Why are episiotomies so bad?

[rebeccalizzie]

Okay, no flames...I'm genuinely asking, not challenging. I've now seen quite a few posts from mamas talking about their tears that took 6-8 months to heal. Um....ow. I've never ever heard of an epi taking that long, I had 4 stitches and was totally fine in 6 weeks or so.

I'm just curious...my doc doesn't perform them anyway, so it's no big deal, but why is it better to have a huge honking tear than a little cut? Is it because epis were so abused and being used for women who wouldn't have torn at all, or are they always bad?

Thank you!

[LeosMama]

you're more likely, not less, to tear if you've had an episiotomy.

and your tear is far more likely to be less serious if you haven't had an episiotomy.

[alegna]

:

[shelbean91]

When I had my epi w/dd, I was sore for several weeks after being in PAIN for a good week or so. When I had ds1 with no epi (and no tearing for that matter) I wasn't sore at all after a couple of days.

[crysmomofthree]

its my understanding (and experience) that many if not most women don't tear at all. Especially if they go slow and do what their bodies tell them (ie no coached pushing) so if most don't tear, then why have a "universal" episiotomy policy, I mean if you give an episiotomy then there IS a cut not to mention the risk of further tearing or future tearing of the scar tissue.

[rebeccalizzie]

Originally Posted by LeosMama

you're more likely, not less, to tear if you've had an episiotomy.

and your tear is far more likely to be less serious if you haven't had an episiotomy.

Well that would explain it

Thank you...I figured there had to be a good reason. Heck, even most doctors I know of don't perform them routinely anymore. I guess I happened to have an "easy" episiotomy, and the mamas who posted happened to have very awful tears.

Off to learn about perineal massage...I want to do everything I can not to tear!

[blessed]

Turns out that natural tears are more likely to heal without chronic complications than episiotomies. Mostly it's sphincter incontinence (leakage of air and/or stool) that folks worry about.

When it tears naturally the muscle typically gives way at it's weakest point so the effect on the sphincter complex may not be as noticable. A doc with a scalpel may end up unknowingly cutting through the strongest area of muscle, damaging the function more profoundly.

[Alana]

Well...the one thing that totally sticks out in my mind was my chiro telling me about his wife's best friend. She had an episiotomy and managed to get a strep bacteria that was flesh eating...and wound up with a total hysterectomy.

Other than that...the thought of being cut makes me cringe. I have birthed 3 children...and the one I tore the least with was my 3rd, it was hardly worth mentioning. I took EPO my last month, and that really helped soften things up.

[CalebsMama05]

I dont want to get another episiotomy just because it itched while healing...i'm sure my doc *tightened things up* with an extra stitch and it took at least 6-8 mos for sex to be painless. and now it hurts.

[CarolynnMarilynn]

Another way to look at it is that an episiotomy is a guaranteed (sp?) 2nd degree tear (through tissue and muscle) and absolutely requires suturing. There may be many complications with this, as previous posters have stated.

A women without an episiotomy *may* tear, but is likely to have a tear less severe than an episiotomy, or no tear at all! Just like fabric will rip more easily with a cut to start it, so will an episiotomy make it more likely for that cut to extend into a third or fourth degree tear (into the rectum or sphincter). Many physicians like to perform episiotomies because they are easier and faster to repair, as the line is straight. However, that straight line means a weaker scar, rather than an interlocking uneven tear along weaker areas. Also, the healing time with an epis is longer and more painful. A natural tear may require more stitches to make sure that all the little bits get put back well, but are often smaller, less deep stitches. Repairing an epis requires huge sutures, but fewer of them, IMHE.

The biggest risks for doing an epis are increased infection and increased chance of tearing into a third or fourth degree tear, not to mention that there is NO research that supports episiotomy, except maybe in situations where the baby needs to be born STAT, and those few contractions it would take to think out the perineum would be harmful to the baby in distress. Epis is an outdated and dangerous intervention, and practitioners who have an epis rate of higher than 1 in a hundred or so (or less) are doing it way more often than necessary, or are ethically-challenged.

[Oh the Irony]

say you have two leaves. rip a tear in one. cut a tear in the other one. now try and fit the leaves back together. the one that is torn is actually much easier to fit back together.

[dynamicdoula]

I get this question relatively frequently from my clients.

Tearing

Tearing is avoidable by several factors- no 'purple' pushing, pushing in upright positions, allowing tissues to stretch instead of trying to get baby out as fast as you can, perineal support, avoiding epidural, not pushing on your back, and encouraging optimal fetal positioning. All of these things are within our own power as we labor. It's not a guarantee that you won't tear, but you're significantly less likely to tear.

Tearing is less traumatic to the tissues (usually) as it is more likely to be superficial and not go into the muscle tissues. Now, of course there are exceptions to every scenario. I've seen some nasty tears and tiny episiotomies, and I've seen gigantic episiotomies and no tearing at all. I had a client give birth to a 10#3oz baby girl over an intact perineum, on her back!

Episiotomy

Routine episiotomy is a surgical procedure that is done not because there is a reason, b ut because that is how it is done (like not letting women eat in labor). Who wants surgery they don't need?

Episiotomies are much more likely to cut down into the muscle structure that makes up your pelvic floor. Pelvic floor damage is getting a lot of press lately due to vaginal birth vs. cesarean birth, but episiotomy is an enormous culprit in this condition.

The body prefers to heal a tear rather than a cut, so healing time is usually faster and with less complications when you tear, rather than are cut. Surgeons (OBs are all surgeons) prefer the cut because it is much easier to repair.

Think about this: some docs give episiotomies so that the laboring woman won't tear. The goal should not be to avoid tearing, it should be to avoid any sort of perineal laceration. Whether you tear or are cut, you are still dealing with a laceration, right? I try to educate my clients/students about avoiding a laceration all together, rather than settling with an episiotomy.

[Triciabn]

This is one of those things I have often thought about... tear or not tear. Everyone gives so much bruhaha to tearing and never getting the hated episotomy... but truth be told...my epi was so not a big deal...healed really easy and without any bothersome complications.

1st birth...episiotomy
2nd birth... slight tear and a stitch or two
3rd birth... stretch and maybe a teeny tear.

With all that... I still liked the epi the best...well strike that, I probably like the small tear and stitched back..That was the best. That waiting till you stretch crap is overrated... My midwife was big on "I rarely have a girl tear,ever". I like her tons.. but I am not impressed by that any more..seemed like way more recovery..WAY more recovery.
Tricia

[NYCVeg]

When researchers finally studied episotomies (after decades of doctors doing them routinely), they found that virtually all fourth degree tears and most third degree tears occurred in women who had had episotomies; women who were not given episiotomies were more likely to have smaller tears or not tear at all. They also found that, except in rare cases of true emergencies, episiotomies had no benefits--except, perhaps, for making things a little more convenient for a doctor who might not want to wait an extra ten minutes for a baby to crown naturally. And, of course, an episiotomy is a procedure that a hospital can charge for--no money to made from tearing naturally (or not tearing at all).

I strongly, strongly recommend Henci Goer's chapter on episiotomy in The Thinking Woman's Guide to a Better Birth. It's very enlightening!

[Emilie]

my midwife is amazing.
she gets all babies out without tears- she does not suture- so that is her way.
she delivers breech and twins with no tears. she delivered my good friends 9 1/2 lb baby with no tear.
say puh puh puh when you are in the pushing. it works.

[Max'sMama]

Originally Posted by blessed

When it tears naturally the muscle typically gives way at it's weakest point so the effect on the sphincter complex may not be as noticable. A doc with a scalpel may end up unknowingly cutting through the strongest area of muscle, damaging the function more profoundly.

I agree completely.

I started to tear with ds and the doc then wanted to do an episitomy, I argued against and as I was not the one weilding the knife, I LOST. So, I ended up with a tear, episot., then further tear. All said and done it took about 12 weeks before I could sit/stand without massive preparation. The doc that cut me wouldn't give me an exact number of stitches in my 4th degree (to the a.verge) tear, but would say more than 60 stitches.

I also had a granuloma that presented itself at 7 weeks postpartum, from the episot. Basically the area that was cut didn't heal straight and even, and I had to have a piece of skin burned off to fix the secondary problem to the episotomy.

From my experience, the torn areas were much less painful than the cut area. Plus the 'huge honking tear' is less likely to be as deep and thorough as the cut, tears don't always go through the deep muscle, as a cut does.

[Mearaina]

I have to say that my epi with dd1 saved her life. I had been in labor for a looong time and there was meconium in her bag of waters, so they put an internal fetal monitor on. After pushing for 3 1/2 hours, her heart rate bottomed out and no matter how much my doc tickled her head it wouldn't come back. He had to vacuum her out, and she couldn't breathe. She was full-term and had to be on oxygen for an hour or so. However, my epi turned into a 4th degree tear. So, while I feel it was necessary, it definitely tore easily. dd2 got stuck at the same part of my pelvis, same thing happened, and they cut me and I pushed her out. 3rd degree tear. I am trying very hard with this one to avoid a cut, but my pelvis is shaped weird and the babes seem to go into distress when they get stuck at this certain point, any enough rambling . I just wanted to say that my cuts tore much worse then they were intended to be, but my doc does not cut unless the babe is in distress. I think I am going to try to push squatting this time to avoid the babe getting stuck.

~Lisa

[rebeccalizzie]

Thank you all! I really appreciate everyone taking the time to answer what I realize is a pretty dumb question--I've seen enough here to know that epi's are bad, just not why! Now I feel like I know how to prepare myself, and what questions to ask my midwife in a few weeks.

[pamamidwife]

Originally Posted by Emilie

my midwife is amazing.
she gets all babies out without tears- she does not suture- so that is her way.
she delivers breech and twins with no tears. she delivered my good friends 9 1/2 lb baby with no tear.
say puh puh puh when you are in the pushing. it works.

Midwives do not prevent tears. All the hand positioning and coaching does not prevent tears. If a mw is taking the credit for no tears, she is assuming that she is too vital in the process.

Sorry, its a bit of a pet peeve of mind. Women are perfectly capable of birthing their babies w/out someone else's hands all over their vulvas....and in fact do better when its their own hands guiding their baby out rather than someone else. Women need no coaching...the ring of fire signals most women to slow down...most women have a sharp intake of breath during this time and slow down anyway.

I also think we need to get away from believing all tears are bad and to be avoided at all costs. Most tears I see are slight and a perfect design of the body to avoid deeper damage to the body. Most tears also heal better without sutures.

I've had first time moms birth 10 and 11 lb babies and had two 13lb babies. No real tears, but I can tell you it wasn't because of me....for all of them, I wasn't even touching their vulvas.
I have a strong desire to make midwives aware that the perineal massage and hand maneuvers we are taught could actually take a woman out of the space of listening to her body...something that is vital in births.

Positions during pushing, hydration, elasticity are all vital parts of tearing vs not. Your mw with her hands on and in your most sexual of parts is not.

[Snowdrift]

Originally Posted by pamamidwife

Midwives do not prevent tears. All the hand positioning and coaching does not prevent tears. If a mw is taking the credit for no tears, she is assuming that she is too vital in the process.

Can I hug you please? Will you be my midwife?

I think I'm a UC-er at heart, but i'm scared ofmissing a vital cue to a problem since it's my first time. My midwives did tell me to not bother with the perineal massage that they strongly enocurage if I'm not comfortable with it, but I think that whatever happens there're gonna be lots of hands where I don't really want them.