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Episiotomy.

Risks and Benefits.

What is Episiotomy?.

An episiotomy (pronounced "ee-pee-see-ah-ta-me) is a cut made with surgical scissors into the perineum before the birth of the baby's head. The perineum is the area between the vagina and anus; the cut is made into the back portion of the opening to the vagina. Doctors do episiotomies because they believe they prevent relaxation of the pelvic muscles, speed the birth, and prevent serious tears. Unfortunately for the 90% of first time mothers and 50% of subsequent mothers who have an episiotomy, these beliefs are simply false.

Possible Drawbacks of Episiotomy.

Here's the bullet:

• Greater blood loss during delivery, since the cut is made through both skin and muscle layers.
• Increased risk of 3rd and 4th degree extension tearing (into the anal sphincter and through the rectal wall, respectively). Thus it causes one of the things it is supposed to prevent. One study found that the repair of such an extension at the time of delivery was inadequate in most mothers, and 50% of these had some degree of anal incontinence (involuntary leaking of stool).
• Episiotomy is of no benefit under usual birth circumstances. It causes pain and debilitation post-partum. In fact, drug companies have found post-episiotomy patients a ready source of subjects for pain relief research.
• Episiotomy may interfere with resumption and enjoyment of intercourse, both short-term and long term.

Possible Advantages.

Under certain conditions an episiotomy may be helpful or needed.

• If the baby is in definite distress and needs to be born very quickly, an episiotomy might help.
• If a mother has certain medical conditions that make her vaginal tissues susceptible to damage, an episiotomy may be beneficial.
• If after reading this, you still feel very strongly that you should have one, that should be your decision to make.

How to Avoid Episiotomy.

It seems clear that episiotomy is usually performed on women who don't need it. How can you maximize your ability to avoid one?

• Get with an understanding care provider. Ask your providers when they do episiotomies. When they say, "Only when they're necessary," ask them what they consider necessary, because some doctors consider them necessary in most births. Even better, ask them what they can do to help you avoid one. If they don't mention some of the things in this list, they may not be able to support you.
• Do kegel exercises to strengthen and become aware of your pelvic floor muscles.
• Use perineal massage to stretch the outlet before birth and accustom yourself to the sensations of birth.
• Vary your positions in labor.
• Use hot compresses on the perineum during pushing.
• Push spontaneously, as your body directs you to. When you feel the burning sensation as the baby's head stretches your perineum, raise your chin and blow quickly and lightly until it passes.
• Do not use stirrups or any position that holds your legs up and far apart. Lying on your side is thought to be the best for avoiding episiotomy.
• Do not use a local anesthetic "just in case" an episiotomy is needed later, it will numb you so you can't listen to your body's signals.

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What happens if I don't have one?.

Nothing bad if you refuse a routine episiotomy, that is, an episiotomy done to "prevent tearing" or speed delivery of a healthy baby.

• If you have some tearing without an episiotomy the chances are less than 5 percent that it will be 3rd degree, especially if forceps are not used.
  • Most tears in the absence of an episiotomy are 1st degree (skin only) or 2nd degree (into muscle structure--no worse than an episiotomy).
  • Some women will have several 1st degree tears in different areas around the vaginal opening, none of which require stitches.
  • Many women, especially second time mothers, have no injuries at all (intact perineum).
• It may take a few contractions longer to birth your baby, but you won't damage your baby's brain or your vagina by not having one. The baby doesn't get "battered" against the perineum, as some medical texts claim. You and your husband will still enjoy intercourse; you won't be all "stretched out", especially if you continue the kegels.

What happens if I do have one?.

Concentrate on healing your injury.

• Kegel, kegel, kegel. Doing these exercises will help you gain muscle control more quickly and help healing.
• Use an ice pack or a frozen sanitary pad wrapped in a washcloth on the area for 20 minutes at a time for 24-48 hours. After this time use sitz baths to help speed healing.
• Sit on a small pillow if you are really sore. Using an inflatable donut is not a good idea, since it may actually increase swelling.
• Avoid anything that makes you sneeze or laugh hysterically!
• Resume intercourse on your terms. Perineal massage may help soften scar tissue as well as letting you know how much pressure or stretching you can tolerate.

Final Thoughts.

The episiotomy decision, like most other decisions in childbearing, is not one that can be made with absolute certainty prenatally. However, by learning what you can do to minimize your risks and selecting a caregiver who supports your decision, you will be well on your way to success.

Episiotomy Links.

• Episiotomy a definitive review of the medical literature, from Henci Goer's book Obstetric Myth vs. Research Reality.
• Who is more likely to get an episiotomy? Socio-economic status does matter.
• Why doctors just can't stop doing episiotomies.
• The ritual aspects of episiotomy.
• Abstract supporting restrictive use of episiotomy.
• Episiotomy and preterm birth.

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