S/O - Justified reasons for an episiotomy?

[MittensKittens]

After reading the other thread about tearing vs cutting, I was wondering if you all think there is ever a "medical need" for an episiotomy? When do you think an epis is justified?

For a mother with an epidural, and a baby in distress? She can't feel what she is doing, so the epis might speed things up?

A brown presentation in which the baby can't get past the tissue very easily?

What do you think?

[babygirlie]

I didn't get a choice. I didn't push very long and was told the baby was losing oxygen and out came the scissors. It happened really fast. I wasn't asked. It was just done. They put an oxygen mask on me also. I felt like I was breathing fine?

[Tigerle]

DS was born at 34w6d due to pPROM. Because of signs of fetal distress and suspected infection, I laboured lying on my left side with an epidural and things speeded up by pit, and needed to be coached to push. They told me that they were cutting to speed things up even more and to make sure that there was the least pressure possible on his skull, as premature babies have softer skull bones. I didn't care at that point, being half out of it, nor was healing an issue (frankly, I had so many other issues with my subsequent care in the recovery ward and how hard they made access to the NICU and pumping for me I cannot even remember much about it. DS needed oxygen and two weeks in the NICU). Even so, his skull was so deformed that he looked like a little alien for weeks. Though I cannot tell whether it would have been worse without the cut, it looked bad enough as it was (especially compared to the other NICU babies, most of whom were of course CS babies with perfectly formed skulls) and I worried for many weeks about it as it seemed to take forever for his skull to round out. I probably would have blamed myself for having refused a cut.

[russsk]

I had an episiotomy after 4 hours of pushing. Baby was not in distress and I could feel everything just fine, but my rectum was inverting with each push and I was beginning to tear toward my urethra (no signs of tearing my perineum). After I finally consented to it (my mw had gently suggested it a couple times) DS practically flew out of me. I'm not thrilled that I had one, but I think it was the right choice in my case.

[GoBecGo]

An epi to get forceps in would be warranted, as would some of the other situations PP's have mentioned. Routine episiotomy is never warranted.

[katelove]

Another circumstance may be shoulder dystocia where the practitioner needs more room to perform a manual rotation to release the stuck shoulder.

An a episiotmy by itself won't release the shoulder though as it is a bony obstruction not a soft tissue one.

[MegBoz]

Originally Posted by babygirlie

They put an oxygen mask on me also. I felt like I was breathing fine?

Yeah, my DS HR was dropping too while I pushed and they held up the oxygen mask to me. I think I said something like, "I don't need that." I definitely was breathing fine! No problem at all! But the nurse said, "It's for the baby, not you." Oooohhh - ha - woulda helped if you told me that in the first place! I guess that makes more sense - me breathing in extra oxygen I suppose gets a higher concentration of oxygen into my blood, which means the baby therefore gets more oxygen.

Originally Posted by katelove

Another circumstance may be shoulder dystocia where the practitioner needs more room to perform a manual rotation to release the stuck shoulder.

An a episiotmy by itself won't release the shoulder though as it is a bony obstruction not a soft tissue one.

I recently read a thread on a midwifery forum about shoulder dystocia & episiotomy. Almost all agreed that it's a bone problem - baby stuck behind bones in the pelvis - not a tissue problem. So epis is not likely to resolve the issue. (As written above only if the epis is needed to allow the HCP to reach in to help rotate baby.)

Unfortunately, many who work in hospitals said they would cut an epis anyway in the case of SD to protect themselves from a liability standpoint, because to not cut an epis with an SD is absolutely viewed as negligence, so they have to.

That's sad (But I can't say I blame them. Prior to reading that MW thread, I had heard myself that epis is needed for resolving SD, so it's a pretty commonly excepted myth.

I hadn't heard of prematurity as a reason to do one, but that makes perfect sense to me.

[Joyster]

My guy needed to be out in a hurry due to a poor heart rate and other complications and so required a vacuum extraction and an episiotomy. I don't want to open up his birth for armchair quarterbacking and I don't regret it for a second.

[lifeguard]

Originally Posted by GoBecGo

An epi to get forceps in would be warranted, as would some of the other situations PP's have mentioned. Routine episiotomy is never warranted.

It's not an absolute that forceps = episiotomy. I had a forceps delivery without one as did a friend of mine. I healed up just fine but did tear quite badly (3rd degree). I wouldn't recommend a forceps delivery mind you!

[WifeofAnt]

One of Ina May's justified reasons is a breech baby presenting testicles first.

[MegBoz]

Originally Posted by WifeofAnt

One of Ina May's justified reasons is a breech baby presenting testicles first.

Hm, interesting. Do you remember why? I mean, there is pressure & his testicles might get a bit squashed, poor baby, but would it really be so much pressure as to cause damage to the testicles?

[WifeofAnt]

Originally Posted by MegBoz

Hm, interesting. Do you remember why? I mean, there is pressure & his testicles might get a bit squashed, poor baby, but would it really be so much pressure as to cause damage to the testicles?

Didn't really say why...

[wombatclay]

Hmmm... I was tearing and my OB hoped to "direct" the tear away from my rectum. It didn't work and I ended up with a small epi AND a 4th degree tear. The interesting thing is that the tear didn't follow the epi (as hoped). But that could be because I was already tearing and then there was a true dystocia (I was unmedicated/squatting, we tried the gaskin manuever and mcroberts, eventually she had to manually rotate dd2's shoulders)... maybe if the SD/SD resolution hadn't added more stress to the tissue the epi would have directed the tear better?

[Jane]

Agree with what's been posted:
A true need to speed the birth, ie fetal distress that's not resolving
To gain access, ie vacuum, forceps, shoulder dystocia maneuvers
When a woman has undergone infibulation and the opening is too scarred to stretch
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[MegBoz]

Originally Posted by Apricot

To gain access, ie vacuum, forceps, shoulder dystocia maneuvers

I've read here on MDC that since the vacuum doesn't increase the diameter of the 'presenting part' that a epis is really not needed to accompany vacuum extraction.
Makes sense to me. But I don't know any stats around it.

[Jane]

I've seen one vacuum for severe fetal distress, where the vacuum just would not fit inside. The physician tried and tried before giving up and cutting.
But, yes, in most cases, there's no need for an epis to do a vacuum.
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[ishyfishie]

I had a band of "fibrous" tissue that wasn't stretching--and I know it wasn't just something the midwife said, it had caused some issues in other arenas as well. My midwives during dd1's birth had a very low episiotomy rate (5%?) and she stopped after almost 2 hours of pushing and said, "I know you don't want one, but I'm not sure this baby will come out without an episiotomy. Will you let me do it?" I'm not sure what would've happened if I'd refused...I assume the tissue would have eventually torn, but even so, dd had a band of bruise around her head where she'd been stuck! MW did a pressure epi, per my request, and when a slight shoulder dystocia ("sticky shoulders"?) occurred some time later, I believe she made the cut a little bigger.

It healed fine and really improved things down there afterward, much to my relief, and dd2 (9 oz bigger with an extra half inch in head circumference) slipped out just fine with no epi. I don't know if that counts as "medical necessity" with dd1, but I definitely feel it was warranted because of that band of non-stretchy tissue.

[somegirl99]

I just had one, was pushing for an hour and a half, baby went into distress and we needed to get him out quick, turns out cord was wrapped twice around his neck.

[Litcrit]

Saving a baby that's REALLY stuck or REALLY needs to get out NOW.

Or, if you're not too lucky, extensive scar tissue from a previous mediolateral episiotomy making it impossible to stretch enough for a 9.4lb baby born with her fist by her head (this was me ). Recovery from being cut through old scar tissue was completely painless, which beats tearing and getting new scar tissue. But this is only if some idiot has already cut you (without asking or informing you ).

[Magali]

I would say it is justified if a woman knows she wants one.