Episiotomy?

[farsk]

Hello Everyone!

DH and I just finished our prepared childbirth classes where we found out that the hospital where we will be giving birth has a 98% rate of episiotomy for first time moms! Yak! We chose this hospital because of the low incidence of c-section only to find out that episiotomys are considered routine. Although I plan on getting the epidural, I DO NOT want a routine episiotomy...but of course if it is MEDICALLY NECESSARY for the health and well being of my child, I will. Of all the info I've read lately, most consider this proceedure unnecessary and in some cases, harmful.

What is your experience with this issue/proceedure? Am I being a complete flake? Thanks in advance for your input!

-Shannon
mom to Ellen (edd 7/28/03)

[Rachels]

This rate is unconscionable. You're right to be concerned. Episiotomy is medically unnecessary (according to legions of medical studies) most of the time, and the practice of routine episiotomy has been deemed one that is "clearly harmful and should be eliminated" by the World Health Organization. It leads to greater severity in tearing, and the cuts from an episiotomy cause more perineal damage than most natural tears. I would be VERY clear with your doctor that you do not want an episiotomy.

There are also some things you can do to help avoid one. Pushing in an upright position, rather than on your back, increases the diameter of the birth canal by 30% and gives the baby more room to come down. It's easier to be upright for birth if you haven't had an epidural, or if it has completely worn off before you push. Also, if you can avoid forceps or vacuum extraction, that will decrease your episiotomy chances.

Your body is made to stretch to let your baby be born. What does this hospital think happened before episiotomies became common? Women throughout human history have been giving birth without being cut to do it. Be firm with your doctor before you go into labor, and tell your partner or husband and your labor nurse to reiterate your wishes when your baby crowns. (You will be in no position to do so-- and you WILL feel like you're going to tear. It's a natural feeling, and it passes.)

FWIW, the most medically indicated reasons to do an episiotomy are vaginal breech birth and shoulder dystocia. You won't be delievering a breech vaginally-- most hospitals don't do that. If your baby's shoulders seem stuck, the most effective way to treat that with the least trauma to your baby is for you to turn on your hands and knees (called the Gaskin Maneuver). Most of the time, that fixes it, no episiotomy needed.

HTH!

-Rachel
Mom to Abigail Rose
5/18/02

[MartiesMom2B]

I didn't want an episiotomy and I let the nurse know. My nurse told my OB/GYN and he said that I would have major tearing if I didn't and the episiotomy would be less painful and easier to repair. As soon as he made the two snips Martie's head popped out. I couldn't sleep at all that night because of the pain that I was feeling between my legs. I did take some major painkillers in the middle of night though. That being said, I was only uncomfortable for 2 weeks, sitting on the Boppy helped a lot. I have had any problems since and no incontinence.

Edited to add: I wanted to have a natural childbirth, but remained flexible after reading about the procedures just in case. My water broke and I was induced with pitocin since I wasn't contracting. My suggestion to you is to discuss this with your doctor and to read/research all you can on any childbirthing intervention because you want to be fully informed of all decisions you want to make with this.

Sonia
Proud Mommy to Martie 4/6/03

[Melanie]

On the advice of my midwife, I took 45 min. skin-temperature baths every night (or almost) during the last month. After the bath, I would squat (usually supported by Dh or furniture) for as long as I could (a few minutes) to help stretch.

When we ended up at the hospital I told both the doctor and the nurse that I did NOT want an epsiotomy, under ANY circumstances. (of course, if it was a matter of health, I would have, but I didn't want them thinking that). I asked the nurse to do perineal massage, either that or she just did. She did this with all of the pre-pushing (the pushing you do before the doc. actually gets there) for about 45 min. and I only had a 'skid mark.'

[brubeck]

When I was giving birth to Amy the head was RIGHT THERE for about 20 minutes as I pushed and pushed. Every time it looked like she was going to come out and she didn't because the head was stuck. Then I started to tear a bit. The doctor gave me a tiny episiotomy (1/4 inch) and pop! out she came.

The tear was much longer than the episiotomy and actually took more stitches and longer to heal. The tiny episiotomy didn't really hurt as long as I kept the ice packs on for the first 24 hours and I didn't need the prescription pain meds they gave me afterwards. I don't really consider this to be a bad experience.

With Andrew I had a very small tear (1 stitch!) and no episiotomy. However his head was 1.5 inches in diameter LESS than his sister's had been.

So I don't think ALL episiotomies are bad, certainly I don't regret mine. But I did talk with my doctor before both births and state how I did not want one unless it was absolutely necessary. They agreed, and I feel like in both cases my wishes were observed.

[mommyj]

Our childbirth instructor suggested perineum massage as a way to try to avoid having an episiotomy. She (and some websites I found that had info on it) recommended starting it around the 34th week of pregnancy. I haven't had my baby yet, so I'm not sure if it works, but I think it's definitely worth a try.

[liya]

I didnt have one since my baby just came out so quickly and did the job himself, but in some cases i feel its necesary you just never know where the little rascals are coming out and where they are going to slice you if they do...You can ask to hold off till the last min, but if its ultimately necesary IMO theres nothing to worry about....it would be exacly like my wound but more precise...My wound was bad he broke me right down to my..., yup you got it in front not in the back...After all the stiching the best is to take care of it and use some dermoplast to keep the area nice and confortable.....

[MegND95]

I did have one, and a third degree tear. OUCH! While I was pushing, the M/W tried to litertally stretch me out to help ease the delivery. Although she did not "deliver" my ds, she directed a very new, young Dr. She later told me that is only one of three episiotomies she has *done*. And in my case, ds had his fist up next to his face, and I guess that's what caused all the trauma. It took a surgeon an hour to repair the damage. Again, OUCH!

Despite the tear and the epi, I recoverd pretty easily, in the first weeks. The immediate pain dissipated pretty quickly. I just took pain meds for a few days and lived with the ice pack pads and witch hazel. My M/W says all has healed nicely. Sex took a little extra time, but after a few months that was no problem.

But, I would certainly make incredibly clear, as some of the other posters suggested, that you do not want one. Tell everyone possible, tatto it on your thighs (just kidding) and make sure everyone in your room knows your wishes. After 30 hours of labor and 2.5 hours of pushing, I did not care what happened, I just wanted him OUT!

I had a planned c/s and a vaginal birth, and both have had their respective issues with regard to recovery. I expected to have vaginal pain after pushing out my baby. But, in all honesty, the pain from my tear and epi lasted longer than the pain of my c/s. After the VBAC, the pain was sporadic, it certainly hung on weeks longer than my c/s discomfort.

Good luck to you and I hope that you can avoid this procedure!

[KathyO]

No, you're not being a complete flake. By all means be clear to the doc ahead of time, and then in the delivery room, that you prefer to avoid this, and that you do not, at this point, consent to one. (You can always change your mind, so this non-consent is not an irrevocable thing.)

In a perfect world, I would have preferred to avoid one, but I have scar tissue from an earlier operation in that area, and scar tissue doesn't stretch too well. So, at the critical moment, the doctor gave me a quick local anaesthetic and a snip, and I really didn't notice either of them, and was too preoccupied with the baby to pay much attention to the stitching afterwards. I had all the usual terrors that it would split apart when I sneezed/had a bowel movement/etc. - of course, it didn't. And resuming sex was probably a little more uncomfortable at first than it might otherwise have been, but that didn't last either. I was afraid to look at it for the longest time, but my husband insisted that the scar is invisible now, and I finally got out a hand mirror and - hey, he's right! I don't mean to say that this means you're incorrect to want to avoid one - I just offer it as a (fairly) positive experience in case you do, for whatever reason, find yourself with one.

Hope that helps!

Best,

KathyO

[chrissyhowie]

Wow. 98% is a very high rate of episiotomy. I echo Rachel's statement about the legions of medical literature that is available that is against the routine use of episiotomy.

That being said, there are certain situations other than breech vaginal delivery and shoulder dystocia that warrant episiotomy. Sometimes maternal exhaustion can play a large role in the decision to perform an episiotomy, just as many moms here have shared their experience of pushing against that last bit of perineum. In addition, if there is evidence of a non-reassuring baby heart rate tracing, there may be a need to deliver the baby sooner rather than later, and performing the episiotomy may provide a means to achieve this. But there is absolutely no role for just cutting the episiotomy without reason or to "prevent" tearing.

Episiotomies heal in the same manner as a tear, so one would not necessarily cause more pain than the other. In fact, I have seen many a tear that was much worse than an episiotomy incision! But again, no one should be cutting you without having an indication or reason to do so. Definitely ask your Ob about his or her attitude toward episiotomy use (tell your Ob about the 98% epis rate), and express your desire not to have one unless medically indicated.

[C99]

Shannon,

Talk to your OB. I was *petrified* of having to have an epis. and thought of bringing in a doula to prevent that. As it turned out, my OB is a big believer in perineal massage -- and in fact, he did little else when I first started pushing. I didn't need an epis., although I did tear a bit.

[stillplayswithbarbies]

Here is a past thread about this:

http://www.windsorpeak.com/dcforum/DCForumID30/1244.html

My story is in that thread. The short version is that the episiotomy was the worst thing I have ever experienced in my life and I will never never let anyone do that to me again.

With my second baby, I had a small tear that healed very easily. What a difference.

...Karen
Jacob Nathaniel 2/27/91
Logan Elizabeth 3/25/03

[houseof3boys]

I was also so opposed to having an episitomy and wanted to tear naturally if it was going to happen at all. We started doing perineal massage about 3 weeks before my delivery thinking that would help. When it came down to the two hours of pushing where you could see the head the ENTIRE time (13.5" of pain), the midwife applied warm compresses and swiped KY around his head most of the time. She asked if I was sure I didn't want a snip and I gave an adamant NO. Here I am 6 days after the delivery and I am still in excrutiating pain. I apply ice packs and sit on the rubber doughnut from the hospital all day long with only little relief. I am taking Advil every 5 hours and taking Arnica tabs as well to help. I was so into my natural childbirth goal that I had and an episitomy didn't seem natural to me. I would really have to read more opinions and studies on it and make a decision for the next baby but boy oh boy do the tear/stitches hurt! I think it depends on the size of your baby and how well he does on his journey out and you won't know that until he is almost there...

[sparkeze]

With a rate like that you should dedicate a whole page of your birth plan to how you don't want one!

I had one because I gave birth with forceps and I think it comes pretty standard with that. It was most definitely painful for many days afterwards, but unavoidable with the forceps.

Ideally, in an unmedicated birth you shouldn't have anyone directing your pushing. Someone could suggest different positions or ideas of course, but by feeling the baby's head one would be able to push gently enough to not tear much. Or that's what I've read anyways - obviously I haven't done it.

Who knew I would have a baby with such a big head? Not me!

[mharling]

Wow, that is a very high rate! I discussed epis. during a regular ob visit and was relieved to learn that none of the doctors 'routinely' performed them and generally tried to avoid them. I did not want and did not have one. I'd like to think that I would have had the same outcome regardless of the DOCTOR'S views of it. :)

Mary & Lane 4/6/03
http://www.shutterfly.com/osi.jsp?i=67b0de21b33928e40550

[AngelaS]

WOW! I've never heard of such a high rate!!

I tore slightly with my first, but since my midwife was massaging, it wasn't bad and I mostly stretched.

With dd2, I sat my bed almost straight up once baby's head was over the pubic bone, my midwife massaged and pushed back baby's hand that was next to her face and POP out she came....no tear, no episiotomy.

Is there a CNM who works at your hospital? :)

[Rachels]

That's true. I gave birth naturally, sitting on a birthing stool, and nobody coached or counted or told me when to push, ever. If you can feel to push and you follow your body's cues, you will deliver at a rate that helps protect your perineum by giving it time to stretch. I didn't tear, and neither did any of the women I interviewed for my dissertation, even though several had 10+ pound babies. FWIW, sustained, directed bearing down (as in, chin to the chest, push to the count of 10, big breath, do it again) has also been deemed a practice which is harmful and should be eliminated by the W.H.O.

-Rachel
Mom to Abigail Rose
5/18/02

[mama2be]

Can I just say if someone counted to 10 every two minutes while I was pushing I would have killed them!!!!!
:)...you witness this on TLC all of the time...

[flagger]

>Can I just say if someone counted to 10 every two minutes
>while I was pushing I would have killed them!!!!!

I did that for Ms. Flagger. They probably could have heard my counting in SC. ;) She was sunny side up and went transverse, finally some manipulation and she was facing how she should be. With the Epidural, Ms. Flagger pushed for an hour and twenty-one minutes. She is soooo glad though she had the epi.

No episiotomy, but she had a 1 degree internal tear.

Edited to add: I don't know this maternity centers episiotomy rate, but their epidural rate is about 80-95%.

[jojo2324]

Hi Shannon!

Just wanted to share another side of the epis. story. I didn't want one AT ALL, and was already in a state when I saw the OB get the snippers out. Then I REALLY started crying. They (the OB and nurses) explained that it was necessary that it be done, a tear is worse than a cut, blah blah blah. In my mind I knew that it was false, but I was to the point of utter exhaustion. I had been pushing at that point for nearly an hour and a half, and I had been without food or drink for over 20 hours. I just wanted the d@mn kid out! :P

So I was cut, and required 4 stitches. Really, what hurt the most was the anesthesia she injected before cutting. And it did hurt a few days PP, but really, I couldn't tell you if it was the epis. or the fact that my nether regions had just done what they did. ;) Gotta love those ice packs! I would say that my epis. was very good, considering the stories I've heard. But it does seem like 98% is astronomically high.

[dogmom]

I agree that a 98% episiotomy rate seems incredibly high. My hospital only had 8%, and there are not considered very natural. Having said that, I was sitting upright for most of my labor, didn't have counting, had a lot of perineal massage, but the head was big, it was my first and I tore. The literature seems to indicate that there is nothing wrong with tearing vs. an episiotomy. I didn't find the pain that bad, but I guess it varies. I good approach would be to ask your OB about the episiotomy rate and the logic for it. For all you know the rates have dropped since the rates were done. You can certainly demand they don't do one on you, but bringing it up before you are in labor would be nice.

Jeanne
Mom to Harvey
1/16/03

[nitaghei]

That does seem to be a high rate!! I would definitely talk with your OB about what you want.

FWIW, here's my experience (and it isn't pleasant). I'd made it clear that I did NOT want a routine epi, and had a birth plan, DH and a doula to back that up. But things really don't work out the way you expect. DS was face up, had a larger than average head and a short umbilical cord. It ended up being a vacuum extraction, after 16.5 hours of labor and 2 hours of pushing. My OB gave me the smallest possible epi. I had HUGE tearing beyond the epi. Let me put this way - it took the OB over an hour to finish the stitching up the cut and tears. And recovery from the tear definitely took longer than that from the epi.

The pain was pretty bad, and I was popping the pain pills for at least 3 weeks afterwards. However, my recovery was probably slowed down by the fact that DS had to go back to NICU 2 days after we brought him home - and I spent the first week running to NICU and sitting in not very comfortable chairs, instead of resting at home. It was probably 3 months before I felt I had recovered.

Having said that, I still believe that a episiotomy should not be routine, but performed only when medically necessary (as it was for me).

HTH - and doesn't scare you too much!

Nita

PS: Despite that - I was telling DH, within 24 hours, how we needed to give DS a sibling! :)

[stillplayswithbarbies]

Same here, Rachel. I did most (all) of my laboring at home sitting up in my comfy easy chair. By the time she was ready to come out, my body was ready and she practically slid out. (almost in the car haha we waited a little too long at home, but hey American Idol was on and I wanted to see it)

Had I been in the hospital all that time, it would not have gone so well. I had 12 hours of easy slow labor and in the hospital they would have wanted to speed things up, meaning that I would have been pushing against a pelvic floor that was not ready yet. (that's what happened with my first)

Oh and I too would have smacked anyone who counted to 10 to tell me how long to push. My body knows what it is doing and will push when it makes sense to do so. How can a doctor on the outside looking in know what my body is ready for.

...Karen
Jacob Nathaniel 2/27/91
Logan Elizabeth 3/25/03

[zen_bliss]

i posted the original "fear of episiotomy" thread. i was right there with you. i think 98% is pathetic and signals an overreliance on the current 'easy on the doc' trend in western medicine. tsk tsk.

i ended up having one after all. DH said it was obvious that it was the right thing to do, which is a help. at the moment, if the doc had said 'i'm amputating your toe now' i'd have said 'go for it.' her head was *right* there for awhile, i was simply so exhausted that my legs were rubber (no epidural) and after the fact, DH said it probably would have been another 20 min of pushing -- 20 min i did not have in me after suffering horribly from being overdosed with pitocin by a sadistic nurse who was anti-natural birth. now pitocin -- stay the hell away from pitocin at all costs if you can.

the doc gave me the choice of a 'pressure' episiotomy or a local, i opted for the local. little pinch, then the snip sound, but no pain. i had a lot of stitches. i couldn't bring myself to look, or ask. afterwards, lots of ice, lots of sitz baths, and dermaplast spray. it did make getting out of bed and walking around difficult for the next week and a half, and going to the bathroom required as much planning and equipment as a military invasion: sitz bath, water bag, peri bottle, wipes, dermaplast spray, fresh pad, tucks... but it is forgotten now. the possible unintended benefit is that she had a perfect little head, no squishing -- nurses kept saying she looked like a c-section baby.

i hope you won't need one, i hope they won't try to force one on you in a vulnerable moment. DH can be a great advocate/run interference for you. As everyone has said, make sure your preference is known to everyone around you, and make it clear that you expect the doc to ask before doing anything.

best wishes for a good birth experience!

[Jenmv]

98% does seem way too high!

In my case my daughters heart rate started dropping dangerously low with the contractions by the time I was 10 cm and the DR wanted her delivered asap. This required the use of forceps(dd had too much hair for the vacuum to stick) and I wound up with a third degree epi. She was born within 15 minutes after I started pushing! Even the nurses were extra sympathetic and commented on how many stitches I wound up with, but much to my pleasant surprise after all of that, I have to say that the pain and healing was not nearly as bad as I thought it would be and I don't have any permanent damage that I can tell.

So I truly hope you do not need an epi, but wanted you to know they are not always as scary as you think they will be either.

[daisymommy]

>FWIW, sustained, directed bearing down (as in, chin to the
>chest, push to the count of 10, big breath, do it again) has
>also been deemed a practice which is harmful and should be
>eliminated by the W.H.O.

I remember reading this in the official Lamaze book "Preparation for Birth" by Beverley Savage. When it came time to push with Joshua, the midwives (whom I loved), told me to do this very same thing!?! I was too scared and exhausted to argue with them. Well, I ended up passing out right at the end, going into shock, and had to be put on oxygen! I woke up feeling like I was going to vomit, and sat up suddenly which made Josh come flying out with such force that that they literally had to catch him, and I tore upwards big time. NOT FUN! So, to make a long story short, I agree that this is a dangerous way to hold your breath and push.
What should I say to them next time when they tell me to do this? I will probably stick with the same midwives place because I do love them, but that's one thing I really disagree with!

[MartiesMom2B]

My favorite TLC birth story moment was when a husband was trying to soothe his wife with massage or something (I think she was wanted to be hypnotized)and she yells at him "don't touch me!" LOL

Sonia
Proud Mommy to Martie 4/6/03

[Rachels]

Yep, and medical research is on your side. This is habit, not medicine. Again, think about how this was done before the advent of electronic fetal monitoring (which, by the way, has been repeatedly shown to increase the incidence of cesarean section by two to three times as much with NO increased margin of safety for mom or baby). Women pushed when their bodies told them to push. The body knows how to deliver a baby without coaching or instruction. Women who push according to their body's instructions have a much lower incidence of tearing, too.

I would talk about this clearly and directly with your midwives during your next pregnancy. Find the W.H.O. guidelines for care in normal birth and bring them to your prenatal appointments. Then hire a doula to help advocate for you at that moment, and tell your DH to tell anybody who is doing this to stop. Chances are you'll push more effectively with considerably less trauma.

-Rachel
Mom to Abigail Rose
5/18/02

[justlearning]

I agree with others that you definitely have a right to be concerned with the hospital having a 98% rate. Before giving birth, I discussed the episiotomy issue with my doctor and he said he only does it if he thinks it's necessary (I was happy to hear that). Well, I did end up getting an episiotomy because my baby seemed to need some extra help and space coming out, so my doctor used the vacuum. (My son was 10lbs., 13 oz.)

I just wanted to say that the episiotomy wasn't bad at all for me. (I'm thankful, especially after reading the others' stories.) I was only sore down there for about 4-5 days afterwards but didn't have problems sitting--except I needed to put a pillow down on our hard rocking chair before sitting on it. I used the water squirt bottle and Dermoplast that I was given by the hospital for about a week. I asked them for a sitz bath but never ended up using it. One thing I was careful about was taking Fibercon tablets and stool softeners so I didn't have to strain when having bowel movements--otherwise, that would have been very painful, I think. A week after my son was born, we took him on his first stroller ride and I was able to walk a good distance without feeling too uncomfortable.

So...I think you should be concerned about the hospital's rate but hopefully if you do end up needing an episiotomy, you won't experience major problems with it.