care of! I was well-versed in 4th degree tearing and the pain that goes with it. (and it is just ugly the healing process these poor ladies endure----and a horrifying sight to behold).
Nowadays, I can count on ONE HAND the number of 4th-degree lacerations I have seen in a couple of years!
I learned the best pracitioners usually take a "wait and see" attitude and with a woman's perineum. Now, in the case where there is literally NO give, or a tight band, THEN they will go ahead and cut a small midline epis. Most don't l cut where I work, unless there is simply no other way around it, or in a case of SEVERE fetal distress/dystocia. And we see very few 3rd degree and even more rarely any 4th-degree tears as a result. Do 4th degree tears happen? Of course they do, but not nearly as often if you let nature take her course and ease into delivery the way nature intended.

That's what happened to me. When i had my son, they performed an episiotomy, and then I ended tearing, a damn fourth degree tear. The recovery of that was horrible, it took them an hour and a half to stitch me up. I'm so against them, unless absolutely necessary. The hospital where I'm doing my rotation, nine out of ten women are having an epiosotomy done, and it sucks!

rastanursern, MSN · Jul 7, 2005

I work with another doc who doesn't even wait till the area has become stretched before cutting....he cuts when it is thick and sounds like....oh my word....my perineum sucks in just thinking about it.

I know that sound, That's exactly what the doc did. It made me cringe, and this was not my first time seeing a birth. These dr's just don't want to take their time.If the delivery is going well and the fhr is ok, why rush to that extent?

sddlnscp · Jul 7, 2005

This is really depressing to me - especially since I had the good fortune of having such a wonderful doctor! I cannot imagine anybody who got into patient care to truly help and care for people doing such things - that's just scary! Ugh! And those poor mothers probably don't know any better and think it was necessary for them to go through so much pain and agony when, chances are, it was not necessary a good portion of the time. So sad.

SmilingBluEyes · Jul 7, 2005

do NOT let it depress you! more and more doctors and midwives are taking the "wait and see" attitude I discussed earlier. Routine episiotomies are becoming very much

"not in vogue" with the newer generation of practioners. Read again, the responses that say we can count on one hand the number of times in years we have seen an epis cut for no good reason, and take heart. Things are changing. And no woman is powerless; she has the right to informed consent for any intervention and procedure and this would include cutting an episiotomy!!!!

Editorial Team / Admin · Jul 8, 2005

Because of litigation matters, most OB's will perform episiotomy to try and prevent pelvic floor relaxation issues and/or rectocele/cystocele matters later on. Many suits are secondary to the fact that the injury might have been avoided had an epsiotomy been performed . Also, some suits have proven that had the epsiotomy been performed, the infant would not have had neurological problems later. I agree, the procedure may not be acceptable in EVERY case, but, physician's are litigation-aware now.