Info on tears vs. episiotomy?

[Lemoncello]

Does anyone have some good links to research and/or information about perineal tears vs. episiotomy? I had a conversation about this with some moms I know, and they were all trying to tell me that having an epi is more desirable than tearing. But I know most people on here would disagree with that. I've read some threads as to the pros and cons, but I would really like to find some actual medical articles, info from the WHO, etc. to help me understand the issue for myself.

[fruitfulmomma]

Have you tried looking on Midwifery Today's website? They should have some more technical info on the issue.

[Lemoncello]

Thanks! I hadn't thought of looking at Midwifery Today. I'm headed over to their site now!

[Joyster]

I have to say I've had both (roughly the same size) and the recovery from the epi was a lot easier. Probably not going to make me the most popular mama here, but JME.

[MittensKittens]

My first thought is that tears do not always occur –*I had two births and no tears.

[Gena 22]

Another thing to consider, I think this is right:

Tears are more likely in the lithotomy position. I credit birthing upright on a stool to getting through without any tears.

[MyFullHouse]

I have no concrete info to add, but I would think the concept would only work if one were to assume that tearing is inevitable.

Of my 4 deliveries, I had 2 measly stitches for one (wish I had passed on that), and a serious repair for another (after pushing out a baby in distress). While I've never been cut, I can say that my recovery from the big repair was only *slightly* more uncomfortable than the recoveries of all my other births.

Now, the actual repair... I told my mw "Please don't be mad if I involuntarily kick you in the face!" But I doubt a repair for a cut would be much more comfortable!

[fruitfulmomma]

would only work if one were to assume that tearing is inevitable.

Right. I *think* I had a couple of stitches with my third (don't remember precisely, it was a little crazy) but I know I did not with any of the other four, even with the last couple who were well over 9 lbs. with big heads.

[HeatherB]

Yeah, the big thing is an episiotomy is automatically a major "tear." And, they have a tendency to tear further, creating far more damage.

I tore pretty badly with my first VBAC. I did end up pushing on my back after some mild issues. They were worried about decels and I got him out rather quickly - more quickly than I even realized I was. That was not a lot of fun to recover from, but wasn't horrid, either.

With my 2nd VBAC, I birthed upright in the water (then turned and sat against the side of the tub for the rest of the body), and had nothing but a "skid mark." And his birth was FAST. I went from 6cm and "tight" around his head to holding him in 17 minutes - and that was with involuntary pushing.

It is absolutely possible to have only minor issues, if any at all, and an episiotomy will ALWAYS be worse than that. Tears can also only go through upper layers of tissues, where an episiotomy cuts through them all. Doctors may prefer suturing epis because of the straight lines. I've attended a talk on suturing and I know that discerning what's torn, where, and how, can take some skill and some time. But from the literature that I've read, tears are more likely to heal properly if they are natural. The tissues interlock better along the natural lines.

Anyway, I would never, ever, ever opt for an episiotomy. I'm sure there are very rare cases in which it would be preferable, but they're certainly few and far between - and MUCH fewer and farther between than most OBs would consider them.

[MegBoz]

Originally Posted by Joyster

Probably not going to make me the most popular mama here, but JME.

Well, I'm glad it was helpful for you, and I won't hold it against you as an "unpopular mama." HOWEVER... the key here is your last statement, "JME" - Just my experience. There may even be hundreds more like you who had the same experience too! But when it comes to medical issues statistically significant sample size is crucial. To make decisions on individual experiences is "anctedotal evidence" & not good practice. (Sorry, not trying to be dismissive of your experience, but I think you know what I mean - I'm talking about what constitutes "evidence-based practice.")

"The Thinking Woman's Guide to a Better Birth" has a chapter on it & everything she writes is referenced by tons of studies. (Details in the back of the book.) That would be my #1 recommendation for stats.

Originally Posted by MyFullHouse

but I would think the concept would only work if one were to assume that tearing is inevitable.

Actually, no. Women given an epis are something crazy like 20X more likely to end up with a 4th degree* tear. (Again, "Thinking Woman's Guide" has the data. It's astounding.)

Quite on the contrary to saving you from a worse tear, the episiotomy results in a worse tear.

People say imagine a piece of fabric - if you are stretching it & pulling it taught, once you put one little cut into it, the rest of it begins to rip easily. I think once you visualize that & really think about that combined with the fact that the data backs it up (4th degree tear much more common with an epis) you can see how absurdly wrong it is to say that epis is better than natural tearing. Not trying to sound snarky, but it really is, truly "absurdly wrong."

In case you're not familiar with the idea, perineal tears are measured in "degrees" from 1-4. 1 is just some of the flesh, 4th degree is a rip all the way through to the rectum - so it can result in incontinence problems. It's a major injury requiring serious surgical repair. and, again, 4th degree tear is much more likely to occur as an extension of an episiotomy.

Episiotomy is generally a 2nd degree tear automatically. So even if it doesn't extend to a worse tear it's often still worse than tearing naturally since a natural tear might potentially be only 1st degree (I had a very minor 1st degree.)

I also had one friend say her doc does epis sometimes to prevent an upward tear. Now, conceptually, I can see how a 2nd degree perineal incision would be preferable to a tear up towards the urethra & clitoris, but that is also not evidence-based.

Finally, with all this being said, I think it's worth noting that OBs may be more nervous about tears & think tears in general are inevitable because so many of the things hospitals do increase the risk of tearing. Sad. As Dr. Marsden Wagner writes, "Fish don't see the water they swim in." American OBs are so immersed in medicalized birth that they don't see the whole big picture & realize their other actions contribute to the problems they think they have to work to solve.
For example:

• epidural
• pushing in lithotomy (flat on back, legs in air)
• "coached" pushing, aka "purple pushing" (Hold your breath to a count of 10 - longer than is naturally comfortable) & "PUSH PUSH PUUUUUUSSSSSSSSHHHHHH!!!"
• perineal "massage" (aka "vagina wrenching") during 2nd stage - hands down there trying to stretch it out/ yanking about & messing with the tissue (causing it to swell, making any tears worse)
• Not encouraging women to stop pushing at the time of crowning & just 'breathe baby out' (see above, "HOLD YOUR BREATH, PUSSSSSSSSSSHHH"

So those are the things American hospitals so often do that increase the risk of tearing. Whereas they often do NOT do things that decrease the risk. such as:

• hot compresses
• water birth
• mama-led pushing (in whatever position she wants)

[kittywitty]

IME, I agree with Meg and Heather. I never had an episiotomy. They swore I'd need one. Even got so far as to numb me down there after pushing 3 hours with my first child (over 8 lbs.). As soon as that scalpel came out, I had to threaten to sue. And what do you know? No tearing at all. Some skid marks is all. They acted ridiculously amazed that a baby came out without being cut out. And no tears (besides "skid marks" that don't warrant stitches) in my other 3 births, either.

[Lemoncello]

Thanks again for all the wonderful input! I found plenty of articles citing medical research on Midwifery Today's website to completely convince me that episiotomies are NOT always better than tears....especially since tears do not always happen, as many of you have noted. And the risk of developing much worse tearing with an epi just made it all the more clear that it is something I would like to avoid. Makes me hurt just thinking about it!

[MegBoz]

Originally Posted by Lemoncello

it is something I would like to avoid.

Yeah, definitely. In order to effectively avoid one, you really need to pick an HCP that almost never does them. I'd be worried about a rate higher than 5% (maybe I'd consider an HCP with a 10% rate.) I think the rate in the US today, overall, is actually like 20%. I believe 5% is the 'evidence-based' rate.

& unfortunately, kittywitty's story isn't all that rare. It's awful, but it's true. I remember reading in the book "Pushed" by Jennifer Block (fantastic, BTW!) That a doula had to put a lot of effort into helping save her clients from them. One doc was starting to do one, doula says, "She doesn't want an epis."
Doc replies, "Well, too bad."
Doula says to mama, "You have to say it. Say something now. You have to be the one to say it."
& the mama snapped out of her labor haze to speak up, so the doc stopped.

Moral of the story being - you're just better off with an HCP who practices the way you want to begin with, rather than trying to argue while you're in labor.

[Asiago]

Originally Posted by Gena 22

Another thing to consider, I think this is right:

Tears are more likely in the lithotomy position. I credit birthing upright on a stool to getting through without any tears.

I agree position is so important. I was kneeling and in various positions (in a pool). I had no tears.

"Get through Childbirth in One Piece" is a good book:

http://www.amazon.com/Get-Through-Ch...2&sr=1-2-fkmr1