My hospital does routine episiotomies on women like me that tore to a 3rd or 4th degree and I'm just wondering what your thoughts are on this?

As far as I am aware the likelihood of me tearing to 4th again especially without an assisted delivery is very small. I may not tear at all.

I'm not happy about talk of cutting me in case I tear and would have a 'wait and see' approach to it.
Claire it sounds like you have a good handle of what you want and what you need, I'd encourage you to stick to your guns. I agree with your assessment of the situation. I see no need for "just-in-case" routine episiotomy. Ultimately it is your call - it is your perineum! But depending on where you choose to be to have your baby, you may need to assert your wishes more strongly in some locations than others.

Is there any alternative to this particular hospital? I'm thinking if they have this kind of rationale for "routine" episiotomies there may be other routine interventions & protocols that are not very conducive to birth as well.

It is great that you are doing the preparation. The Pink Kit has a good section on internal work - it' like perineal preparation plus. The point is not to make your tissues stretch or put yourself through "Perineal Boot Camp" - it is all about becoming familiar with your body, confident with its awesome capabilities and comfortable with the sensations. (Be *gentle* - no forcing - your body doesn't need it. It is capable of stretching so long as caregivers are patient.)

My understanding is that when using upright positions, the pressure of the baby's head on the stretching peri is better distributed than when you're sitting/lying back. Hands & knees can be a favourable birthing position, you can go onto your elbows to slow it down and just gently *breath* the baby out.

You can do much to protect your perineum by avoiding the need for an instrumental delivery (ventousse and forceps) - by keeping active, upright and on the move - walking, rocking swaying and submerging to manage the contractions; and avoiding epidural if possible. A doula may be helpful with this.

I supported two first time mothers who were completely active throughout labour and pushed effectively. Both chose variations on kneeling for 2nd stage. One had a rare button-hole tearing and had a 4th degree tear. This was because the head was on a slightly unusual angle. The other mother managed a posterior birth beautifully. It was taking some time to get from "head on view" to crowning. Eventually they decided to do a small episiotomy, and the mother consented. She healed up fine. I think perhaps with a bit more time, she could have done without the episiotomy, but she was ready to accept a bit of help, they held off for quite a while. So while being active and upright is certainly optimal and your best bet, it does not always guarantee perfect results. (Once again it depends much on location - these were hospital births - many homebirth midwives have much higher rates of intact perineums because they are so patient and let birth unfold at its own rhythm.) I do think tho that in these two cases if they had been confined to bed, the damage to the perineum may well have been worse.

Giving birth in water has excellent results for intact perineums, because the woman can really relax and it all happens so gradually and gently.

Hope all goes well Claire, it's great you are researching your options.