Episiotomy vs tearing

[Lauren31]

In your opinion which is better/easier for recovery etc? Tearing, maybe deeply, or an episiotomy? I have heard both and I can't seem to find a decisive answer either way. I want to put on my birth plan, please do not give me an episiotomy without my consent but WHEN would I actually consent to that!?

[noobmom]

I choose to tear. The idea is once the snip is made, well, you're going to at least have that much to heal from, whereas if you don't get snipped, then there's a chance you won't tear at all. If you were going to tear deeply, it won't make a difference if you've already been cut, you'll still tear more.

As for consent, if there is a situation where the baby needs to come out fast or if forceps need to be used, you'd probably want to consent to being cut.

[ursusarctos]

They do the episiotomy when the head is starting to come out. They should always gain your consent before doing an episiotomy, or any procedure for that matter, as long as you are conscious. You can definitely make a note in your birth plan about not having a routine episiotomy, and it's not something that needs to be done in a hurry so you can certainly repeat that if they tell you that they need to do one.

The "logic" behind *routine* episiotomy (baby is coming normally with good heartrate and the hcp says "hm, it looks a little tight, let's widen the opening with a cut") is that it prevents tearing, which is harder to suture than a straight cut. Apart from the obvious factor of preventing a tear by cutting (I have seen this compared to preventing someone running into a pole by hitting them on the head with a frying pan), routine episiotomy is not supported by medical evidence. Studies (sorry don't remember which ones, maybe someone else does) have shown that episiotomy does not decrease perineal trauma and in fact increases the rates of deep 3rd and 4th degree tears. This is because, once there is a cut in the perineum, the pressure of the head can extend that cut more easily than it can tear an intact perineum.

Also, I am not sure if there are studies about it, but I have read that tears heal better than cuts.

I don't know about episiotomy when the baby needs to come out immediately. In Heart and Hands (a midwifery text) it says that this is the only time episiotomy is warranted. Haven't read any studies about this kind of episiotomy. However, they should still notify you/obtain consent and explain why they need to do it. "Just because it seems a bit tight" is NOT a good reason for them to cut. "The baby's heartrate is dangerously low and he/she needs to come out NOW" might be.

If I were you, I would also try to find out what the rate of episiotomy is at the place where you are going to give birth and possibly discuss it with your hcp. You could also discuss ways of helping your perineum to stretch, such as hot compresses, massage, warm oil, etc.

[katelove]

My birth plan says "No episiotomy". If my attendants *really* want to do one they will tell me anyway. If I don't give them a get out clause in the form of an exception to this rule they may think twice about whether it is really needed

Below is a link to a summary by Henci Goer of the research on this subject.

http://www.efn.org/~djz/birth/obmyth/epis.html

[Therese's Mommy]

Well, I will just tell you my experiences. With my first I had in my birth plan that I didn't want one. The OB that was on told me he was old fashioned and preferred to do one. I consented to let him do one if he felt it was necessary. I really only did this because he had been convinced since 26wks that I was going to be a section and he came in that morning to tell me he was going to "let" me push but that if I didn't make good progress I was going to the OR. Anyway, he cut me. My dd was 7lbs 12oz and he needed 4 packets of stitches to sew me up. I was sore for a while.

With my second I didn't have one, she was 9lbs 2oz and I think I had a stitch or two. Recovery was still pretty rough. She was a hospital birth and I had to birth the way they wanted and not the way I wanted.

With my third I had a hb. No cut, baby was 9lbs and I didn't have a single stitch. Recovery was a piece of cake. I was allowed to push in the position I wanted and I think that made the biggest difference.

[JorgieGirl]

Unless it were a life or death emergency, I'd always choose tear. Your body will only go as far as it needs to. Most often, it's not through muscle, however a cut, no matter how small IS through muscle. Also, your body heals a tear better since it follows the natural path of the body. It might be easier for a Dr to stitch a straight line, but it's not necessarily better for your body to heal that way.

[SeekingJoy]

The research supports tearing instead of a routine episiotomy. Have you seen Goer's Thinking Woman's Guide to a Better Birth?

One way to conceptualize it is that with a tear -- if even needed -- your body will tear at the angle and only to the degree needed to get the baby out. If you get cut, someone external to the birth process decides how deep to cut and at what angle.

[orangefoot]

My feeling is that they cut as far as they want but you tear as far as you need.

I had an episiotomy with my first for I don't know what reason but it was Mexico and that was that. I tore with my second and third, one underwater and one not, I didn't tear with my 4th despite her being born brow presenting.

I would only consent to a cut if a vacuum or forceps were needed and that was a matter of life or death.

[cappuccinosmom]

I'd rather chance a tear than guarantee a cut.

I've had minimal tearing with all three of my children, and two of them were "huge" (around the 10 lb mark). A couple of stitches, and I was good. Healed very quickly and had very little pain except for a heavy, bruised feeling for a few weeks.

[MegBoz]

Originally Posted by JorgieGirl

Unless it were a life or death emergency, I'd always choose tear. Your body will only go as far as it needs to. Most often, it's not through muscle, however a cut, no matter how small IS through muscle.

Right, I think an episiotomy, since it's through muscle, is considered equivalent to a 2nd degree 'tear', whereas even if you do tear, it may only be 1st degree (skin & mucus membranes.) I only had a small 1st degree.

However, What about episiotomy preventing UPWARD tearing??

I haven't read anything on this concept. Honestly, I can see how a cut into the perineum could be preferable to tearing up near the urethrea & clitoris. I had a 'skid mark' that felt like a rug burn between my urethrea & clitoris - still at 10 weeks PP!! It felt EXACTLY like a rug burn or skinned elbow. (Thankfully it didn't hurt all the time, but when I or DH touched it, it was sore & sensitive.)

Is there any research that supports this? I've read "The Thinking Woman's Guide" at least twice & I don't remember this issue coming up.

A friend of mine told me her OB says he'll make a cut sometimes if it looks like the mama is about to tear upwards since he's seen that before & it's bad & he wants to spare women that.

[Kelly1101]

Originally Posted by noobmom

As for consent, if there is a situation where the baby needs to come out fast or if forceps need to be used, you'd probably want to consent to being cut.

This. There is no need for routine episiotomy-- OB's used to think so decades ago, but there have been studies done since then that show it's more harmful than a natural tear.

However, if the baby is stuck and it becomes a dangerous situation, an episiotomy is needed.

[lifeguard]

An episiotomy is not necessary for all forceps deliveries. I had a forceps delivery with ds & was left to tear. It was a bad tear (3rd degree) but I'm not convinced an episiotomy would have been any better & healed up really well.

[katelove]

Exactly. An episiotomy *may* be needed to facilitate a forceps delivery in some circumstances as forceps add approximately 1cm to the diameter of the presenting part. This should be assessed on a case by case basis though and not just done as part of the "routine".

A vacuum assisted birth is even less likely to require an episiotomy as the vacuum cup does not add to the diameter of the presenting part at all.

[AnnieNimIty]

Also, IMO, there is always time for them to ASK if you want a cut or not. I had one OBGYN say, a) I wouldn't want to know if I was getting cut. and b) there wouldn't be time to tell me that they were doing it.

a.... yes I would want to know. and b .... the Dr. who attended the birth had time to bring it up 3 times before DD was born.

[aiccerb]

Originally Posted by MegBoz

Rig

However, What about episiotomy preventing UPWARD tearing??

I haven't read anything on this concept. Honestly, I can see how a cut into the perineum could be preferable to tearing up near the urethrea & clitoris. I had a 'skid mark' that felt like a rug burn between my urethrea & clitoris - still at 10 weeks PP!! It felt EXACTLY like a rug burn or skinned elbow. (Thankfully it didn't hurt all the time, but when I or DH touched it, it was sore & sensitive.)

Is there any research that supports this? I've read "The Thinking Woman's Guide" at least twice & I don't remember this issue coming up.

A friend of mine told me her OB says he'll make a cut sometimes if it looks like the mama is about to tear upwards since he's seen that before & it's bad & he wants to spare women that.

I had a bad anterior tear (upwards) with my 2nd babe (who was a 9lber) and I often wonder if my healing/longterm affect might have been better if I'd had the episiotomy when the dr. suggested it.

[nikirj]

An epis might prevent upward tearing, but so would changing how you're supporting the tissues. I don't feel like that would be a valid reason to cut an epis.

[MegBoz]

Originally Posted by nikirj

An epis might prevent upward tearing, but so would changing how you're supporting the tissues. I don't feel like that would be a valid reason to cut an epis.

But is there any research on the issue? I'm curious.

[nikirj]

The research actually says it makes no difference.

Wrt support: I know "the studies" say that perineal support etc doesn't make a difference, but I think in this case "the studies" are wrong. While I was a student I did a lot of tracking and found that some preceptors were definitely better than others at preventing tearing. In particular, the one that believed the studies (thought there wasn't really anything she could do, women either tear or they don't) had really really bad rates. The problem with all those official studies is that they compare no support to some unknown standard of support provided by an OB who may or may not have any good idea of what s/he is doing anyway; I've seen some really crazy "methods" of preventing tearing by OBs that I can't imagine would help in the slightest and probably even make things worse. If that was the kind of "support" in the studies, no wonder it didn't work.

ETA - research definitively supports tearing over episiotomy. Episiotomies are more likely to result in more significant extension tearing, and are almost guaranteed to create a greater degree wound than a tear would. Tears take longer to repair. IMO there are only two good reasons to cut an epis: 1) during a dystocia if there isn't room for your hands (I've had a few dystocias and not needed to cut an epis to make room, so...) and 2) in acute fetal distress where it seems that cutting an epis will speed delivery.

[bicyclingbethany]

I was one of those "life or death" episiotomies. My son's heart rate had been dropping below 70 and the midwife said "if you don't push him out with this push, I'm going to have to cut you!" I couldn't, and she had to give me a 2nd degree cut.

It definitely happens.

[Alyantavid]

I had an episiotomy with my first. With my second, I declined it and tore. I'd take the episiotomy recovery over the tear recovery any day. It was awful.