episiotomy and vacuum?

[wombatclay]

Heyla!

I'm meeting with my care provider in a few weeks and will discuss this with her, but since it's giving me nightmares I'm hoping someone here can provide me with some info as well!

I was given an episiotomy prior to my care provider using a vacuum to assist in my dd's birth. I had been pushing for ~4 hours (this was my first VBAC birth) and although dd's head had been visible for some time she wasn't moving down further. It was decided that her head was stuck on the pubic bone and after trying all sorts of positions (the ones I remember were supported squat, dangle, squat with squat bar, hands and knees, side lying, semi reclined, and even semi recline with my feet up on the squat bar but there were probably others!) and a variety of "hip squeeze/pelvic press" attempts, and oil/compresses on the tissue, my care provider asked to do an episiotomy.

She told me I was already tearing a little and although it would be my choice, she thought the episiotomy would be necessary. I was in no real condition to think about it really (med free birth, pushing for 4 hours, so my brain was elsewhere) but I did know she was very conservative in terms of "cutting" and very natural birth supportive (trained on the Farm, had one of her own births there) and decided that if she felt it was necessary then maybe it was.

Eagle eyed hindsight suggests otherwise...she cut a very small episiotomy (DH was watching) and then used the vacuum to help direct dd's head under the bone. DD's head was delivered with the next push but then shoulder dystocia occured. DD was stuck for 4 minutes as everyone got very focused/intense. I was flipped a la the gaskin manuever and then flipped back, and eventually dd made it out. She was/is fine but I have a 4th degree tear and all that entails.

I'm sure the episiotomy contributed to the severity of the tear but I'm certainly not blaming her for the tear! Without the SD we'd be talking about 3-4 stitches, and obviously SD is pretty unpredictable. We had tried all sorts of non-surgical interventions before she mentioned the episiotomy.

So, my question... (and I will ask her at our meeting) I'm trying to figure out why an episiotomy could have appeared "necessary" at the time? As I said I've been having nightmares replaying that cut over and over and over and hope to find some "peace through detailed info", if that makes sense!

I've spoken with DH and my doula and although my care provider discussed the episiotomy with me she did not discuss the use of the vacuum as an option (I didn't even realize she was using a vacuum I was so far out of it!). Would you generally cut an episiotomy if you planned on using the vacuum? I'm wondering if perhaps she "knew" she was going to need the vacuum to shift dd off the pubic bone and so cut the episiotomy?

Or, if I was already tearing would an episiotomy seem logical to direct the tear?

Since she is so hands off and was so supportive of non-surgical intervention (she was suggesting many of the positions we tried, and instructed the nurses how to do an effective pelvic press) it seems unlikely that she suddenly decided after 4 hours that "what the heck, let's bring on the scissors!". But I'm trying to figure out what she may have been thinking at the time...

thanks everyone...I really appreciate it!

[doctorjen]

I don't generally do an episiotomy for a vacuum. Vacuum can be applied without one. I do see more spontaneous tears with vacuum, I think for 2 reasons - 1. the vacuum doesn't allow for the slower natural stretching to take place and 2. I generally don't go to vacuum for just long second stage until quite late in the game and often moms who have been pushing a long time have swelling which seems to make tears worse.
Now, take what I say with the proverbial grain of salt, because I wasn't there, I don't know what she was thinking or seeing, and I have the luxury of no responsiblity here at all. Having said all that, if someone has really pushed a long time, I generally will offer vacuum extraction first. If baby still seems stuck - ish, I will once in a great while do an episiotomy if it looks like the baby is right there, and especially if there are heart rate issues going on. This is really rare for me - like I'm thinking I've done 1 epsiotomy in the last 150 births, or so.
I don't believe in using episiotomy to "direct" a tear, I don't think it works, and I think if someone has a small natural tear starting, cutting, even in another direction usually just adds another big laceration. If I see a natural tear starting, I generally just try to keep my hands off it, and if I was using a vacuum, I'd try to bring the baby's head as slowly as possible. I know other birth attendants feel differently about this, but I've never seen an episiotomy work out at providing a smaller area needing repaired, or preventing a third or fourth degree extension.
Also, shoulder dystocia is more common with vacuum or forceps, as pulling the baby quickly does not allow for the natural rotation of the shoulders seen with spontaneous pushing.

[wombatclay]

Thanks...those are all things I was thinking. I can't figure out why she suggested the episio (or why I said yes! I'm a doula, I know the research, why on earth did I say ok?). But she is soooo hands off that I have to believe she saw some need/reason. Obviously I'll ask her at the 6 week appt but I was just trying to figure out what she may have been thinking.

FWIW, she used the vacuum during one contraction to move dd's head under the bone but I birthed the head on my own. Then the SD happened. Or at least, that's what dh and my doula said. And my doula has attended a number of births with this care provider (this cp is one of the few local "natural birth" advocates in the med community, and one of only a handful who attend vbac) and this was the first episiotomy she'd seen her (or her partner) do. Her partner also told me later that I was their first 4th degree tear in something like 10-12 years.

I just can't figure out the possible "why" behind the episio...and I think I "need" a reason (even if it's a "bad" one) that makes sense in order to let it go.

[Charmie981]

I'm a CPM and therefore don't use the vacuum, BUT, I've been at a few births where vacuum came up as an option, and I've only ever met one doc who was willing to apply the vacuum w/o an episitomy.

I clearly remember, in my first son's birth, being "offered" the vacuum (because I was saying/screaming "GET HIM OUT" and the doctor thought I actually WANTED him to do that ). In a particularly lucid moment, I asked if he'd do the vacuum without an episiotomy and he said "No." I opted not to have the vacuum.

So it's quite possible that she didn't feel she could use the vacuum without doing the episitomy, although clearly it can be done in at least some (probably all) cases of vacuum extraction.