When is an episiotomy truly necessary?

[MujerMamaMismo]

I had a wonderful, relatively easy, short (7hours) normal physiological birth-centre birth 13 months ago. I loved the experience and can't wait to do it again (at home next time).

After 4 hours of pushing however, my baby's heartrate dropped and I consented to an episiotomy, mostly out of exhaustion and impatience. At that point, I already had a 2nd degree tear.

So I'm wondering if my episiotomy was truly necessary? I suspect it wasn't but they got me in a moment of vulnerability.

Is an episiotomy ever essential?

[snoopy5386]

I don't know 4 hours of pushing seems like a long time....I had an epi with DD after 2 hours of pushing - she slid out in the next push. Could there have been another way? Probably....the midwife asked if I wanted to change positions and I said no - too exhausted and she didn't push the issue. I may have not needed the epi in that case, but I'll never know for sure.

[lkmiscnet]

I don't think tearing, unevenly too boot, would be preferred over a clean incision.

I had a 6.5 hour labor. My OB wanted to do an epi, but I asked her to keep trying to massage the area with the oil she had, as she had started already doing. She obliged and one of the nurses brought in a mirror so I could see the progress of my baby's crowning head, or lack thereof, while I kept pushing. After 30 minutes I could see that my son's head just would not fit, so I relented and agreed to the epi. I hardly noticed any pain after the lidocaine wore off--just slight stinging when going to the bathroom for a few days.

My OB said that a tear is not easy to repair, as is a clean incision.

In hindsight, I have no regrets, but I wouldn't know otherwise. Just my experience...

[alegna]

Actually, the research I've read does show that a tear is preferable.

The last study I read on the subject basically said that an episiotomy is needed if it is ABSOLUTELY crucial to get the baby out within a minute or so. It concluded they are VERY rarely needed.

-Angela

[Sileree]

It was probably necessary if baby was in distress.

The WHO lists the following legit reasons:
- Fetal distress
- If the mother is circumcised
- To aid in a complicated delivery, for use of forceps, etc. (not always though)

[SwanMom]

I've only torn, but my mom was cut many times & hated it. She finally was allowed to just tear during her last birth & said it healed so much better.

Just 'cause a cut is easier to stitch than a tear doesn't mean it's more comfortable or heals better.

[MujerMamaMismo]

Yes Angela, my understanding is that a tear is preferable though it seems that the tear I had did not create the room needed to get DS out.

DS was in distress but only very newly and I wonder if they gave him enough time to recover on his own. Once I had the epi, he was out in seconds. His apgars were 8 and 10 which leads me to think that he wasn't that distressed!

Thanks for your thoughts. It's interesting to see what the WHO says...and also to see that there's definitely room for individual interpretation in their guidelines.

What would a homebirth midwife (assuming she's the least interventionist person in this birthing community of ours) say?

[mntnmom]

My first babe's head was presenting sideways, and there was some visible meconium. Dr. did an epi so he could get his hands in to turn her head. I don't know if it was *necessary* or not, but he certainly did. And even though I tore very badly as a result, I think it was probably the best choice.

[MegBoz]

Originally Posted by lkmiscnet

I don't think tearing, unevenly too boot, would be preferred over a clean incision.

Just the opposite, actually. The tear is BETTER because it follows the skins natural fibers! Nothing in our bodies is ever perfectly straight - so the "jagged" tear goes along with the body more naturally than the 'straight' incision.

Originally Posted by lkmiscnet

My OB said that a tear is not easy to repair, as is a clean incision.

This is one of the very few things that OBs say about epis's that is actually true. But I don't think the fact that the epis is easier to repair than a tear is a good reason to needlessly cut flesh!!!!! [Well, "needless" in most cases, that is.]

Originally Posted by MujerMamaMismo

What would a homebirth midwife (assuming she's the least interventionist person in this birthing community of ours) say?

I'm not a MW, hopefully we'll get a reply from one. But I would guess they'd agree that the only legit reason to do one is if baby is in distress & must get out within about a minute - AND - other efforts have already failed. For example, OBs might do an epis for shoulder dystocia, but MWs will do "The Gaskin Maneuver" - named after Ina May Gaskin - just have the mama get on her hands & knees. Standing up or getting more upright (supported squat) is also very helpful.

Of course, these tactics are very near impossible if the mama has an epidural, as most mamas in hospitals do, so OBs often aren't even aware of such alternate methods of resolving a shoulder dystocia, or getting a baby out fast.

From all that I've read, HB MWs very, very rarely ever do an epis, if ever.

[mbhf]

I think my episiotomy with my first birth was warranted, though it took me a few years to think so. I had pushed for four hours in every position we could come up with. My baby was posterior and asynclitic (sp?) and he came out after about 10 more minutes of pushing after the episiotomy was cut with vacuum assistance. It was certainly not my ideal birth, and led me homebirth with my others, but I no longer feel bitter or angry about my episotomy, especially after talking to several MWs (both my homebirth MWs and some hospital based CNMs) who were all very surprised that I was "allowed" to push that long in a hospital. So now I am just thankful that my CNM decided to come in and attend my birth when she was supposed to be on vacation and I didn't end up with one of the OBs she worked with. Just my anectotal experience, of course. And I haven't had an episiotomy since, just a few very tiny tears.

[chandasz]

Episiotomy is needed when baby needs to come out fast, when using forceps/vacuum, if mama is circumcised, if mama is tearing into the clitoris.

Episiotomy will cause a much more severe wound than tearing naturally (absent fundal pressure). To illustrate-- take an intact piece of paper to represent an intact perineum-- pick it up and pull it taut-- it won't rip easily if at all. Now-- cut a slit into the edge of that same paper and pull it taut again and you will see how easily it tears....

[cappuccinosmom]

The other posters have good lists for real reasons.

It never really made sense to me to cut for failure to progress with pushing. Maybe it's the adrenaline after the cut that gives that final speed-up. But if that area isn't a physical barrier to the baby coming out (as it would be if a woman had FGM or an actual disorder constricting the muscles), what's the point of cutting it???

[MegBoz]

Originally Posted by chandasz

Episiotomy is needed when baby needs to come out fast, when using forceps/vacuum, if mama is circumcised, if mama is tearing into the clitoris.

Bolding mine.
I asked about this on a thread here about a month ago. The science is absolutely certain - epis leads to WORSE perineal tearing - some studies showing something insane like a 28X greater chance of a 4th degree tear (all the way through into the anus) with epis vs. no epis (natural tearing.)

HOWEVER - I think I personally might risk a worse perineal tear over a clitoral tear. So is there any evidence to support this?

it seems there still is not. The fact remains - epis leads to worse tearing, worse recovery, more pain during sex, etc.

[lifeguard]

Just wanted to add that forceps does not have to equal an epi. I had a forceps delivery with ds & tore like heck but no epi as we had agreed ahead of time. I don't regret the tear & think although it might have been faster to stitch if he had cut it couldn't have healed any better than the tear did.

[seeing_stars]

I tore through my labia into my clitoral hood with my first birth, no tearing second birth and had an episiotomy during my third birth because of a shoulder dystocia. I'm at peace with the fact that the episiotomy needed to happen, but that was BY FAR my hardest postpartum recovery.

[cappuccinosmom]

Q about shoulder dystocia:

In my understanding, the shoulder is not stuck at the perinium, but hung up in the pelvis. How does and episiotomy relieve that? I'm not able to connect the concept with the anatomical reality of the perinium not being a pelvic bone.

[Mandynee22]

I have no regrets about mine with DD. Her cord was wrapped and getting her out then was important. I had to stop pushing so my Dr could unwrap it. Her one min apgar was 2, she was blue (and not the normal "she'll pink up" blue), she had to be given oxygen etc. There was no vac or forcepts use. I did end up with a fourth degree tear but it wasn't much more difficult of a recovery than with DS with whom I naturally tore but only to the tune of a couple stitches. It still stung to pee if I didn't use my peri bottle right either way

[blissful_maia]

Originally Posted by cappuccinosmom

Q about shoulder dystocia:

In my understanding, the shoulder is not stuck at the perinium, but hung up in the pelvis. How does and episiotomy relieve that? I'm not able to connect the concept with the anatomical reality of the perinium not being a pelvic bone.

An episiotomy is sometimes done in the case of shoulder dystocia to allow the care provider more room to free the baby. Definitely not always necessary, but when several different maneuvers have been tried with no success, it can be helpful.

[erin_brycesmom]

Originally Posted by MegBoz

HOWEVER - I think I personally might risk a worse perineal tear over a clitoral tear. So is there any evidence to support this?

No, I don't think there is any evidence to support that idea. I haven't researched it in a while though so I'm not sure if there has been any newer research. After the birth of my first (I tore upward), I did extensive research on that very idea and could not find any evidence to support the idea that an episiotomy would be better. The opposite actually. I actually used to say that I wished I had been given an episiotomy but after researching, I no longer think that way. And to add to that, there really is no way to know if you are going to have a clitoral tear so it's impossible to make the choice of risking a worse perineal tear over a clitoral tear. The vast majority of all upward tears are not clitoral lacerations but instead very minor lacerations that heal quickly.

And not directed to the quote above but I just wanted to throw it out there that at a certain point an episiotomy may be necessary to aid in forcep/vacuum extraction or to get a baby out 2-5 contractions faster due to distress but in so many of those cases, it never needed to come to that. Having a provider massage your perineum does not help and instead makes things worse. Pushing in a non-body led position usually makes things worse. Cervical checks leading to pushing before the body is actually ready can make things worse and on and on. So while the final decision to do the episiotomy may be necessary, even in some of those cases it could have been avoided. I realize this isn't the case all of the time but food for thought.

[nikirj]

Originally Posted by cappuccinosmom

Q about shoulder dystocia:

In my understanding, the shoulder is not stuck at the perinium, but hung up in the pelvis. How does and episiotomy relieve that? I'm not able to connect the concept with the anatomical reality of the perinium not being a pelvic bone.

What someone else said: if there are maneuvers that a provider can't do because there isn't room, it might be a reason for an episiotomy. In the two worst shoulder dystocias I've managed, I've been able to get my hands in where they needed to be and there wasn't a need for an epis and there wasn't tearing. Providers who cut an epis automatically when they think there will be a shoulder dystocia are creating an additional problem.

I haven't yet met the situation where I thought it was necessary to cut an episiotomy, and I know a lot of women who have been practicing midwives for a good long time and have never cut one or have only done 1 or 2 in long careers.

re: getting baby out faster...it seems like telling a mama that her baby needs to be born in the next push is a pretty powerful motivator and probably takes off more time than cutting an epis would. It's probably different for women who are anesthetized and can't really feel the effects of their pushing effort, or for women who have been listening to a pushing cheerleading chorus for a while (so the change in tone isn't obvious).

All that said, I can imagine scenarios when I'd cut an epis, and I can't say they're never necessary. I think they're rare especially in OOH births.