A Rant on Episiotomy - Page 2

[Turquesa]

It's too bad that this info isn't recorded on birth certificates. Unnecessary epis are very much a public health issue, so it would be nice to pin down some raw data on how often epis in general are happening.

By the way, this pamphlet says that hospitals shouldn't do epis more than 20% of the time, and they "should be working to bring that number down." 20% seems like a lot, and why does bringing that number down have to be such an incremental process? That's not a rhetorical question. I'm curious if I'm missing something....

[eclipse]

They did one on me for no apparent reason and I was SO pissed. Iw as actually saying "No, Don't!" and the guy did it anyway. It was so hard to recover from that birth compared to my later two, when I didn't have one - it even made things like breastfeeding harder because I was in so much pain that I had a hard time sitting up for long enough and was taking strong pain meds to help get through it. It still makes me angry when I think about it. My husband was understrict orders on my second two births to yell and grab the hand of anyone picking up scissors. Thankfully, no one tried with those births.

[Marissamom]

I'm going to say that there are *VERY* rare situations where it's preferable to have an episiotomy. I had a band of scar tissue from horrid, disposable tampons when I was a teenager, and it would*not* stretch DD was so stuck and would get down to that point and then I could feel her slid back up in between contractions. maybe if I had been able to use gravity I could have forced it to tear, but after about 15 pushes where we were completely stuck, and DD's heartbeat going way lower than the hospital was comfortable with, I was given the choice of c-section or episiotomy. I chose the episiotomy. maybe, in a different environment, or with a different doctor (I was stuck with the one on call) I could have torn instead. The thing I'm actually madder about then the episiotomy was that she did a crappy job stitching me up. now, I really don't think that the more routine perinial episiotomy is ever truly necessary, there are some times when the episiotomy is not the worst choice.

[AuroraPolaris]

I`m glad this have changed through the years.
My mother gave birth to 4 girls, all of them average size. She gave birth laying straight on her back, feet in stirrups, and she was cut every time.

I have given birth 3 times, the last time twins. Every time I have written in my papers that I would not accept an episiotomy.
And I never had one! The midwife told me straight after the birth of number two that she nearly had to cut, because the babys hart rate was dangerously low the last contractions. If I didnt tell her I didn`t want one several times during labour, I guess I would have one. But she tryed her best to meet my wishes, and thankfully it turned out ok.

From what I could google midwives here try their best to avoid episiotomy these days. They only cut for the baby, if he/she really need to come out as quickly as possible.

[minkajane]

I was watching a birth on TV the other day and right as the baby was about to come out, the doctor says all nonchalantly, "We'll just make a little room..." and snip snip snip! There was no consent, no question, just "a little room"!!!! She only pushed for like half an hour, so there was no reason for it. It was obvious the doctor does them as a matter of routine. And the fact that he was so laid-back about it even on camera makes it so clear that he sees no problem with it.

I hate watching those shows, I don't know why I do it. The abuses that you see ON CAMERA are so bad. It shows you that they're so widely accepted that they're not even considered at all. And if they're that bad on camera, what's happening when the cameras are off???

[karanyavel]

My ex-OB told me she performs episiotomies "as needed". She didn't cut me, but I didn't give her a chance -- I pushed the baby out in one hard shove because I was so adamant that she not cut me. As a result of the "superwoman push", I had a 3rd degree tear. I bet if I'd been able to push at my own pace, I wouldn't have had nearly as much tearing. Ugh.

She repaired my tear very poorly, too.

Luckily, this time I am using a midwife practice & freestanding birth center.

--K

[Storm Bride]

I've never had one. It's the only plus I see to having had all c-sections.

[ursusarctos]

Originally Posted by MegBoz

Get out of here! FIFTY PERCENT of FTMs get epis? Wow! I think the nationwide rate here in the US is like 30%, so I'm shocked that it's even worse in Finland! (Of course, that's not to say US maternity care is better, but I'm just saying on this particular issue, I'm shocked that we're better.)

Yep. At least that's what they told my friend at her birth preparation class and she told me. It scared her, too, she kept telling me how she really hoped she didn't need one and I kept trying to tell her that she probably didn't and that they couldn't cut her if she told them not to (I have the impression that they are generally respectful of your wishes if you let them know) but she didn't seem to believe me There is just no way a 50% rate is necessary. But they pass it off as if it is.

Originally Posted by mamabadger

Could it be that the U.S. episiotomy rate is lower than it might be because its C-section rate is higher?

Maybe. Last time I checked Finland's was 17%, but the hospital where my friend gave birth has one of 9%.

[MegBoz]

Originally Posted by minkajane

I was watching a birth on TV the other day and right as the baby was about to come out, the doctor says all nonchalantly, "We'll just make a little room..." and snip snip snip! There was no consent, no question, just "a little room"!!!!

<snip>

The abuses that you see ON CAMERA are so bad. It shows you that they're so widely accepted that they're not even considered at all. And if they're that bad on camera, what's happening when the cameras are off???

So, yeah, that little smiley lineup sums up my feelings on those mainstream birth shows as well. I totally feel the same way - if that's how they act on camera, what's it like off?

Although I suppose the doc feels that since the patient has accepted his care, then she has left it up to the doc to "manage/ guide/ direct/control/ protect" the situation as the doc sees fit.

Maternity care in America makes me insane enough as it is - so I do try to avoid the temptation to look at any of those shows for even an instant since odds are very high that it will make me crazy (well, crazier - ha!).

[Smokering]

So... I'm having a hard time seeing how episiotomy is EVER necessary. Some of you seem to accept a low (but not zero) rate as inevitable - how come? Aren't they usually done when the baby is quite far down in the birth canal? And if it had got that far, doesn't that prove that the vagina is big enough to birth it? (Er, it... him or her, you know.) I mean, I know some mothers tear, even with good positioning - not that most of them get that chance in mainstream hospitals! - but isn't tearing considered to be a better deal, as it might be superficial, whereas epis always cut through all the tissue? I mean, tears can just be on the surface of the perineum, which would be analogous to the doc "scoring" the perineum like slashing a loaf of bread... but they don't do that, they cut all the way through, deeply into the muscle.

Can anyone enlighten me?

[Mamatoabunch]

Episiotomy angers me so much I can barely talk about it. I have never had one, although I have a cut on my womb, b/c supposedly it was too dangerous to deliver a breech twin. I also have never torn, but have only pushed on my own terms w/ all my HB's.

A few months after I gave birth to my twins I was present at a friend's birth, her second, so this was 16 years ago. The OB, w/o asking, just got scissors and cut. I was so horrified, the sight of that has never left me. It was so incredibly wrong. I viewed it as a direct assault. It surprises me that more women do not. It is almost as if most women are some how conditioned to just accept assault if it happens in the birth climate.

[ursusarctos]

Originally Posted by Mamatoabunch

I viewed it as a direct assault. It surprises me that more women do not. It is almost as if most women are some how conditioned to just accept assault if it happens in the birth climate.

This. And then when you mention, even gently, that things like episiotomy aren't really necessary and can be refused, you are not believed.

[Marissamom]

Originally Posted by Smokering

So... I'm having a hard time seeing how episiotomy is EVER necessary. Some of you seem to accept a low (but not zero) rate as inevitable - how come? Aren't they usually done when the baby is quite far down in the birth canal? And if it had got that far, doesn't that prove that the vagina is big enough to birth it? (Er, it... him or her, you know.) I mean, I know some mothers tear, even with good positioning - not that most of them get that chance in mainstream hospitals! - but isn't tearing considered to be a better deal, as it might be superficial, whereas epis always cut through all the tissue? I mean, tears can just be on the surface of the perineum, which would be analogous to the doc "scoring" the perineum like slashing a loaf of bread... but they don't do that, they cut all the way through, deeply into the muscle.

Can anyone enlighten me?

see my earlier post, I had scar tissue that wouldn't stretch, wouldn't tear. babies heart-rate was not good. There is also the occasional time when the baby is in distress and can't wait until mom has stretched .

[eclipse]

Originally Posted by Smokering

So... I'm having a hard time seeing how episiotomy is EVER necessary. Some of you seem to accept a low (but not zero) rate as inevitable - how come? Aren't they usually done when the baby is quite far down in the birth canal? And if it had got that far, doesn't that prove that the vagina is big enough to birth it? (Er, it... him or her, you know.) I mean, I know some mothers tear, even with good positioning - not that most of them get that chance in mainstream hospitals! - but isn't tearing considered to be a better deal, as it might be superficial, whereas epis always cut through all the tissue? I mean, tears can just be on the surface of the perineum, which would be analogous to the doc "scoring" the perineum like slashing a loaf of bread... but they don't do that, they cut all the way through, deeply into the muscle.

Can anyone enlighten me?

Well, I think I read that an episiotomy can help a baby come out an average of a couple of pushes sooner than no episiotomy. So, in a case where there's an emergency, I can see where a doctor might decide that the fastest way to get a baby out is the best way in that moment. Everyone I've ever known that had a forcep or vacuum extraction has had one - I'm not sure if that's because it's actually necessary to get the tools in or just for the convenience of the doctor.

[MegBoz]

Originally Posted by Smokering

So... I'm having a hard time seeing how episiotomy is EVER necessary. Some of you seem to accept a low (but not zero) rate as inevitable - how come?

The only reason I know of is shoulder dystocia (SD) - IF there is not enough room for the HCP to reach in - to get their fingers in to help manipulate the baby to help dislodge him. That's it, so far as I know.

Although I read an interesting thread on a MW discussion forum where pretty much all agreed that SD was a bony problem - NOT a fleshy one - i.e. baby is stuck in the pelvis, NOT stuck behind a brick-wall-like perinium. Therefore epis really doesn't make sense as a solution to resolve it.

HOWEVER - many said they'd cut an epis anyway for liability purposes. It's considered a "standard of care" to do epis in case of an SD, so failure to do so would leave them extremely liable. Sad, but I can understand it from the MW's point of view.

But, again, if there's an SD & the HCP can't reach in to help dislodge baby, the epis could legitimately be necessary to make room.

Originally Posted by Mamatoabunch

Episiotomy angers me so much I can barely talk about it.

I'm glad I'm not the only one. I feel like I must be a little crazy for how much it infuriates me! I had a profound physical reaction when I watched the video I mentioned in my original post. (The way he was talking to her was also horrible - it sounded JUST LIKE he was coaching his buddy through a heavy set of bench presses at the gym. Perfectly appropriate choice of words & tone for the gym, but um, yeah, not so much for a birthing mama.)

My heart rate jumped to probably well over 100 (& being a fit person, my normal resting HR is around 60) & I'm sure my blood pressure spiked as well.

Originally Posted by Mamatoabunch

It was so incredibly wrong. I viewed it as a direct assault. It surprises me that more women do not.

Sadly, even those who DO view it as "medical battery" -which is a CRIME, and it IS the crime of medical battery to do epis without consent - even women who DO view it that way have no legal recourse. Epis lawsuits basically never win. I think it was in the book "Pushed" that I read an interview with a lawyer who takes pro-bono maternity cases, such as against VBAC-bans. She said she gets calls for epis all the time & just can't take the cases because it just almost always fails.

So, yeah, I guess that's a reflection of the view of our society on the whole.

Originally Posted by Marissamom

There is also the occasional time when the baby is in distress and can't wait until mom has stretched .

I wonder about that one though - so if baby is in distress - and low enough in the birth canal that rushing a vaginal birth is the better route than emergency CS - in that case, I would imagine they might reach for the vacuum or forceps (if just asking mom to push with all her might was insufficient.)

STILL - in that case, isn't it better to still just tear naturally? I know epis isn't necessary with vacuum, so I would imagine if mom hasn't stretched yet, it STILL might be better to just let tearing happen naturally.

Originally Posted by eclipse

Everyone I've ever known that had a forcep or vacuum extraction has had one - I'm not sure if that's because it's actually necessary to get the tools in or just for the convenience of the doctor.

I read here on MDC that the vacuum doesn't increase the circumference of the presenting part. So it's not necessary to accompany vacuum. Makes sense to me when you think about it.
I've also read here that it doesn't need to accompany forceps, but I can see some logic there since the forceps DO increase the circumference of the vaginal canal beyond the size of the baby, so I can maybe see more need there to make room to get the tool in. But I don't know. Besides, I think forceps are relatively rare in the US today anyway.

[Smokering]

Hmm. In terms of shoulder dystocia, isn't that usually resolvable by the Gaskin manoeuvre? Would doctors do both?

Even if a HCP had to "force" his fingers inside to help the baby out, there's a possibility the resulting tear would be more superficial or smaller than an epi cut, right?

The scar tissue things makes sense, though.

[Storm Bride]

With respect to when they're necessary, I'm wondering about the "steering" of a tear? I've heard medpros say that if a woman starts to tear, an episiotomy can guide the tear in a different direction, making it less likely to extend into the rectum, for instance. Does anybody know if that's valid?

[MegBoz]

Originally Posted by Smokering

Hmm. In terms of shoulder dystocia, isn't that usually resolvable by the Gaskin manoeuvre? Would doctors do both?

Even if a HCP had to "force" his fingers inside to help the baby out, there's a possibility the resulting tear would be more superficial or smaller than an epi cut, right?

The scar tissue things makes sense, though.

Well, I think Gaskin maneuver (Hands & knees, right?) would be really tricky with someone who's had an epidural. Maybe not impossible, but potentially too time-consuming to manage when it's a true SD & time is of the essence. & most women in American hospitals have epidurals. (& most American women give birth in hospitals - like 92% or so.)

Of course, there's McRoberts too - which IS possible with an epidural (on back with knees up).

Good point on tearing still being better in case of reaching into the vagina.

Yes, agreed, scar tissue makes sense. Although my MW just told me she had a 4th degree tear! Which I would imagine results in lots of scar tissue, and perinial massage throughout late pregnancy allowed her to birth in the future - I think she said - with NO tearing! (or maybe very minimal, I forget) But she is a big fan of perineal massage.

[MegBoz]

Originally Posted by Storm Bride

With respect to when they're necessary, I'm wondering about the "steering" of a tear? I've heard medpros say that if a woman starts to tear, an episiotomy can guide the tear in a different direction, making it less likely to extend into the rectum, for instance. Does anybody know if that's valid?

Interesting Q.

I read that medio-lateral epis (angled cut) results in less rectal trauma vs. mid-line epis (straight down). IIRC, medio-lateral is much more common in Europe, but is rare in the US - so at least as far as the USA is concerned, a medio-lateral epis being done to avoid rectal trauma is rare & is not what contributes to our way-too-high rate.

I know I read, I think in "Thinking Woman's Guide" that docs will cut if they think a tear is 'impending' - but only because they think the cut is better - not to take it in another direction. (I think Henci Goer commented on how that was idiotic - tears happen or they don't. They don't "impend!")

I did have one friend say her OB said he'd do epis if a woman was about to tear upward. I thought that sounded interesting, I certainly would rather have a 2nd degree cut in the perinium (& I think epis are generally 2nd degree by default) than some tears up near the urethra & clitoris! So that made some logical sense to me, but others on MDC said that's not evidence-based either.

Besides, I have to wonder, if the tear starts happening, would it really be possible for a cut in another direction to STOP that tear from continuing further? I have to think it's unlikely.

[Smokering]

Well, I think Gaskin maneuver (Hands & knees, right?) would be really tricky with someone who's had an epidural.

Oh yeah... good point.

I did have one friend say her OB said he'd do epis if a woman was about to tear upward.

How would he tell? Would the skin look really paper-thin and stretched or something? I agree I'd probably rather be cut downwards than tear upwards... but like you said, tears happen or they don't, they don't impend. I'm not sure how you'd get prior notice of tearing upwards.