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Episiotomy vs. Tearing

post #1 of 32
Thread Starter 

A recent discussion in the home birth supplies thread spurred my interest in collecting some articles about episiotomy vs. tearing.  I have access to several online journal libraries through dh so I can search out a few articles.  But, please feel free to add your own information, understanding, and/or anecdotal evidence to the mix!

post #2 of 32
Thread Starter 

 

Quote:
Episiotomy increases perineal laceration length in primiparous women
 

Charles W. Nager MD, Jason P. Helliwell MD

From the Department of Reproductive Medicine, The University of California, San Diego, Medical Center.

Received 27 October 2000; revised 8 March 2001; Available online 9 May 2002.

 

 

Abstract

Objective: The aim of this study was to determine the clinical factors that contribute to posterior perineal laceration length. Study Design: A prospective observational study was performed in 80 consenting, mostly primiparous women with term pregnancies. Posterior perineal lacerations were measured immediately after delivery. Numerous maternal, fetal, and operator variables were evaluated against laceration length and degree of tear. Univariate and multivariate regression analyses were performed to evaluate laceration length and parametric clinical variables. Nonparametric clinical variables were evaluated against laceration length by the Mann-Whitney U test. Results: A multivariate stepwise linear regression equation revealed that episiotomy adds nearly 3 cm to perineal lacerations. Tear length was highly associated with the degree of tear (R = 0.86, R2 = 0.73) and the risk of recognized anal sphincter disruption. None of 35 patients without an episiotomy had a recognized anal sphincter disruption, but 6 of 27 patients with an episiotomy did (P < .001). Body mass index was the only maternal or fetal variable that showed even a slight correlation with laceration length (R = 0.30, P = .04). Conclusion: Episiotomy is the overriding determinant of perineal laceration length and recognized anal sphincter disruption. (Am J Obstet Gynecol 2001;185:444-50.)

Copyright © 2001 Academic Press. All right

 

post #3 of 32

Good thread, Jaimee! One thing I really really like about my OB, even though he wants to "strip" the cord instead of waiting for it to stop pulsing if I go to the hospital is that he does NOT believe in episiotomies unless ABSOLUTELY necessary and listed very legitimate reasons for cutting vs. tearing. But he said he sees alot better results for healing tears than cuts and encourages his patients to tear rather than be cut and also mentioned what the WHO says about cutting vs. tearing and which is more beneficial, which he cited tearing was better. :)

post #4 of 32

My anecdotal evidence: Having had both a 2nd degree episiotomy and a 3rd, nearly 4th degree tear - tearing is way better! The scar from my cut hurt literally for nearly 3 years, until I gave birth again and got re-stitched up. There was no way I could even consider sex for 9 or 10 weeks after the cut; we had sex pain-free at 5 weeks after the tear. I do believe that a lot of that also had to do with the skill of the person repairing the laceration, but the difference was astounding.

 

As far as preventing a tear, from everything I've read, I'm focusing on strengthening the tissue and making sure it's really healthy vs. perineal massage/stretching-type stuff. I've read that yeast infections can really weaken the perineum, so I've been proactively preventing yeast. I also plan to start taking vitamin C and E, and using vitamin E oil and evening primrose oil topically soon. I'm trying to remember to do squats instead of Kegels to strengthen my pelvic floor as well.0

 

I'm not particularly interested in perineal massage because you read so much conflicting advice. Some sources say it can actually do harm, and I find it pretty uncomfortable anyway, so I've never really put much effort into it.

post #5 of 32
I'm not sure if I need to worry about this or not. I didn't tear at all with either birth. Not even the tiniest bit. I wasn't even sore the next day. And dd2 was 9lbs 7oz. I'm not sure if this means I won't tear this time or not. That's what I'd like to believe... I wonder if there are instances of tearing with the third+ for the first time...?

I didn't do massage, either. I tried with dd1, but really couldn't reach. Ha! I do remember being very careful with pushing both times. I ended up on my back/side by choice (sheer exhaustion) and would not spread my legs far at all. I was like, no!! this is as far as they are going!! The baby will still make it out!!
post #6 of 32
Thread Starter 

 

Quote:

Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial


Dept. of Obstetrics and Gynecology, Univ. of Munich-Großhadern, Munich, Germany
Dept. of Obstetrics and Gynecology, Univ. of Munich-Großhadern, Marchioninistrasse 15, D-81377 Munich, Germany


Abstract

Background. The indication of the restricted use of episiotomy at tears presumed to be imminent is not clear. Methods. Randomized controlled trial with two perineal management policies. Use of episiotomy: (a) only for fetal indications and (b) in addition at a tear presumed to be imminent. Participants: 146 primiparous women with an uncomplicated singleton pregnancy at >34 weeks of gestation. For the intention-to-treat analysis those 109 women were included who vaginally delivered a live full-term baby between January 1999 and September 2000: 49 women in group a, 60 in group b. Outcome measures. Reduction of episiotomies, increase of intact perinea or only minor perineal trauma (intact perineum and first-degree tears), third-degree tears, anterior perineal trauma, perineal pain in the postpartum period, pH of the umbilical artery, Apgar scores, maternal blood loss. Results. Episiotomy rates were 41% in group a and 77% in group b (p < 0.001). Women in the restrictive policy group had a greater chance of an intact perineum (29% vs. 10%; p = 0.023) or only minor perineal trauma (39% vs. 13%; p = 0.003) and had significant lower pain scores postpartum at different activities. There were no statistically significant differences with regard to third-degree tears, anterior trauma, pre- and postpartum hemoglobin concentrations, Apgar scores and pH of the umbilical artery. Conclusions. Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.

 

post #7 of 32
Thread Starter 

 

Quote:

Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study


Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
College of Nursing, Chung Tai University of Medicine and Technology, Taichung, Taiwan
Department of Obstetrics and Gynecology, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan


Abstract

Background: The episiotomy rate has declined worldwide but remains high in several countries such as Taiwan. The effects of episiotomy on women's health should be a constant concern. Few data are available on the effect of episiotomy by validated measures. Objective: The present study examined the effect of episiotomy on pain, urinary incontinence, and sexual function up to 3 months postpartum. Design, setting and participants: A prospective follow-up study of 243 women who completed the Taiwanese versions of the Short Form McGill Pain Questionnaire, International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form, Female Sexual Function Index, and a demographic questionnaire after vaginal delivery in a Taiwanese medical center. Methods: Differences between those who did and did not have an episiotomy were tested using ANCOVA, adjusting for age, parity, newborn weight, and vacuum delivery. The reliability and validity of the measuring instruments were assessed using Cronbach's α coefficient and factor analysis. Results: Women who delivered without an episiotomy had significantly lower perineal pain scores at weeks 1, 2 and 6 postpartum compared to women who had an episiotomy (p=0.0065, 0.0391, 0.0497, respectively). Women in the no-episiotomy group had significantly lower non-localized pain scores at week 2 postpartum compared to women in the episiotomy group (p=0.0438). The mean urinary incontinence score was significantly higher in the episiotomy group 3 months postpartum (p=0.0293). No significant difference in sexual function score was found between groups. Conclusions: The results indicate that episiotomy increased pain at weeks 1, 2 and 6 postpartum, and urinary incontinence at 3 months postpartum. Awareness of the relationship between episiotomy and women's health will help health care professionals develop policy and promote the application of restrictive episiotomy. © 2010 Elsevier Ltd.

 

post #8 of 32
Thread Starter 

 

Quote:

Outcomes of routine episiotomy: A systematic review


Center for Women's Health Research, University of North Carolina, Chapel Hill, NC, United States
Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC, United States
Department of Obstetrics, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
Cecil G. Sheps Ctr. Hlth. Serv. Res., University of North Carolina, Chapel Hill, NC, United States
Research Triangle Institute, Research Triangle Park, NC, United States
Center for Women's Health Research, University of North Carolina, Campus Box 7521, 725 Airport Rd, Chapel Hill, NC 27599-7521, United States


Abstract

Context: Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use. Objective: To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. Evidence Acquisition: We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality. Evidence Synthesis: Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function-pain with intercourse was more common among women with episiotomy. Conclusions: Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some propotion of women who would have had lesser injury instead had a surgical incision.

 

post #9 of 32
I was pretty lucky last time in that I didn't tear or need an episiotomy, but the nurse at the hospital told me they hardly ever do them anymore. I don't remember where I read this but it stuck in my mind(in a really really bad way) but the writer made a comparison to a piece of cloth. If you were try to push a tennis ball through a small hole in a cloth, the cloth would stretch out and might even tear a little. But if you were to take a pair of scissors and make a cut in the cloth as you were pushing the ball through, it would most certainly tear even further than you might have anticipated. Does that make sense? Sorry for the disturbing mental image right before dinner!
post #10 of 32
Thread Starter 

 

Quote:

Comparison between different perineal outcomes on tissue healing


Currently practicing as a CNM at Hutzel Hospital in Detroit, MI, United States
Member of ACNM and Sigma Theta Tau USA
University of Illinois at Chicago, United States
NAACOG, United States


Abstract

Perineal healing was compared between 181 women with episiotomies and 186 women without episiotomies at one to two weeks after delivery. Subjects were medically indigent low-risk women who had normal spontaneous vaginal deliveries at the same tertiary-care hospital. Maternal age, race, parity, and birth weight did not have an independent effect on perineal healing. Perineal outcome at delivery and length of second stage exhibited a significant relationship with perineal healing. Overall, there was a 4.9% incidence of delayed perineal healing due to wound separation or clinical infection. In the episiotomy group, 7.7% of the subjects experienced delayed perineal healing compared with 2.2% in the no-episiotomy group. This was statistically significant using Pearson chi-square analysis. These results suggest that women without episiotomies exhibit better perineal healing than women with episiotomies. © 1991.

 

Anyone interested in reading more articles or has the point been adequately made?  winky.gif

post #11 of 32

I asked for no episiotomy last time, but I did tear a pretty good 2nd degree tear. I was sore for a few days, but I really didn't think the recovery was that bad. I did what I called the "spa treatment for my crotch" every time I went to the bathroom and that kept me feeling pretty good. I did just talk to my midwife about this today though... Last time, I was watching myself push in the mirror. It actually really helped me with my pushing and knowing where to focus the pushing. But when I saw her head get close I said out loud "She's coming out now" and pushed her out with all my might. There really was no stopping me and I'm sure that's why I tore like I did. My midwife and I talked about that today and she said this time if she sees me doing it again, she will do her best to keep me focused on gently pushing the baby out a little at a time to help with the stretching. She did say it's likely I will tear again since the tissue is weaker from tearing last time, but she'll do what she can to help me.

post #12 of 32

I am looking at the info Jaimee is providing and shaking my head. Episiotomies leading to or worsening incontinence due to the pelvic floor being cut? How tragic the price that's paid for the doctors' so-called "preventive measure". Possibly leading to future medical intervention of that problem as well as the possibility of chronic pain during intercourse. It's so sad, and the fact that not many doctors are taking episiotomies out of their routines WITH this evidence is even more disturbing.

 

Mal, you could just wait on the pushing until the baby is literally crowning on its own. I'm very sure that's why I didn't tear last time. I pushed gently twice and she was out. It sure beat the 45 minutes it took to push my son out, because I was pushing him down from a higher station in the birth canal.

post #13 of 32
Quote:
Originally Posted by IwannaBanRN View Post

 

 

Mal, you could just wait on the pushing until the baby is literally crowning on its own. I'm very sure that's why I didn't tear last time. I pushed gently twice and she was out. It sure beat the 45 minutes it took to push my son out, because I was pushing him down from a higher station in the birth canal.



That's much easier said than done sometimes! I had planned to let my body do most of the work with my son, but once I got the urge to push, there was no way I could fight it. His big old head came flying out, which I'm sure is why I tore. I pushed for 45 minutes with him, which was much better than the 2 hours with DD! If it feels right, I may try to lay on my side this time when pushing to try to reduce tearing.

post #14 of 32
Quote:
Originally Posted by meesh933 View Post

That's much easier said than done sometimes! I had planned to let my body do most of the work with my son, but once I got the urge to push, there was no way I could fight it. His big old head came flying out, which I'm sure is why I tore. I pushed for 45 minutes with him, which was much better than the 2 hours with DD! If it feels right, I may try to lay on my side this time when pushing to try to reduce tearing.



Believe me, I know! I had a weak epidural by choice, so I felt pretty pushy, but I was also ignored about it until I told them she was crowning. lol 5 minutes before I started pushing, I told them twice I needed to push and they kept glancing at me, then continuing to talk. Then I was like "um......I need to push. She's crowning." My OB: "Oh! Well, she sure is, isn't she? Let's get this baby out then!" It was kind of funny when she told me I did such a good job and how strong my pushes were. Looking back now, it was my body doing the work involuntarily and that's what alot of doctors don't get. The baby CAN come out by itself without help. It's the body's reaction to involuntarily push the baby out. Telling a mom to stop pushing or NOT to push is just plain ignorant. The body is still gonna push it out. lol

 

post #15 of 32
Thread Starter 

Mal, pushing with my second was a lot different than with my first, so have hope!  With my first I worked and worked and she went out and back in, and out and back in...  It felt like it took forever, I felt like I was forcing it and I did end up with a minor, first degree tear.  With my second it took one push to get him down to the perineum and 1.5 more pushes to get him out.  So easy, no tearing, and he was bigger.  I think just letting yourself do what you need to do when you need to do it usually works out pretty well for the most part.  I think the evidence on perineal support is also not terribly conclusive.  I might have passed by an article on that very thing today... I'll have to look again.

post #16 of 32

I had an episiotomy and 4th degree tear with my 1st child. Horrible - stitching mw up was one of the most painful parts of the labor, I was scared to poop for a good week after the birth because any pressure down there hurt so badly, and it took months to recover. With my 2nd and 3rd children I had no episiotomy and no tearing at all (and one of those kids was 11 pounds). So I personally cringe at the thought of an episiotomy and have made it very clear to my OB that I really, really do not want one. I figure if I'm going to tear, I'm going to tear...no use speeding it along with an episiotomy.

 

post #17 of 32

I had/have an absolute NO SCISSORS policy.  None.  Ever.  Don't even come near me with them.  Heck No.

 

The thought of being CUT down there totally freaks me out.  I'd rather tear, thank you very much (and thankfully all the evidence is in favor of tearing). 

 

I didn't tear with DS1 and my MW is convinced I won't tear this time either.  She believes it has a lot to do with the mother's diet- a healthy diet produces healthy tissues that stretch etc.  I don't know, I've heard the same thing about stretch marks though.  I don't have those either.  *KNOCK ON WOOD*  Well, except my breasts.  They look like a freaking map of LA.  Sigh.

 

SO who knows.  We did perineal massage last time and my MW was really great about gently helping the tissues stretch over the head.  Bless her heart.  I'm sure this MW will be just as wonderful in that regard.  

As an aside, I thought FOR SURE last time that I had MASSIVE tearing because holy freaking mercy jaw.gif doesn't it just feel like your entire bottom just EXPLODED into a million bits and pieces??!?!  Yeesh.  Surely I'm not the only one who felt this way....

post #18 of 32

My former pre-natal carer had some good thoughts on this issue when I said i didn't think I liked the idea of episiotomy. Her words have fortified my stance against having it done.

 

If you tear naturally, the tissue down there will most likely find the path of least resistance and tear in between muscle fibers.

 

If you get cut down there, they cut through everything (including the muscle).

 

Now, I'm sure muscle tissue can be affected, but I do agree with the body taking the easiest route to tear. It makes perfect sense.

 

[quote]As an aside, I thought FOR SURE last time that I had MASSIVE tearing because holy freaking mercy jaw.gif doesn't it just feel like your entire bottom just EXPLODED into a million bits and pieces??!?![/quote]

 

OMG - I did not just read that lol. Now, I'm scared haha.

post #19 of 32

My former pre-natal carer had some good thoughts on this issue when I said i didn't think I liked the idea of episiotomy. Her words have fortified my stance against having it done.

 

If you tear naturally, the tissue down there will most likely find the path of least resistance and tear in between muscle fibers.

 

If you get cut down there, they cut through everything (including the muscle).

 

Now, I'm sure muscle tissue can be affected, but I do agree with the body taking the easiest route to tear. It makes perfect sense.

 

As an aside, I thought FOR SURE last time that I had MASSIVE tearing because holy freaking mercy jaw.gif doesn't it just feel like your entire bottom just EXPLODED into a million bits and pieces??!?!

 

OMG - I did not just read that lol. Now, I'm scared haha.

post #20 of 32


Quote:

Originally Posted by jbk21 View Post
As an aside, I thought FOR SURE last time that I had MASSIVE tearing because holy freaking mercy jaw.gif doesn't it just feel like your entire bottom just EXPLODED into a million bits and pieces??!?!  Yeesh.  Surely I'm not the only one who felt this way....


Alright, I'm officially terrified of birthing right now. Thanks jbk21. ROTFLMAO.gif

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