EPISIOTOMIES (or “things that make my vagina want to suck up into my body”)

WARNING: GRAPHIC IMAGES!

Episiotomy…one of the few words in my field that truly makes my stomach flip. Simply put, an episiotomy is when a surgical cut is performed with scissors to the perineum (area between the vagina and anus) during the birth of a baby. My stomach flips just writing that…think about it! We’re talking about using surgical scissors to cut your vagina – holy cow!! My pelvic floor just sucked up to my throat just thinking about it….yikes!

People, it seems, don’t want to talk about episiotomies – and I can’t say I blame them! It’s not a pleasant thing to think about by any means, but because they are still WIDELY used (one study showed an 83% rate in the US) I think it’s an important topic to discuss, no matter tight my knees need to be during the discussion (as I mentally try and protect my bottom) and no matter how hard you will wrinkle your nose and try and look away…it’s important to talk about this!

WHAT THEY SAY:
Why do care providers do episiotomies? There are a lot of answers to that question – but most are hogwash. Let’s address each one, shall we?

* To prevent tearing
First off, how do we know you will tear when you birth your baby? Are we psychic? Can we look at your skin and tell how much it’s going to stretch? Of course not! And there are so many factors involved with how much your skin will stretch that there’s absolutely no way to predict. (I will get into those factors later)  Even when they say, “if it looks like you will tear” or “I will make that determination when the baby’s crowning”…I still call BULL!! I have seen too many times when baby is crowning, all signs point to tearing, looks like a super tight fit, I’m bracing myself for a lengthy repair….only to look afterwards and say, “Wow! She doesn’t even need a single stitch!”
Secondly, what is so wrong with tearing? What makes an episiotomy preferable to tearing? The only thing that makes it better than a tear is how easy it may be for your care provider to repair it. Tears, it has been shown, heal faster with less scar tissue and less pain than an episiotomy – the relatively rough edges of a tear ‘grip’ better and heal better than an episiotomy. Also, a tear will go through the thinnest tissue first – with your baby only taking from your body what it must in order to be born. An episiotomy will go through *this* arbitrary tissue right *here* with our scissors…and it’s probably a much thicker tissue that would have been totally fine if we hadn’t intruded with our scissors.  So compared to an episiotomy – tears hurt less, heal faster, have less long-term effects to our sexual function, less long-term effects on incontinence issues, less risk of infection……so we’re doing an episiotomy to save us from these things WHY?
Thirdly, an episiotomy can actually cause more severe tears/injury to the area!! We used to think that doing an episiotomy would prevent bigger injuries to your bottom because we controlled the direction and amount of injury…and we have since found that it’s not the case. Yet I still hear this time and time again from care providers – they will do an episiotomy and say, “it’s to prevent her from tearing into her rectum” (or some such rhetoric). Studies do NOT back that up and, in fact, show that episiotomies increase the risk of that happening!! At least one study showed that doing a routine episiotomy more than doubled your risk of those more severe injuries/tears to your bottom!!

* To prevent incontinence later
As I said before, an episiotomy doesn’t help prevent those more severe injuries to your bottom and can even contribute to them…so it should come as no surprise to hear that it doesn’t protect your bottom from having problems later in life, too! In fact, bowel incontinence is increased if you have an episiotomy. As for urinary incontinence (peeing yourself a little when you laugh, sneeze, etc) – I’ve heard this as an excuse to do an episiotomy as well as a supposed benefit to a cesarean…and it’s not true. Urinary incontinence is a risk we take when we choose to grow older…regardless of whether we’ve had a baby or not! In fact, studies have shown that postmenopausal nuns that have never been pregnant have similar urinary incontinence issues as postmenopausal women who have had multiple babies vaginally! So understanding that age (and gender) are a greater factor for this problem, and understanding that episiotomies increase the risk of greater trauma to your bottom…how can anyone possibly think that episiotomies HELP us later on??

* Baby’s big
Ssssoooooo……? Unless you’re inferring that a big baby is more likely to cause your vagina to tear and therefore you’re doing an episiotomy to prevent a severe injury to her bottom, then I don’t understand what difference this makes? And if that’s what you’re inferring, then I would like to point you back to the section “to prevent tearing”.
If what you’re inferring is that the baby won’t be able to squeeze through unless you cut an episiotomy….hogwash. The difficulty in birthing a baby is a BONEY PELVIS issue, not a soft tissue one. If baby can fit through your bones, it can fit through your soft, squishy, stretchy skin tissue! An episiotomy does nothing about your boney pelvis, and if your pelvis can open up for your baby then I’m sure your skin can…and if it can’t then you might tear some, in which case you’re definitely no worse off than if you’d had an episiotomy.

* Pushing too long – speed up delivery
Pushing too long according to whose time table? Not only that, but an episiotomy has not been shown to notably speed up a normal delivery.

* Delivering too fast
Yep…if you’re delivering too slow they might cut you, and if you are delivering too fast they might cut you. You can now see why it’s so important to talk to your care provider before you are in labor!

* Baby’s heartbeat tells us that baby’s in immediate danger
YES! This may be a legitimate reason to do an episiotomy…if it gives us more room to work to assist in getting that baby born faster, yes….then all of the risks of an episiotomy may be worth it! If you or your baby are in immediate danger, then we do what we have to (episiotomy, forceps/vacuum, cesarean…) and deal with the consequences later.

FACTORS THAT CONTRIBUTE TO WHETHER YOU TEAR OR NOT:

Earlier I mentioned that there are so many factors involved with whether or not you will tear that neither I nor anyone else can looking at you and predict if you will tear. There are, however, many factors well within our control which may influence your likelihood of tearing or not.

1. Your general health and hydration: good diet, good fluid intake, healthy lifestyle…all make our skin beautiful and glowing and stretchy. The skin in our vagina (pink, sensitive, stretchy) is very similar to the skin on our nipples….and also our lips. Think about those three areas and you will find many similarities. Have you ever been dehydrated, not taking care of yourself, and go to laugh at something and your lip splits? Your mouth is made to stretch open in a variety of configurations (including a smile)…but not being healthy has caused it to fail at its job. Same thing with your vagina: take good care of your body and health and it is likely to stretch and do the job it was meant to do. Unhealthy, dehydrated….not as likely to perform up to its full function.

2. Your position for pushing: Please look at this picture I have labeled for you… …notice the J shaped curve that the baby must navigate while you are pushing in order to be born. If we were to take this picture and rotate it 90* so that she was laying on her back, you would notice that not only is she pushing completely uphill, but that the baby would need to go up and OVER the perineum like a ledge, putting maximum pressure on that area as the baby is born. Different positions effect the bottom in different ways and can increase or decrease the risk of the mother tearing. (this is all I’m going to say about pushing positions as I could do an entire blog post on just this one subject – and might in the future)

3. Speed of delivery – and almost always the influencing factor to this is not how fast you birth, but how fast you’re told to birth. Usually a woman will listen to her body’s signals and push with great force when needed, but lightening up and slowing down when her body has stretched as much as it is comfortable stretching at this point. When she is instructed how to push, counted to, told “harder harder…more more…keep going..” she is inclined to over-ride her body’s signals to slow down and increases her risk of tearing.

4. Genetics: unfortunately we know that some of us have better skin than others…and so yes, this can be a factor. A minor one…but an issue nonetheless.

5. Position of the baby: A baby who is coming out with a hand by their cheek, or who is coming out rather sidways, or who is coming out posterior (facing your pubic bone) increase risks to your body…and often mothers with babies in these positions rock and move and assume positions during labor and pushing that give her the best chance to overcome this challenge.

HOW TO TALK TO YOUR CARE PROVIDER:
I’ll give you a hint…it is extremely rare to find a care provider (doctor, midwife) who will admit that they do “routine episiotomies”! They almost ALWAYS will say, “Oh no…only if she absolutely needs one!”
That will be their answer if you ask them, “do you do routine episiotomies?” so let me give you a better question to ask: “When do you do an episiotomy?”
If your care provider responds with, “only if it looks like she will tear” or something similar…then you have your answer. If s/he says, “I will make that decision at the time..” then you have your answer. If s/he says, “Only if there is an emergency and the baby’s in trouble…”
Well, then…..there you have it.

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