Episiotomy question

[NoraB]

I asked my OB about episiotomies and was pleased to hear her reply that she definitely does not do them routinely. She did mention that, if she's very concerned that a mother will tear up into the urethral and clitoral area, she'd be likely to make a cut in the perineum. She said that tearing can occur there b/c "after the head comes out it immediately goes up."

While it seems reasonable to me to make a cut in the perineum to avoid a tear into the urethra, etc, I'm wondering how really common that is or if it's due to the supine birthing position. Anybody have any knowledge or experience in this? Advice?

[Belle]

"after the head comes out it immediately goes up."

What goes up? Is she saying that after the head comes out you'd tear?

A cut in the perinium is an episiotomy. I think you'd be better off tearing. And yes, being in the supine position will increase chances of tearing. So will pushing to a count.

[my5girls]

The supine position will absolutely increase the chances for an episiotomy; its simple gravity. There are far more beneficial positions for both you and baby; on all fours, squatting, standing, semi-propped, etc. Changing positions helps lessen the chance too.

As for pushing to a count, this is also unnecessary; if you do not have pain meds, your body will leave you with no choice but to push, and you'll know when it's time to take a break. With my DDs, I never really "pushed"; I just focused my energy into "bearing down" for as long, or as short, as I felt like. All four DDs literally slid out...no need for interventions or counting.

I wish you the best of luck.

[mightymoo]

There are also other alternatives to an epis. if it does look like you might tear up - I believe the attendant can use compresses and support that area to keep tears to a minimum. (I've heard of this as 'supporting the perineum', but I assume similar principles would work for the other areas)

[USAmma]

Yes, you need support. Here's a graphic photo from my birth (on my back b/c of epidural-- my choice) with my OB supporting me. I only tore a tiny amt to one side (right where his first finger is) because her head was not fully straight coming out. It was turned to one side. Otherwise I think I would have come through intact. I told him NO cutting. I didn't need any stitches.

http://im1.shutterfly.com/procserv/4...6108IbNWLVu1bW

[NoraB]

Thank you all so much!

[pamamidwife]

I'd rather tear - even up - than to have someone cut me through tissue and muscle. You're more at risk for problems with a cut. However, I don't know that I'd just let it go - I'd tell your OB that you don't want to be cut (if you don't want to) no matter what it looks like. There's always a "reason" for many docs to pick up the scissors.

[doctorjen]

I agree with pam. I have only exceptionally rarely seen a tear upwards be anything more than a skid mark - sometimes even a deep skid mark, but almost never even needing stitches. Sometimes it helps to put a little pressure on the fetal head to keep it flexed as it is born. You see moms spontaneously doing this themselves if allowed to push the baby out and support themselves with their own hands.
Pushing in an upright position encourages better head flexion, too, and has the added benefit that your birth attendant can't see the perineum as well and therefore can't decide that things aren't stretching well and need to be cut.

[NoraB]

Great advice! I had wanted to avoid an episiotomy for sure, but the OB did confuse me a little w/ the "tearing upward" thing. I'm glad I asked here.

[carrietorgc]

just wanted to agree with everyone else - i had two little skid marks and a minor 1st degree tear with dd - my midwife and the nurse did tons of warm compresses and perineal massage and i think that helped a bunch.

[WinterBaby]

I don't know about the tearing forward being related to supine positioning. I pushed upright, on a birthing stool, and forward in the clitoral and urethral area is where I felt a lot of pain. So while my midwife supported my perineum, I used both hands to support the front area and the baby's head, which helped me slow down the pushing and not tear. I'm not sure if in a supine birthing position I'd have cradled the baby's head and my own tender bits though. (Doctors do let you do that, right?)

[mlis]

I was told that I would tear 'up' with ds and got scared and allowed an episiotomy. I had only been pushing for a few minutes and the dr seemed very *concerned* His head was born on the next push. I'm SURE I didn't need the cut and am very angry about it now. The cut hurt much worse and took soo long to heal. I couldn't sit to nurse for a while. My dr. also had a 'I only cut if it looks like you will tear up' rule.. I think that its just an excuse to get the baby out faster.

[doctorjen]

Originally Posted by WinterBaby

(Doctors do let you do that, right?)

Well, some do anyway!

[doctorjen]

I just wanted to add something about doctors' training and their comfort levels with tears, long second stages, and episiotomies. I'm not really meaning to make excuses for docs, but more to explain how they think.
When I was in training, episiotomies were pretty much the rule, especially for first time moms. When you are used to seeing births with episiotomies, you don't get used to seeing the natural stretching that goes on if you leave the perineum alone.
When I got out in practice, I vowed not to cut routinely. It was so hard in the beginning to know what was normal. I had only rarely seen a first time mom push her baby out without being cut, and usually the ones who didn't get cut were because they pushed the baby out so fast. Of course, some first time moms do push their babies out quickly. Many times, though, crowning is a nice slow process, particularly if you are not also yelling/counting at the mom. It was hard to learn that the perineum would stretch, even in those cases where only 1 millimeter of head more was visible with each push. The perineum feels like a tight band of tissue around the baby's head in a lot of women, and it doesn't necessarily feel like there is any give there. But lo and behold, if you leave a woman alone, the perineum very slowly stretches. I was surprised over and over that what felt like firm tissue holding up the birth slowly gave and allowed the baby to slowly emerge.
If you have never seen that process first hand and are used to the quicker birth that happens with an episiotomy, it is hard to get used to.
Like I said, it is not an excuse. In fact, to my mind, there is no excuse for not learning what a normal birth looks like, but there are a lot of docs who've never taken that opportunity. As a result, they think that the head distending the perineum for 20 minutes or more must be harmful. And worse, they think they can predict who will tear, and who won't and therefore have to get in there and intervene. I don't think it's truly possible to predict bad tears - with the possible exception of women who get very bad perineal swelling while pushing. Many times, moms who I thought might tear didn't. And occasionally, I've been surprised by a deeper tear than I usually see. I almost never see a tear that's equal to or worse than an episiotomy, though. And I rarely see a mom who's experiencing significant pain months after birth.

[AdoptChina]

I did not get an episiotomy with any of my births. I did tear though. First time was a small tear down, not a biggie but needed several stitches. Second time I tore really bad---tore down again and also had a large tear up towards my urethra. I think this was due to DS 2 having his shoulders get stuck. Hurt for quite a long time. 3rd delivery I had a small tear but dont think I even got stitches (cant remember lol)......Im very glad I didnt get any episiotomies....even with the bad tear. Don't let them talk you into something just because its what they "normally" do

[girlndocs]

I agree with Pam: make your boundaries/instructions *very* clear if you stick with this care provider. I fell into a similar trap: the medwives told me they didn't "routinely" do x,y,z and the other, but when I was in labor -- whoopsie! how's about that? -- they found reasons to do all those things anyway : So there are probably a lot of practices that won't admit to doing things like episiotomies *routinely* but still do them so often they are in fact part of the routine, just with excuses.

Asking about the percentages of births with x intervention is more informative than asking if it's routine, I think.

[crazy_eights]

Originally Posted by doctorjen

It was hard to learn that the perineum would stretch, even in those cases where only 1 millimeter of head more was visible with each push. The perineum feels like a tight band of tissue around the baby's head in a lot of women, and it doesn't necessarily feel like there is any give there. But lo and behold, if you leave a woman alone, the perineum very slowly stretches. I was surprised over and over that what felt like firm tissue holding up the birth slowly gave and allowed the baby to slowly emerge.
If you have never seen that process first hand and are used to the quicker birth that happens with an episiotomy, it is hard to get used to.
Like I said, it is not an excuse. In fact, to my mind, there is no excuse for not learning what a normal birth looks like, but there are a lot of docs who've never taken that opportunity. As a result, they think that the head distending the perineum for 20 minutes or more must be harmful. And worse, they think they can predict who will tear, and who won't and therefore have to get in there and intervene.

I think a lot of docs who are used to episiotomies see that normal stretching and they either think that the perineum is 'holding up the delivery' or that the fact that you can see a little bit of head and this big distended perinium over the baby's head means the mom 'isn't stretching and will tear'. Really sad that they have never seen that miraculous, slow stretching with the head appearing bit by bit.

And if I hear one more OB tell a mom long before the head is near the perineum 'you have a tight band of tissue here, you are going to need an episiotomy', I might get violent .

[Ligmom]

Just wanted to add that having an episiotomy doesn't necessarily mean that you will not tear upward (or downward for that matter ). I have known women who's docs have cut them "so they wouldn't tear", and they ended up with both--and occassionally a cut down and a tear up. OUCH

[NoraB]

Thanks again for the continued information!

I do plan to stick w/ my OB, but I will be much more insistent on this episiotomy issue.

[tinyshoes]

drjen, I think it's very valuable to have insight into the OB's perspective. Once I heard a doula explain why an OB would cut an episiotomy. For a long time, I thought that doula was a FREAK--siding with The Man?

Now I often quote her--OBs are surgeons first, and they are witnessing a pathological condition (childbirth) and potential damage to the body (the tearing) and how do they protect and best serve the patient? Snip, snip.

Seroiusly...having a baby involves risks, including risks to your perineum.

Seriously...jogging involves risks, including risks to the skin on your knees.

But would you cut your knee, through the muscle, just because you might fall down and skin your knee? FOR REAL, in my opinion, these two examples are equal.

NoraB, don't insist--demand. If you do not want an episiotomy (I had one with my first birth, and I have been on a crusade against episiotomy since then, because it was profoundly horrible...and my snip wasn't unusual; my experience was typical typical typical) do not condone it. Have your dh or doula watchin' for your OB to grab the blunt-tipped Mayo scissors during your child's birth, so that your wishes can be honored.

Would you go to a salon and be "more insistant" that your stylest not shave your hair off, because it looked like the haircut was going to be lame anyway? Just like your stylist, you are paying the OB for his/her experience, knowledge, and talent...and you are paying them to GET WHAT YOU WANT. You are not paying them so they can do what they feel like doing. (Contrary to popular opinion! I'm talkin' theory!)

Remember: a TEAR is like a skinned knee; superficial. An episiotomy is ALWAYS THROUGH skin and muscle, and is what causes a tear to or into the anus.