Is it really possible for a practitioner to predict this?

[MissMuffet]

I finally found a homebirth MW in my area (most MWs are hospital based). When we were discussing episiotomies she said a woman 'rarely' ever needs one. She said, however, that there are rare instances when she can just tell that the mama is going to tear upwards- into the urethra, for example, or some other type of tear that might result in long term harm & discomfort. At these times she makes a small cut into the supple, fast healing perineum and the mama is then spared from any other tears. Everything I have read says that there is no proof for this- the mother might not tear at all, and, if she does get cut, it might extend into something terrible. But the MW assured me that it does indeed happen, and as a MW for 30+ years, she just instinctively knows when a bad upwards tear is going to happen and the only way to try and avoid it is an episiotomy.

My deepest fear is having yet another episiotomy and I am worried that if she actually believes they are *sometimes* useful, I might just end up with another one.

That said, she has a very hands off attitude regarding birth and sees her role as a MW as that of an unobtrusive observer watching a natural process unfold. 

[mwherbs]

How many episomities has she done?

[mamaharrison]

exactly^^^

Can you just talk to her and tell her that you absolutely under no circumstances consent to one. Sign a waiver. She can't do it if you don't give consent or if you give prior NON consent. Is it something she is comfortable allowing to happen as it happens vs. using her own judgement--even if she is correct. Of course, then you would have to understand that if you did have a nasty tear into the urethra and had not given consent for episiotomy that would be your judgement not hers--informed refusal, it's called. I would think that if you signed an Informed Refusal form she should honor your wishes and fi not then you KNOW she isn't the MW for you and you can look elsewhere OR you can decide if it is a big enough risk factor for you to go elsewhere or stay instead knowing that it is unlikely to happen and somehow trusting that if it did she usd her best judgement to help you have a better experience. Only you can decide, but this is the way to get full knowledge up front about it. 

Ask her about an informed refusal release.

[MissMuffet]

We were actually discussing episiotomies right as I was walking out her door. I only asked her as an afterthought because I thought I was sure of her answer, given her let-nature-run-its-course birthing philosophy. I had already decided to ask her how many she'd actually performed and, regardless of her opinion at the moment, not to cut me please.

My question is-

a.) is it possible for an experienced MW to just *know* that her patient is going to have a nasty tear. And

b.) will an episiotomy, under those circumstances, prevent a greater evil?


Thanks!

[mamaharrison]

Originally Posted by MissMuffet 

We were actually discussing episiotomies right as I was walking out her door. I only asked her as an afterthought because I thought I was sure of her answer, given her let-nature-run-its-course birthing philosophy. I had already decided to ask her how many she'd actually performed and, regardless of her opinion at the moment, not to cut me please.
My question is-
a.) is it possible for an experienced MW to just *know* that her patient is going to have a nasty tear. And
b.) will an episiotomy, under those circumstances, prevent a greater evil?
Thanks!

I am an experienced bodyworker and as such I have a great working knowledge of the body in certain capacities. I can often make educated guesses on how tissues will behave during therapies while in treatment and in fact this is part of what makes me so good at my job, IMO/E. I would have to say that if I had 30 years of experience as a typically hands off MW that I am sure that I would have developed an 'eye' for anticipating how the tissues are progressing/stretching/acting as I were watching a babe born down the birth canal. So, yes, I do think that this is a skill that an experienced MW may very well have.  I think you may be misinterpreting her 'knowing' as if it were something she divinated from the mystic or decided early in labor vs. when she is actually using many different learned observational skills in her determination or opinion or predicting of the way the tissue may behave in the next momentt as she is actually watching the birth unfolding in front of her. Isn't this why we want experienced practitioners vs. newbies--they have developed skills that simply can't be taught or learned without direct observation and hands on experience. 

I am not trained on episiotomies, but it is logical to think that in anticipation of a terrible tear that would go deep into the urethra possibly affecting lifelong functioning if consent was given for an episiotomy and one was performed that may prevent the tearing of tissue towards the urethra and thus preserve the tissue in that area in favor of the now cut open perineum. Not that there wouldn't be issues with the cut tissues that would be any better necessarily--I would think that I would want to research that further before I held that same opinion--that of course, is your MWs opinion and your may differ especially if the act of being cut brought more trauma for you emotionally than tearing and coping with potential injury to your urethra. 

Goo luck.

[fayebond]

My MW does do episiotomies, but has only done ... 6 ? ... ish... in her 20 some odd years.  It makes sense that in the moment she could tell, oh, that's not a normal bulge there.  Yours might have more, but its not a be-all-end all, unless that's just not you.  Talk to her about your fears, MW appointments are about relationship building as much as anything else.  The MW I'm seeing isn't 100% jivving with my personality, but I trust her, and that's the biggest thing to me.

[MissMuffet]

Originally Posted by mamaharrison 

So, yes, I do think that this is a skill that an experienced MW may very well have.  I think you may be misinterpreting her 'knowing' as if it were something she divinated from the mystic or decided early in labor vs. when she is actually using many different learned observational skills in her determination or opinion or predicting of the way the tissue may behave in the next momentt as she is actually watching the birth unfolding in front of her.

I have been scarred (pun intended) one too many times by an OB swearing, right at the heat of the moment, that I was gonna rip horribly if she didn't make a small snip to prevent a greater evil. When I read the literature, it says over and over that episiotomies have NOT been found to prevent hArm, and, in many cases, make things worse. So I am just a bit wary now of someone saying they just "know" it will happen. In any case, I think the most important thing is just to find out how many she has actually performed and go from there. The first thing I told her when we met was that I was seeking midwifery care and a hb due to the long term pain I still have from previous epis. I appreciate everyone's replies.

[mamaharrison]

Originally Posted by MissMuffet 


I have been scarred (pun intended) one too many times by an OB swearing, right at the heat of the moment, that I was gonna rip horribly if she didn't make a small snip to prevent a greater evil. When I read the literature, it says over and over that episiotomies have NOT been found to prevent hArm, and, in many cases, make things worse. So I am just a bit wary now of someone saying they just "know" it will happen. In any case, I think the most important thing is just to find out how many she has actually performed and go from there. The first thing I told her when we met was that I was seeking midwifery care and a hb due to the long term pain I still have from previous epis. I appreciate everyone's replies.

With all due respect, I feel like you asked for opinions but already have your own, which is fine, but why ask for others opinions when your is already set--there is absolutely nothing wrong with you following your very own intuition on any subject--supporting research or not--a woman has every right to say, 'I don't want you to cut me NO MATTER WHAT your opinion is of the present situation and where it may be leading.' That is enough ; ) So, then just talk to her about that and so long as she agrees to informed refusal and you feel you trust her in that regard you should be just fine ; )

ALso, I do NOT count HBMWs the same as OBs and I would trust my MW over an OB declaring this in a heartbeat. OBs are not trained in normal, physiological birthing and are trained to see pathology where there may in fact be none. I mean, if she is an episiotomy loving MW and that is her 'thing' then she certainly wouldn't be considered a hands off MW. I'm willing to bet that she has done few of them especially as compared to an OB who has been in practice as long as she has, but of course simply asking her should clear this up.

FWIW, I agree with you. I wouldn't NOT want to be cut for any reason even by a MW who was using her observational and experiential skills to predicte a nasty tear that would have lasting consequences. The act of being cut open {which I have not expereinced in this regard} would definitely be traumatic for me and for most women's bodies vs. tearing being the body's way of naturally coping. However, I had a natural 2nd degree tear into my perineum with my DD who was born with a nuchal arm and it was definitely traumatic and has had major long term consequences for me, too. So, not being cut and tearing instead doesn't always = no damage or trauma either. She carved a canal through my lower vagina with her elbow and the tear, although nothing crazy horrible, has left me with significant scar tissue and a completely different sense of feeling--changed how sex feels and everything :( and it has been 3+ years since. Now, I am glad to not have the added trauma of being cut and wondering if that really needed to happen, it doesn't negate the fact I do deal with long term issues from the natural experience.

If you don't trust your MW on this issue, I think you would do best to find another MW ASAP since it is a very big issue for you. No reason to wonder and worry needlessly ;)
Best of Luck.

[MissMuffet]

Naturally I do have an opinion- my opinion is that episiotomies suck and I want to do anything to avoid one. But I have no idea about whether or not a mw or dr can predict that one is actually needed. Like I said, I've read a lot about the subject and everything I've come away with is: there's no proof they prevent harm. This is why I'm asking if experienced mws can tell when an episiotomy is absolutely necessary and whether an epi will indeed prevent harm at that point - or if that is just hogwash. This is why I appreciate your response about your own experience in bodywork and being able to tell how tissue is going to behave at a certain point. It shows someone totally ignorant about the topic (me) that it probably is possible to anticipate a tear and try to take it off track I guess by snipping another area.

Sorry about your long term perineal issues. It would be ironic if I spent all this effort avoiding an episiotomy only to end up with something just as painful.

Also, there are no other hb mws around unfortunately. I live in a country with birthing practices like the 1980s in the US (episiotomies something around 80 % would be my estimate and women in fact request them because it leaves them 'neater' down there). And hospital mws are just like regular nurses.

[dannic]

Also ask her what type of perineum support she can offer or has experience with...I have torn on the same y shaped place with three briths...the first was the worst, the second followed the scar tissue, and the third, though much smaller, was more difficult to heal.  With my fourth, I really emphasized my desire to not tear and my MW supported the perimeum during the pushing stage and no tear, YAY!  I am weeks (days?) from my fifth birth and am planning the same thing...also am oiling, lathering? lol my perineum regularly right now in hopes that it helps in the stretching...not sure if it will, but worth a shot.  Anyway, hope this isnt' too off track; just thought it might help to hear her response in this area as well...