How necessary are episiotomies?

[WhatToDo]

My mother said the worst thing about my brother's and my delivery was the episiotomy. After taking a class in women's reproductive health, I understand that episitomies are performed more often than is necessay so that the babies can be born faster for the doctor's ease.

How often are episiotomies really necessary and how often does your unit perform them?

[lifeLONGstudent]

Not unless they have too. I had 2 epis and a 4th degree + with my daughter...she was hung up by the cord.

OMG - you should get a medal (and WEAR it everyday)....

this might be a stupid question, but why is an episiotomy a bad thing? (I never had one.....I had a section with my only child - that was after I got to push for about 3.5 hour ... pit started Friday night and section was Sunday).

Isn't it better (and easier to repair) if you have a cut verses a tear? Please explain.

[SmilingBluEyes]

Allow me to try and help with a visual :

take a piece of paper. put a tiny rip in the edge (a fascimile of an episiotomy). NOW put real pressure on the paper with your hand. Where does it rip? (at the tear). That is the image I try to give people when they say, "what is the big deal about an episiotomy?". Done imprudently and injudiciously, this can CREATE a worse tear, all the way thru the perineum to the rectum. You see, the trick is to know when it is necessary and how/what specific time to do it (as a baby is coming). And then CONTROL the head as it delivers. Hope this helps.

[tiggerforhim]

this might be a stupid question, but why is an episiotomy a bad thing? (I never had one.....I had a section with my only child - that was after I got to push for about 3.5 hour ... pit started Friday night and section was Sunday).

Isn't it better (and easier to repair) if you have a cut verses a tear? Please explain.

Well....it's easier for the DOCTOR to repair, but it's harder to heal, is much more uncomfortable, or can be for intimacy. A tear is along more natural lines in the tissue (if a tear can be called 'natural') and will heal back together more easily. I did not have one, my son was 8lbs, 13 oz and I only tore less than 1st degree - but I had a midwife, not an md. I am and will always be against them. If you are going to tear 4th degree, don't add to it by making an inroad for the tear to get worse. I will kick out any person's teeth if they approach with a scalpel - unless the baby is in distress. Then you can cut me open and give me a scalpel myself to get the precious child out before there is permanent damage. As a peds nurse I see lots of chronic kids....oh boy.

[ayndim]

Also many tears are superficial, meaning only the skin or 1st degree. An episiotomy is almost automatically a 2nd degree (meaning skin and muscle). And many extend into 3rd or 4th degrees (into the rectum). So while the cut may be easier for the dr (who btw is getting pd good money) it is harder on the mom. Think of the pain levels of no tear or skin vs muscle. My MW told me a tear is not more difficult to repair because there is no guarantee she will have a tear to stitch and even if she does it is more likely to be a small one. Even if tears are more difficult it is not about what is easier for the dr but what is best for the pt. Ease for the dr is the whole reason women give birth lying down rather than how they choose. So the dr can sit at the end of the bed. GRRRR!

Here is an exerpt from an article

http://www.gentlebirth.org/format/woolley.html

A group of obstetric residents in North Carolina used a different approach [21]. One resident was selected to use episiotomy only for fetal distress or operative lady partsl delivery, while his colleagues continued their use of episiotomy (all midline) at their own discretion. Patients were not randomized to attendants, and no information was given as to how patients were allocated among the residents, but they were shown to be similar in birth weight, nulliparity, race, prematurity, operative lady partsl delivery frequency, and incidence of low Apgar scores. The restricted use of episiotomy was associated with a lower risk of third-degree perineal laceration, 1.8% versus 13.2%; when subjects were subdivided by parity, this difference remained significant among nulliparous, but not parous, women, though a similar trend was apparent even in the latter. Interestingly, no patient in either management protocol experienced a severe tear without a preceding midline episiotomy.

[ayndim]

This is article is interesting

http://www.birthpsychology.com/messages/episiotomy/episiotomy.html

[BabyGuide]

episiotomies ("cutting into the connective tissues and muscles in the area between the lady parts and the orifice to widen the birth canal in order to ease the baby out") were once routine procedures for childbirth. it was widely believed that the cut would ease a woman's delivery and avoid the deep, jagged tears that might happen. it was also thought to prevent urinary incontinence, and that it would keep a woman's pelvic floor from becoming too lax, and even prevent a prolaped (dropped) uterus. recent research now shows that having an episiotomy actually increases a woman's chance of severe tearing, excessive bleeding, infection, and swelling. the procedure has also been implicated in anal incontinence. as some of us know from first-hand experience, it can cause severe discomfort afterward and make sex painful. surprisingly, the 2002 edition of gabbe, et. al's "obstetrics: normal and problem pregnancies" (one of the basic obstetrics textbooks for doctors-in-training) states episiotomies are stil performed "in 50 percent of lady partsl deliveries in the united states" -- but my sense is that the practice is dropping off as doctors become more aware of research to the contrary. the texbook then states on the next page: '"median episiotomies [cuts between the base of the lady parts and the rectum] are associated with an increased incidence of third- and fourth-degree lacerations. such injuries are associated with a high incidence of long-term incontinence and pelvic prolapse." a newer technique adopted from europe cuts at the side of the lady partsl wall, but the textbook states that such cuts are longer and require a more lengthy repair and states "the side to which the episiotomy is performed is usually dictated by the dominant hand of the practitioner." doctors and midwives routinely don't give their patients "informed consent" on this procedure. that is, they don't explain the risks to the mother. rather, they just announce (usually while the mother's compellingly in the midst of her pushing), "i'm going to make a 'little' cut to make things easier," or somesuch. and even if she says "no," they may go ahead anyway. that's why it's important to talk about this before labor.

below are two places to start studying up about the procedure so that you can be more informed:

http://www.cochrane.org/cochrane/revabstr/ab000081.htm

http://www.choicesinchildbirth.com/articles,%20research.htm#episiotomy

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[landonsles]

This may be a silly question, but....

If someone has already had two or more epis, would the buildup of scar tissue necessitate an episiotomy for future births? Especially if the cuts overlapped or were on top of each other? (Just wondering in case I have any more kids, b/c epis are NOT fun)

Thanks

[lifeLONGstudent]

Thanks to all of you for the explanations... I am getting a better understanding (before now, I have only heard the physician propaganda - easier to repair, yada, yada, yada).

No more kids are in my future , but I still like being informed.

Thanks again,

lifeLONGstudent

[SmilingBluEyes]

This may be a silly question, but....

If someone has already had two or more epis, would the buildup of scar tissue necessitate an episiotomy for future births? Especially if the cuts overlapped or were on top of each other? (Just wondering in case I have any more kids, b/c epis are NOT fun)

Thanks

Well, that would depend on the individuals (mom and baby). For example: How badly does mom scar? How much buildup of scar tissue? And how big and what position is the baby in? The answers can vary, so it's not necessarily so that "once an episioitomy, always an episiotomy". Each case must be considered individually. Hope this helps.

[madwife2002, BSN, RN]

I have been a RN/RM since 2000 and I have only seen 3 episiotomies done in that time. 2 for fetal distress and one for rigid perineum. I have never done one myself in more than 200 hospital births and many home births.

I myself as a woman have had a birth with one and a birth without one, and I have to say the healing experience of the episiotomy leaves me with very unpleasant memories.

[AngieSC]

I totally agree with the "only in emergency" philosophy. With my first baby I had an episiotomy that lead all the way to the rectum with full forceps and had stitches on the inside and out. It took me months to get over that physically. It was so painful.

With my other two children the doctors allowed me to tear and it was so much easier to heal. My second child was considerably larger than the first....right at ten pounds and that was so much easier than the after math of the episiotomy.

[keeper]

Landonsles,

I had a friend who had had four episiotomies and went on to have only a skin tear in her fifth birth that required only two stitches. My preceptor midwife has seen good results with clients rubbing rose oil into their scars prior to labor. She never cuts women and in six months working with her, she has only needed to suture one woman. (For smaller skin tears, including mine, she uses prepared seaweed to hold the skin together.)

Sarah