Episiotomy and How to Avoid It
Once thought to be a beneficial procedure that would make birth easier for the baby and protect the mother from trauma to the birth canal, episiotomy has been found in study after study to be more harmful than beneficial except in a few cases. Yet, it continues to be practiced routinely in many hospitals in the U.S. and around the world.
Get Through Childbirth in One Piece!
An Original Article for MidwifeInfo by Elizabeth Bruce*
Episiotomy is the cutting of perineal tissues during delivery. Women are not routinely anesthetized before an episiotomy. This inhumane treatment is based on the theory is that ?she won?t feel a thing? due the baby?s head on the perineum. While there is a natural numbing effect, the area is still sensitive to pain during this time.
Most American doctors believe that women need an episiotomy to give birth. They espouse that stretching may leave the muscles a little slacker than will a carefully timed episiotomy; one in which the perineum wasn’t allowed to stretch excessively before the incision was made. Nonsense! It sounds credible, but there is not a scrap of research to back this statement up [believe me, I?ve looked]. An article in Obstetrics and Gynecology recently concluded, ?Routine episiotomy is no longer advisable.? Unfortunately, the practice continues. A woman giving birth vaginally in America today has at least an 80% chance of receiving an episiotomy. A research review by the World Health Organization, however, indicates that evidence only supports a 5 to 20 percent rate. While billed as a simple operation, episiotomy carries the risk of complications, including excessive blood loss, hematoma formation (a form of swelling or bruising), infection, and abscessing. Even with a small episiotomy, sexual functioning can be affected. Unfortunately, postpartum pain can make it harder for new mothers to breastfeed and bond with their infants.
The good news is that there are many things you can do to get through childbirth intact. Here are my suggestions, based on experience and careful research:
Choose Your Attendants Carefully. The clinician is the one who makes the final decision to cut, usually when you are not in a position to argue. A recent study of first-time mothers shows that the number-one risk factor for episiotomy is your care provider. In one hospital study, midwives performed the fewest episiotomies (21.4%); faculty physicians performed in the middle, and private providers cut the most episiotomies. For midwives who deliver out of the hospital, rates are often even lower. Birth center episiotomy rates average about 7%, while some lay midwives have rates as low as 1%.
Try a Waterbirth. Giving birth in the water significantly reduces your chances of receiving an episiotomy. In one British study, the episiotomy rate was five times lower in the waterbirth group when compared to the control group. Michel Odent confirms these results: ?On the occasion of his 100th water delivery, [he] reported that in 100 waterbirths he had attended, there were no episiotomies performed and only 29 cases of tearing, all of which were minor surface tears.? For many women, immersion in warm water during labor is a dream come true. It lowers the woman?s blood pressure and reduces pain, and labor is often quicker in the water.
Hire A Doula. Hiring a doula is a great asset for keeping your perineum intact. A doula is a woman who stays with you during labor and helps both you and your partner to feel comfortable. It is possible that just having another women with you during labor helps reduce blood pressure, stress, etc. Whatever the reason, doulas work. In one study, the presence of a doula resulted in a 60 percent reduction in epidural requests, and a 40 percent reduction in forceps deliveries. Both procedures are major contributors to high episiotomy rates.
Before Delivery: Simple, but Effective Preparations Kegels are exercises that you can perform anywhere, anytime. Practice 10-20 kegels a day until delivery. Concentrate on releasing the muscles as well as tightening them. Women who have a scar from a previous episiotomy or tear often worry that they will tear again along the same line. Because scar tissue is less pliable than regular skin, some midwives recommend rubbing hypericum ointment into the area prenatally to prevent re-tearing. Many women with previous episiotomies have gone on to give birth intact, often to bigger babies!
To Massage or Not to Massage? Perineal massage, in which the perineum is massaged with or without oil in the weeks preceding childbirth gets mixed results in medical studies. Many studies show that massage protects against perineal trauma in first-time mothers. Other studies contradict this finding, and show no benefits to perineal massage in any mothers. A homebirth study actually associates perineal massage with higher rates of damage. The bottom line (pun intended) is you should do massage if you?re comfortable with it, but otherwise, don?t feel obligated to try it.
During Delivery: Position, Position, Position! The position you assume when giving birth may be the most important factor in avoiding perineal damage. The top positions for preventing tearing are (drumroll, please) hands-and-knees and kneeling. Side-lying is better than on the back, if necessary. The knees should always be about shoulder-width apart during delivery ? no wider. Knees should be pointing forward, not to the sides. Studies show a significant reduction in tearing when the mother assumes either a hands-and-knees or kneeling position at delivery. In these positions, the baby gets a better supply of oxygen; the mother is comfortable; there is minimal tearing, maximum opening of the pelvic outlet, and relaxation of the perineum.
Avoid the Epidural. Avoiding an epidural is also necessary to preventing perineal damage. In one study, women with no analgesia had the highest rate of intact perineums, that is, no episiotomy or tear (34.1%), while women who received epidurals had the highest episiotomy rate (65.2%) Another study shows that women who got an epidural were more than three times as likely to suffer third- or fourth-degree tears (tears into the rectum). An epidural prevents the mother from assuming optimal positions during delivery. She is denied the natural sensations of an urge to push, and has to rely on external sources to tell her when it is appropriate, instead of listening to the wisdom of her body.
Good Management of Delivery At a typical home or birth center birth, a skilled midwife will deliver the baby in such a way as to minimize trauma to the mother?s perineum. She helps the mother assume an upright position, encourages her to soak in warm water, and eases the infant gently into the world, one shoulder at a time. Many midwives use hot compresses and olive oil to further ease the transition. They let the mother know that she can trust her body to help the baby out in his own sweet time, as long as there is no fetal distress. If you make it through delivery without lacerations, you may be amazed at how normal you feel. Most women can comfortably get up and walk around the very first day after an unmedicated, intact birth. The perineum will still be sore, but you may not even need pain medication.
1. Eisenberg, Arlene et al. What to Expect When You?re Expecting. NY:Workman, 1996. P.285.
2. Eason, E. and Feldman, P. ?Much Ado about a Little Cut: Is Episiotomy Worthwhile?? Ob/Gyn 95 (4):616-8. April 2000.
3. Bowes, Watson. ?Should Routine Episiotomy be Performed Routinely in Primiparous Women?? Ob/Gyn Forum 5, No. 4 (1991):1-4.
4. Wagner, Marsden. Pursuing the Birth Machine: The Search for Appropriate Birth Technology (Camperdown, South Wales, Australia: Ace Graphics, 1994), 165-174.
5. Robinson, JN et al. ?Predictors of Episiotomy at First Spontaneous Vaginal Delivery.? Obstetrics and Gynecology. 96(2): 214-18, Aug. 2000.
6. Otigbah, CM et al. ?A Retrospective Comparison of Water Births and Conventional Vaginal Deliveries.? European Journal of Obst/Gyn & Reproductive Biology. 91(1):15-20, July 2000.
7. Harper, Barbara. Excerpt from Gentle Birth found on www.waterbirth.org/whywater.html
8. Balaskas, Janet. Active Birth. Boston: Harvard Common P, 1992. P. 209.
9. Klaus and Kennel. Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth. (Old Tappan, NJ: Addison Wesley Longman, 1993).
11. Labrecque, M. et al. ?Randomized Trial of Perineal Massage During Pregnancy.? Am J Obst/Gyn. 182(1 pt. 1): 76-80, Jan. 2000.
12. Aikins-Murphy P. and JB Feinland. ?Perineal Outcomes in a Home Birth Setting.? Birth. 25(4):226-34, Dec. 1998.
13. Nodine PM and Roberts J. Factors associated with perineal outcome during childbirth. J Nurse Midwifery 1987 May-June;32(3):123-130.
14. Legino, LJ et al. Ibid.
*Elizabeth Bruce, mother of four, is the author of Get Through Childbirth in One Piece!: How to Prevent Episiotomies and Tearing , available through barnesandnoble.com. She is a CCE with Birth Works, and can be contacted directly at Wals01@cs.com. Elizabeth also has a website where she addresses episiotomy issues; the address is www.intact-birth.outputto.com
The following comment on episiotomy was taken from the website for the American College of Obstetricians and Gynecologists.
WASHINGTON, DC — Episiotomy should not be a routine part of labor and delivery according to a Clinical Commentary in the April issue of Obstetrics & Gynecology. The American College of Obstetricians and Gynecologists (ACOG) does not recommend routine use of episiotomies. However, the study authors conclude that the procedure is still performed too frequently (one third of live births in 1996) and does not result in decreased incidents of urinary incontinence.
An episiotomy is a surgical incision made into the perineum area between the vagina and the anus to widen the vaginal opening and help shorten delivery time. Historically, the procedure was thought to prevent maternal pelvic organ prolapse, urinary incontinence and lacerations that healed poorly. Doctors also believed that a prolonged labor led to birth trauma, cerebral palsy and other neurological disorders in the infant. Not true, according to commentary authors Erica Eason, MDCM, FRCSC, from the Department of Obstetrics and Gynecology at the University of Ottawa, and Perle Feldman, MDCM, FCFP, from the Department of Family Medicine at McGill University in Toronto.
The authors reviewed numerous short- and long-term studies comparing women who delivered with an episiotomy to those who did not. They also looked at studies on the development of infants delivered after an extended second stage of labor compared with those delivered after an episiotomy. They found no significant differences in infant outcome. For certain maternal conditions, women without episiotomies fared as well or better than women who received episiotomies.
Even long-term studies that followed children and examined their IQ and motor deficits at age seven showed no correlation between poor neurological outcomes and length of labor, the authors reported.
Studies revealed that women with intact perineums or those who delivered via cesarean section had the strongest pelvic floors and were therefore less likely to end up with a worse prolapse than women with episiotomies. The studies also found no differences in incidence of urinary incontinence. In fact, women with intact perineums experienced less blood loss, less risk of infection and less perineal pain after delivery.
The authors identify several factors that may influence whether an episiotomy is performed including a physician’s time pressures, malpractice concerns, lack of experience with slow perineal stretching, and a style of practice that emphasizes intervention. They added that the medical profession should abandon conventional teaching that a longer second stage labor and perineal stretching are harmful.
Contact: Erica Eason, MDCM, FRCSC, at the University of Ottawa via e-mail at firstname.lastname@example.org.