Episiotomy vs. Spontaneous laceration?

Specialties Ob/Gyn

Published

All of the research I have read says that episiotomies are done frequently but moms do better without having one. I have also read research that shows moms who have episiotomies have greater incidence of 3rd & 4th degree lacerations, whereas moms who do not recieve an episiotomy usually only have 1st to 2nd degree lacerations.

My question is with all of the research why are OB's continuing with such a high rate of episiotomies. Also, in your practice, do you agree with the research findings that show the risks of episiotomies outweigh the benefits?

:angryfire: Routine epis are TORTURE, and I wouldn't agree to another routine epis for ANYTHING!!! THe recovery is hell, especially when you end up needing another sx to repair the epis repair a few months later.

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Specializes in LTC/Behavioral/ Hospice.

I had 3 routine episiotomies for my 8 lb 8 oz'er, 8lb 6 oz'er, and 6 lb 8 oz'er. I then had a homebirth, had a slight tear, and a 9 lb 8 oz'er. :)

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I had my daughter 23 years ago after pushing for 4 hrs. I had a quack for a dr that took a shower and shaved at home before coming to deliver me because he had to go to the office later(delivered at 7:30am). He gave me an episiotomy even though she was hanging out almost while waiting for him to come!! Then I tore to a 4th degree through the rectum, can we say PAINNNN! I wanted to kill him.

I had my son 10 years later and was an OB nurse and Lamaze instructer too. I went from 3cm to complete and crowning within 45 min. I had that natural instinct of having to push. I was yelling at my OB that I wanted him to do the episiotomy so I would not tear. He laughed and said "you don't need it, push". I actually sat up and argued with him. I had the baby and did not tear. I could have gotten up and danced after he was born! What a difference the OB doctor makes and a little knowledge. I was sure glad he did not listen to me!! LOL!!! :p

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A great book to read that addresses this issue, if you haven't already read it, is "Obstetric Myths VS Research Realities" by Henci Goer.

Not all OBs continue to practice in such a manner. There are two OB/CNM groups that catch babies at my hospital, and they both rely on evidence-based practice. So in my hospital episiotomies are generally only performed when there's no time to allow tissues to stretch, when babies need to come out NOW.

I wish it were like that everywhere. Not too long ago, an online friend on another message board wrote that she was thinking about finding a new OB midway through her pregnancy because her OB told her that "95% of primips required episiotomies" because the human baby's head is too big for the lady partsl opening :rolleyes: .

BTW, she found another OB!

Palesarah,

AMEN! :rotfl: Where I work as a L&D RN, episiotomies are NOT routine. The doctors and midwives speak with the mom BEFOREHAND and ask what are the specifics of their labor. It gives the patient control and allows them to choose! But in my short three year experience as an L&D RN, I have seen where the patients insists without some flexabiliity on not having an episiotomy and they would tear ugly fourth degrees like you would not believe. The doctors and midwives would ask as the babes are crowning (the mom perineal tissue around babe's head would whiten thus a sign that the tissue's gonna tear) if they would like a little cut. I read in this thread earlier that it is wise not to have any routine things done just because they are routine, but it is smart as well not to ignore and refuse a necessary intervention when it is offered.

I work with OBs/CNMs who do warm water soaked cloths on the perineum as babe nears delivery and that helps the perineum to stretch as well. I like that! It's comforting to our moms at a time when alot is going on and uncomfortable--- :)

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Specializes in OB, lactation.

I have a friend that had two big 9lb+ babies - 1st one w/ epi and second w/ small tear - she much preferred the tear.

I will make yall sick and say that I didn't have an episiotomy OR tear with any of my 3 births. I think they did perineal massage &/or warm cloths with all three.

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The first one...I had an episiotomy to allow for vacuum extraction after several hours of pushing...hurt like hail and I tore 4th deg. She was 9lb4oz

Second one...begged for no episiotomy...had a very rapid (induced) birth and he didn't take his time at all, tore along previous epi...4th deg as well with a TON of swelling. she was 8lb 11oz...I spent almost 2 weeks on icepacks..had to send dh back to the hosp for more cold sani pads.

Third one...same as #2 pretty rapid birth...tore 4th deg again...not as much swelling but not much to sew together AGAIN and the stitches tore out. she was 8lb 14oz

Fourth one...new doctor. Asked him to cut me if it looked like I'd tear. He took his time and allowed me to stretch(what's left down there anyway)...2nd deg lac with stitches and some smaller lacs not needing

stitches. Easiest recovery...he weighed 9lb 11oz.

the bottom line (no pun intended) routine is NOT necessary but there are times when it would be prudent to either slow down and allow stretching or make a little more room if a tear is imminent. Just my .02 worth.

~T

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OMG!!!! God Bless you for going on to have more children after the 1st

4th degree!!! I was hurting just reading about your experiences! You are living proof of why women have babies and not the men!:chuckle

The first one...I had an episiotomy to allow for vacuum extraction after several hours of pushing...hurt like hail and I tore 4th deg. She was 9lb4oz

Second one...begged for no episiotomy...had a very rapid (induced) birth and he didn't take his time at all, tore along previous epi...4th deg as well with a TON of swelling. she was 8lb 11oz...I spent almost 2 weeks on icepacks..had to send dh back to the hosp for more cold sani pads.

Third one...same as #2 pretty rapid birth...tore 4th deg again...not as much swelling but not much to sew together AGAIN and the stitches tore out. she was 8lb 14oz

Fourth one...new doctor. Asked him to cut me if it looked like I'd tear. He took his time and allowed me to stretch(what's left down there anyway)...2nd deg lac with stitches and some smaller lacs not needing

stitches. Easiest recovery...he weighed 9lb 11oz.

the bottom line (no pun intended) routine is NOT necessary but there are times when it would be prudent to either slow down and allow stretching or make a little more room if a tear is imminent. Just my .02 worth.

~T

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Specializes in all things maternity.

When I first worked OB we had a older doctor that routinely cut 4th degree episiotomies and they were horrible to watch. This women had horrendous pain and I felt so bad for them. A few of us got together and decided we had to stop him. We started "hiding" the scissors on the table until after the baby was born and we tried our best to call him into the room at the last minute so he wouldn't have time to find then. After the delivery, just move a few things and VIOLA....the scissors reappeared. Of course, we had to be able to produce those scissors fast in a emergency. Soon, all the nurses were setting up the delivery table with the missing scissors....

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All the 4th degrees I have seen, were episiotmoy extensions. I have never seen a 4th degreee laceration. Luckily, only 1 of the dos I work with does them on a regular basis, and we hardly ever see her. Our largest practice, made up of OB's and CNM's rarely do episiotomies.

You do not want to see a 4th degree happen spontaneously!!! You will suffer from vaginissmus after you see it!!! When I saw one, it was like slow motion. The baby's head then forehead, then, it was as if layer by layer......just an explosion of tissue......I cringed visibly when I saw it.

Anyway, I was 20 when I had my first child....and I don't even know why I didn't want an epis...but luckily my CNM delivered me. She mineral oiled my perineum to allow me lubrication and time to stretch....and no epis, no tear. With my second child, 18 mos. ago, I chose a physician I work with to be my OB and I know his practice methods. I told him we would do the least in terms of interventions....and I got that within reason.

(I SROM'd and my baby took a four minute decel to 60s in labor, and rather than rush to cut me, he internalized me, amnioinfused and baby was okay. Four hours later, I had a bouncy baby cutie bootie boy!)

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I have more of a question about episiotomies. Since i am a male I can;t really offer any stories, but I don't think my wife had one with our 1st child (8lb 14 oz). What I was wondering is what does 1st, 2nd, 3rd, and 4th degree represent? I know it is the tear/laceration, but how do you determine what is what? I am looking in my text book, but I only see the 2 types, not the degrees. It may be in there but I haven't found it yet. I am starting Maternal-Child this semester.

Thanks :p :rolleyes:

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

4th degrees rarely occur SPONTANEOUSLY. Often, they are extensions of episiotomy cutting.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

See my answer in the episiotomy thread:

First of all, you are confusing terms.

An EPISIOTOMY is a deliberate cut into the perineal body, made by a trained care provider, to make more room, or relieve a "band" of tissue that appears to prevent the baby from being able to be delivered without apparent difficulty. Use of episiotomy techniques is considered very controversial; some doctors and midwives prefer to take a "wait and see" attitude, and let a woman deliver, tearing, possibly, believing a naturally-occuring LACERATION is better for healing, in the long run.

LACERATIONS vary by degrees as follows:

First degree: lady partsl mucosa

Second degree: lady partsl fascia and perineum

Third degree: External Anal Sphincter (partial or complete)

Fourth degree: External Anal Spincter (EAS), Internal Anal Sphincter (IAS), and rectal mucosa

Most deliveries, if handled properly, and the nurse and doctor do not stretch or manipulate the perineal body excessively, and the baby's delivery is not too rapid, the resulting tear rarely exceeds first or second degree. Sometimes, for very large babies, or rapid expulsion, you will see 3rd/4th degree tears happen. Also, you may see an "extension" to 3rd/4th degree of an episiotomy occur in some cases.

Imagine this by putting a tiny tear in a piece of paper, then putting extreme pressure on it---what happens? It tears further, along the tear line you created. This is why, among some reasons, the use of episiotomy is so controversial. Increasing numbers of doctors are now deferring episiotomy for a "wait and see" approach, which I personally, like.

Hope this helps you.

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