When is an Episiotomy Medically Necessary? - Page 2

[lifeguard]

Originally Posted by AlexisT

As someone posted above, they can be necessary for complicated deliveries--forceps and some shoulder dystocia maneuvers come to mind.

I had a forceps delivery (no shoulder dystocia) & no episiotomy. I think this is rather rare & the tearing was horrid but I still don't regret it. So forceps & episiotomy do not need to go hand in hand.

[phatchristy]

I believe that true fetal distress would be an indicator.

The assistant who worked w/my midwife once asked her about it. She said 'she'd only perform an episiotomy when truly necessary.'. Then she asked her how many she'd done....and she'd done 2! I mean 2 in like TWENTY years! Wow!

She also attended quite a few births during this time--she's rather busy and owns a birth center.

[ishyfishie]

I'm not sure if mine was truly "medically necessary"--pushing in a different position or massage might have resulted in a different situation. I had a band of "fibrous tissue" that was restricting dd's head from coming any further (you could see the distinct ring around her head for days afterward). I actually had had issues with this "fibrous band" during, uh, personal relations () and feeling as though it were tearing slightly each time, so I knew exactly what my midwife was talking about when she mentioned it. Do I think it would have been possible to birth dd without the episiotomy, sure! I probably would have torn given the position I was in, but I do think it's possible other measures might have prevented it from being such an issue...but I do feel, in my case, it was warranted at least, if not "medically necessary." I don't feel it will be an issue at all with the next birth because of the episiotomy (and it's improved our "relations" as well because that super tight band is no longer a problem), but the episiotomy isn't even on my list of regrets from the delivery and aftermath. Had it been an OB I didn't know or trust, I'm sure it might have turned out much worse! My midwife knew I didn't want one, doesn't do them as standard practice, and did as little damage as she possibly could.

We did end up with a slight shoulder dystocia but that was AFTER the episiotomy!

[Astraia]

Originally Posted by ishyfishie

We did end up with a slight shoulder dystocia but that was AFTER the episiotomy!

That sucks, two complications in one birth!



Shoulder dystocia is a bone-on-bone problem (shoulder gets stuck behind pubic bone), the episiotomy is good for the extra maneuverability though.

From what I've been reading it's less necessary to do one for SD if mom is on hands and knees, it helps open up the pelvis enough that you can sometimes (depending on the provider and the size of their hands, I guess!) avoid an epis

[DoulaVallere]

After three years of really regretting allowing my mw to perform an episiotomy on me, and months of reflection and research through my doula class, I'm now 100% sure I was one of the 5% who needed one. My mw knew I didn't want one and had about a 5-8% episiotomy rate so I really felt confident that if she ended up doing one it would be really necessary, but I still felt guilty about allowing it for a long time because I thought it meant I didn't "really" have a natural birth.

My son was ROT (ie, he was on my right side, facing my leg - neither face down nor sunny side up but facing sideways) and had two nucal hands...fists up by his cheeks. I had a 39 hour labor and had pushed for over 2 hours in a semi squat and FINALLY got him to near crowning. I was physically exhaused and just laid down on the bed and was at the point of just being totally spent. Got in a side lying position (my sister had to hold my leg up because I physically could not) and as his fist got close to my vaginal opening I was SURE I was going to tear upwards. I have pictures of him crowning where I have both hands pressing downward over my clitoris. I mean SURE I was going to tear. My mw decided to do a pressure episiotomy and he was born on the next push. It took me 6 weeks to get over the urethral bruising his fist caused so that I could hold my urine normally and not just wet myself every time someone turned the faucet on.

To me, that was totally medically necessary. I would go through that painful recovery all over again to prevent an upward tear and possible nerve damage.

With my second birth, he was perfectly positioned, pushed for 20 min, and had a small tear that needed 2 stitches.

[Juvysen]

My midwife said she didn't do them very often (talked to me about the research on them, etc), but after pushing for two hours (crowning for like half an hour) my daughter's heart rate started diving and my midwife told me that the heart rate was concerning her and that she'd give me a couple more pushes to get her out but if not she thought an episiotomy was worthwhile. I agreed to it, pushed a couple times, but didn't make her budge, and then after the epis, she came right out. It was small (7 stitches) and i feel thankful that my midwife discussed it with me before just cutting, but afterwards I learned more and I wonder why she didn't have me change positions to try and get the baby out instead of just cutting.

I have a friend whose 10 lb baby was blue and had the cord wrapped twice and was hard to get out - they were really pushing to get him out... getting her to duck walk, foot up on the wall, etc. Her midwife told her later that if he hadn't come out within the time frame he did, she was going to suggest an episiotomy, for the baby's safety. As it was, the baby came out limp and blue and needed oxygen and such (it was very scary for my friend), but not full on resuscitation.

[AutumnAir]

Originally Posted by Belle

I can't see any situation where it would save the mother's life. They don't do episiotomies until the baby is already at the perineum. There are a few situations where it could possible save the baby's life but not many. It doesn't prevent tearing either. If they don't give you the skills you need in medical school to prevent tearing you have to use the only skills you know how. Doctors are taught how to cut, so they cut.

My midwives had an 5% Cesarean rate. Understandable. Sometimes they are necessary. Their episiotomy rate was 0%. They've never needed to do one.

Not always. They cut a huge episiotomy on me while DD was still held up by a cervical lip - I hadn't even started pushing. But in my case it was simply a method of punishment (I was a homebirth transfer).

From my reading (there's a great chapter in Henci Goer's "Obstetric Myths" book) there are very rarely any good reasons to perform one. She presents evidence that not only do they increase the likelihood of severe tears and damage to the pelvic floor, but they are almost never useful even in situations like SD and forceps delivery.

If I had been given the chance I would never have consented to an episiotomy. We may think we are more 'civilised' than the cultures who perform female circumcision, as mentioned above, but it's my honest belief that episiotomy is no more than a medically and socially accepted form of female genital mutilation, serving no real purpose other than to 'haze' or initiate new mothers. But that's just me.

[abigail_b]

My OB told me yesterday that he had to do his first epi in years just last week. He almost NEVER does them, but apparently this woman was totally exhausted and had completely given up. The baby was starting to show distress and he felt it was an epi or a c-section. I would much rather have an epi than a c-section!

[Mrsboyko]

10 hrs of pushing followed by a transfer becasue baby was just NOT moving down. I had an epi and ended up with a 4th deg tear after a vaccume assisted delivery of my son. If I had been home with my first birth (DD) it probably would have neded much the same way instead of a c-section. She too was face right (head facing my right hip, back along my left side) and would not budge.

[Turquesa]

Originally Posted by abigail_b

My OB told me yesterday that he had to do his first epi in years just last week. He almost NEVER does them, but apparently this woman was totally exhausted and had completely given up. The baby was starting to show distress and he felt it was an epi or a c-section. I would much rather have an epi than a c-section!

I'm wondering how it could come down between those two options. I'm the OP, and from most of the responses I'm getting, it sounds like medically necessary epis happen when the baby is already low and engaged. Wouldn't it be too late for a cesarean by then? Maybe somebody else here would know...? :

[cileag]

Originally Posted by Turquesa

I'm wondering how it could come down between those two options. I'm the OP, and from most of the responses I'm getting, it sounds like medically necessary epis happen when the baby is already low and engaged. Wouldn't it be too late for a cesarean by then? Maybe somebody else here would know...? :

Actually, it's pretty much never too late for a C/S. I think one of my least favorite scenarios is a failed vacuum c/s, with an episiotomy--during the surgery part of my job is to then climb underneath the drape and push UP on the head if the OB cannot get the baby out of the incision.

And in an absolute nightmare situation, there's there the Zavanelli manuever which involves pushing the delivered head back into the birth canal and up in order to perform a c/s in the case of a shoulder dystocia. It is obviously a last resort, often after they have tried double episiotomies, Mcroberts, hands and knees, the woods manuever. It is truly awful.

[DocsNemesis]

Well, for me: I had been pushing with the whole count to 10, breath, count to 10 method for about 30 minutes. It wasnt working well at all for me, as I couldnt get enough breathing in between and found myself feeling woozy.

My ds' heart rate crashed to almost nothing. His head was right there, not crowning yet, but still down there. Basically at the point, it was either an emergency cesarean or a major episiotomy. His heart stayed down (at 20 bpm), the doc did a episiotomy, and had him out in one push. It took about 20 seconds. It hurt like hell (I had no epidural, at least not a working one, and there was no time to numb me so I felt it all), but it was worth it to get him out that fast and not have to deal with VBACing later, nor recovery from a cesarean.

So, in my case, I'd say it was necessary. In any case where its a choice between that and a cesarean, I'd go with an episiotomy. Especially when baby is right there and in distress.

Omg, I just thought...what if you get one and still end up with a cesarean? That would suck so much!!!

[Mandynee22]

I think it was totally nec. in my case with DD. (she's almost 10 now)
My Dr needed to get her out as fast as possible. The cord was wrapped around her neck pretty tight. He cut me and I had to stop pushing after she was out a little so he could loosen it or whatever. Her one min apgar was 2. She was blue and not breathing. If it saves 2 minutes off the birth process, those 2 mins can DEF mean a lot.
Her 5 min apgar was a 7.
She was 9lbs, 3 oz. I also had fourth degree tearing which may or may not have been because of the epi but it was worth it (obviously)
I tore with DS too (he was only 7lbs 9 oz but his head was somewhere above the 90th percentile) but only needed a couple stitches. I didn't have an epi with him

[almadianna]

My midwife is proud to say that she has never given a episiotomy for her birth center or homebirths. I do not belive that an epi is really medically necessary in many cases at all.