Calling all opinions on episiotomies

[Claire]

Hi everyone,

I sustained a bad tear after a forceps delivery (episiotomy related) with my first child. I healed perfectly well and am going for vaginal again this time.

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.

I'm going to get the 'area' ready with lots of massage - I'm lucky I have no residual issues whatsoever and the scar itself is smooth, not painful and mostly absorbed as opposed to raised and thick.

I'm just interested to hear what you think?

Thanks

[Claire]

Me too Caro!

I have purchased an Epi-No and will defintely use it a bit nearer the time, plus DH is willing and able to help manually.

[Edensmumma]

i would rather tear than be cut any day...

[Berry]

A friend used epi-no and gave birth naturally 10-days overdue to a big baby without any tearing or episiotimy.

Another friend who tore the first time has recently had her second bub and didn't tear or need episiotimy either.

Just wanted to let you know those couple of examples.

But if you do have an episiotimy, don't worry about it - I had one with my first bub and it was no drama and healed well - just a yucky thought having it done though!

[Inanna]

Claire I personally had a 3rd degree tear with my first child. I healed really well using lots of herbal treatments. I haven't torn with any of my subsequent births.

Inform yourself fully, come to your decision and state that to your care provider. It' s really difficult to state your case unless you can quote stats and facts. I will find a link to some articles for you.

It is my personal experience both with my own body and being at births that tearing with a non instrumental birth is better for your body and easier to heal. Also the question of if I tear do I want sutures needs to be adressed.

I will find some links...

[becmc]

There is a really good book called 'the thinking womens guide to a better birth' and it has alot of interesting info about episiotomies. Basically the theory in the book is that perineums are like fabric, you can stretch it really really far until it tears, but put a cut in it with some scissors and it will just continue to tear along that line very easily. I had a c/s with my last birth so don't have personal experience, but the women I know that ended up with the worst tears always had episiotomies first. So personally I am avoiding it.

[Lulu]

I would rather tear than be cut any day...

[Heaven]

I think it's up to you, the hospital can't just do something to your body because it's 'routine'. They have no idea if you're going to tear or not until it happens. So yeah, get all the stats and facts you can and tell them what you want. Good luck!

[Julie Doula]

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.

[Tobily]

^ I totally agree with everything Julie has said above.

Routine episiotomies are totally unnecessary and I'd also encourage you to be very clear with them that you do not wish to have one if you've made that decision.

Remember that they can't do anything to you without your consent, and they will be especially wary of doing so after you have clearly and loudly told them you don't want it.

Make sure it is put on your file beforehand, have it in your birthplan, and make sure your support people are clear as well.

All the best

[feeb]

Be strong and stick to yout beliefs and wants.

No where needs to do rountine epis on anyone it is all a wait and see game!! some times the perineum will strech up well other times it wont.

Research shows tears heal better than epis so be active and use positions to faciliate birth eg on hands and knees, standing, sitting on toilet!!!! are all the best!!

good luck

[Ca Plane Pour Moi]

You (or your DH) have to agree to the episiotomy first, no matter if it's routine or not. They're done for the ease of the obstetrician, I am sure, and they'll try to bully your DH into agreeing if you refuse. Just be warned... or maybe your hospital will be better than mine!

[Julie Doula]

yes Feeb, I've heard sitting wrong way round (or right way round heh heh) on the toilet can work well, esp with a pillow on the cistern to make it more comfy ... and maybe someone aiming the shower head at your lower back!

Sitting & rocking on the birth ball can be nice too. You can circle your hips too, especially in a clockwise direction which can help a baby move more anterior. The only thing is, don't stay like that too long without a break, get up, move around to encourage blood flow and oxygen to all areas.

The birth pool is my best bet for excellent perineum support and least chance of tearing.
At the NCT class in England, our instructor suggested I sit in a bucket in the birth pool.

Huh?

Yes I know it sounds strange, she said. Then she produced a bucket and asked me to sit in it. Not on it. In it. I saw what she meant. It was the perfect height off the floor for a supported squat, and the rim of the bucket was just nice for support for my seat. Then she added a folded towel for more padding. It was ridiculous how comfortable it was.

During labour, I had a bucket in the birth pool with a brick in it to stop it from floating off. I sat in it on a (wet, obviously) folded towel to rest in bt contractions, and could stand up and lean over the edge of the pool during contractions.

I alternated the pool with upright standing/swaying moves. Pushed on all fours because I had pretty tender haemorrhoids (sorry! TMI alert - but I know I have one 'sister in suffering' on that count - ) and standing squat was too intense on that region. No tearing but my babe was only 7 pounds so I guess I was lucky! Still, my friend's first (also a homebirth) was 9 pounds and likewise no tears. I think having the freedom to move instinctively as you wish and do what YOU feel you need to do to birth your baby helps a lot.

Nuther tip for birth pools - floating bubblewrap on the top keeps it nice and warm while you're not in it.

[Claire]

Hi everyone,

Thanks for your replies! After such a ridiculous cascade of intervention with my daughter, I really am opting for a much more hands off approach this time around. I actually feel a bit miffed though that I have to persuade hospital staff that I know what I'm doing because I am going against the grain. It's my body and my baby!!

Flowerchild - thanks for bringing up the stitches thing, I hadn't even thought about it. I'm going to have to do some research to find out when I would or wouldn't need stitches. I really don't want anything unnecessary done, I have faith that my body can heal itself for the most part.

Becmc - Like you I have a doula this time around and she's actually coming over this week, she's bringing that book with her. I am sure I will find it a very informative read.

Julie - I have the pink kit and we are slowly working our way through it - I have to say I really like the way it helps you connect with your body and your own uniqueness. I'm only a few chapters in but I'm hoping that a combination of being armed with evidence based research, preparation of the perineum, good breathing techniques and visualisation and knowledge of my body will get me to the stage of birthing the head without pain relief. I think that I need to feel in order to control birthing the head properly. This time not allowing the midwife to rush me and breathing the baby out instead of pushing......

As for being in the water - that's the one thing I might not have access to unfortunately.....from memory there's one shower for the entire birthing suite.

[becmc]

Bit OT but I was talking to a friend from mums group the other day who is expecting her second bub in 6 weeks. She sustained a third or fourth degree tear, after an episiotomy, with her first. When she had a recent appointment she was voicing her concerns over tearing again, and the midwife told her to breath the baby out rather than push. My friend questioned that and said she was told to push with her first. The midwife said they always tell first timers to push because sometimes second stage can take ages with the first baby!!!!! WTF!!!!!
No wonder so many poor women end up with episiotomies and big tears! Totally unnecessary I think!!

Claire, birthskills is another great book. The lady who wrote it reinforces that pereniums are made to stretch. Why would so many women be born with bodies that could not birth their babies without tearing. It just isn't right-modern intervention causes tearing, not natural birth!! Good Luck with your doula!

[paradise lost]

My DD came down and out while i actively avoided pushing (by mooing loudly - they kept telling me she was posterior and i wasn't really dilated). I pushed once and sustained a tiny tear too small for stitching.

I think it sounds like you KNOW you don't want an epi. I have to say that to me the policy makes no sense - if you don't have and epi you might have a torn perineum, so what exactly are they avoiding - you'll definitely have a perineum in need of repair with an epi! My GF has had both (2nd degree off-centre tear 1st bub, 2nd degree midline epi with #2). She said the tear took ages to stitch compared to the epi (which is atraight line) but that the epi was much more painful for her afterwards. They healed at about the same rate but the scar from the epi is more raised than that of the tear. Her children are not 5 and 7 and she's had 2 more since, one in a midwife centre, one at home, and no tearing at all.

It sounds like you are very well-armed with information. From that point of view you're likely not to tear at all (being in tune with your body and knowing your facts) so if i were you i'd politely inform the hospital that you're sorry that it's policy is to perform episiotomies on everyone in your situation because YOUR policy is not to let people randomly cut your genitals.

Bx

[BellyBelly]

I have an article on directed pushing vs bearing down and while directed pushing results in a shorter second stage, you are more likely to tear... so great advice you have there and well done on your research!

[Fi]

I had an episiotomy with Jenna due to the forceps labour, and I was worried about tearing with Hamish.
I had absolutely no problems, and he was pushed out quite quickly with a normal sized head, and I didn't tear at all. Just a couple of grazes.

Afterwards the midwife was surprised that I had had an episiotomy at all, she was watching the whole pushing stage and never mentioned that I didn't have enough "slack".

Try not to be too worried about anything happening. Leave it up to nature, but be prepared and do your perinium workouts now