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.

19 Comments

  1. Amy Drorbaugh wrote:

    LOL! I loved the title.

    Monday, April 12, 2010 at 12:40 pm | Permalink
  2. Sheridan wrote:

    Great post! I love the questions to ask a care provider at the end and the answers and what they may mean!
    Thanks!

    Monday, April 12, 2010 at 1:07 pm | Permalink
  3. Stephanie wrote:

    Thanks so much for all the great info! My mom did nothing my entire pregnancy but tell me how I needed to make sure they gave me an episiotomy! She tore into her rectum with her 3rd, the only non-episiotomy after 2 routine ones…surprise surprise she had such an awful experience right. Anyways, she was convinced it was because my brother was too big and they wouldn’t routinely do it. So now for all future birthers in our family we hear nine months of this garbage. Scared the bejeezus out of me until I started doing my own research, so I really really appreciate reading such great info.

    Monday, April 12, 2010 at 1:43 pm | Permalink
  4. Kelli wrote:

    I know you said you don’t need to write a book in a previous post because they have been written before but maybe a pamphlet on “How to ask your care provider questions so you get their honest answer.” And then I could find a way to sneak them in every hospital L&D handbook in town before OBs pass them out. Strange that these are my exciting daydreams…thanks for another great post!

    Monday, April 12, 2010 at 6:38 pm | Permalink
  5. mystic_eye wrote:

    I believe that “or who is coning out posterior” should be coming not coning… but I admit I could be wrong as coning is a whole other thing

    Monday, April 12, 2010 at 7:22 pm | Permalink
  6. mystic_eye wrote:

    However, I had another question regarding repairing tears.

    My midwife couldn’t stitch up my tear until the next day (looooooong story) and she found it was much easier to approximate the edges because the swelling was gone. Of course if you use lidocaine or similar you are going to have swelling from that.

    I know it used to be a rule that they wouldn’t stitch wounds that were older than a certain amount of time (often 24 hours). But her careful stitches I think have finally corrected the damage caused by my first baby and the horrific repair job that was done.

    I was wondering if you had any thoughts on that.

    Monday, April 12, 2010 at 7:25 pm | Permalink
  7. Lindy wrote:

    OMG I love this post! My mom was in nursing school when I was born back in the mid 80’s and ALWAYS said “It’s better to cut than tear”. (Ironically she has still has lots of bathroom issues from her episiotomy.) She still kind of believes in them and recently said “Well you were breech- I HAD to have an episiotomy!” to which I replied, “Probably not if you had been squatting!” Ugh! The indoctrination of the hospital system- UCK! I just hope things continue to change!

    Monday, April 12, 2010 at 7:26 pm | Permalink
  8. Julie Westover wrote:

    Ouch! Just felt so upset thinking about what doctors know and what women DO NOT KNOW… time to start talkiing more, rather than silently feeling this —ouch!!!

    Tuesday, April 13, 2010 at 10:33 am | Permalink
  9. mishalee wrote:

    What are your feelings on perineal massage? Dr. Brass recommended it to us near the end of our pregnancy and I think it helped a lot.

    Tuesday, April 13, 2010 at 1:13 pm | Permalink
  10. elfanie wrote:

    Mishalee:
    I’m not as much of a fan as she is…see this blog post for my reasons…(about halfway down)

    Tuesday, April 13, 2010 at 3:02 pm | Permalink
  11. Amanda wrote:

    Nice blog! A midwife once told me that if you put the two halves of a perineum in the same room together, they would find each other. It brought a nice visual to my mind!

    Thursday, April 15, 2010 at 6:56 pm | Permalink
  12. I had an episiotomy with my first baby and a terrible repair that resulted in a surgery to fix it 22 months later that was very, very painful.

    I opted to let things happen as they would with the next three. I still tore but better results. The last two were home birth babies had the repairs were done by a patient midwife and it made the world of difference how it felt due her wonderful repair. I felt comfortable to sit almost immediately afterward and they healed much quicker.

    Friday, April 16, 2010 at 8:30 am | Permalink
  13. Liz wrote:

    This is great! i was told by my doctor i needed to be cut. i refused. i had my daughter without a tear. i didnt need a single stitch. because of that dr. i am going to use a midwife/doula for every pregnancy here on out.

    Sunday, April 18, 2010 at 11:38 pm | Permalink
  14. Tracy wrote:

    What a great post. Still annoys me to this day that I had an episiotomy with my first baby. They just did it with no warning and the recovery from that was far worse than one small tear and non-episiotomy births since then.

    On a side note, I would LOVE to read your thoughts on pushing positions! 🙂

    Wednesday, April 21, 2010 at 2:46 pm | Permalink
  15. Sara wrote:

    The birthing position thing annoys me because I wanted to badly to push upright for my delivery but of course was put on the bed when I arrived pushing (not quite on my back but not squatting like I had been doing at home). I only tore a little during the delivery but I feel like if I had been allowed to push in the position I wanted to I might not have torn at all.

    Thursday, April 29, 2010 at 1:26 pm | Permalink
  16. Maggie wrote:

    Please DO write an entire blog post on pushing positions…that would be fab. And as always, I bow down to your amazing logic. You are AWESOME.

    Friday, May 14, 2010 at 12:43 pm | Permalink
  17. Christina wrote:

    Very nice blog! I am gonna share it to my female friends. I am Eastern Europaen and here giving birth to 1st baby means 99% chance of episiotomy. I opted for a doula and she helped to avoid that nasty experience. My friends simply did not believe me. I had some tears, only to the upper tissues, 1st grade, not that bad. 3 stiches, then next day I moved, walked, sat and took care of my newborn normally. After 6 weeks there was no visible scars (checking in mirror) 🙂 I was very happy!

    Tuesday, July 19, 2011 at 3:57 pm | Permalink
  18. sajid wrote:

    What a great post. Still annoys me to this day that I had an episiotomy with my first baby. They just did it with no warning and the recovery from that was far worse than one small tear and non-episiotomy births since then.

    On a side note, I would LOVE to read your thoughts on pushing positions! 🙂

    Friday, January 18, 2013 at 3:53 am | Permalink
  19. Chelle wrote:

    Oh Lord have mercy.. I’m pregnant with baby no.3, I’ve had two wonderful homebirths, despite having to be transferred twice for suturing in theatre due to x2 third degree tears. Despite the tears I loved birthing at home-an amazing experience. This time I’m 30mins from the hospital, my OB wants me on my back for an episiotomy e en my midwife thinks this will help due to “tough” scar tissue as to give baby more room. I am praying I font know what to do! Every time I decide to have the dreaded cut, I read something else to change my mind. That’s the only real reason I’m going in hospital.. I don’t want to be on my back either ouch! I give birth on all fours I’m most comfortable that way. Also being told no water birth due to them not bring able to see what’s going on down there.. I don’t want to be reckless but I don’t really agree with any of their suggestions and it just looks as if I’m being stubborn. I want a home water birth with nonintervention as far as possible. I want candles, peaceful music and my children to see their baby as soon as he’s born. Am I being practical???

    Wednesday, June 5, 2013 at 6:14 am | Permalink

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