A Rant on Episiotomy - Page 3 - Mothering Forums

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#61 of 85 Old 11-07-2010, 02:41 PM
 
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Originally Posted by Smokering View Post
Hmm. In terms of shoulder dystocia, isn't that usually resolvable by the Gaskin manoeuvre? Would doctors do both?

Even if a HCP had to "force" his fingers inside to help the baby out, there's a possibility the resulting tear would be more superficial or smaller than an epi cut, right?

The scar tissue things makes sense, though.
It's not always resolvable by Gaskin, even if the woman hasn't had an epidural (though that accounts for a lot). There's a series of maneuvers done for SD. (The "official" mnemonic has all-fours last on the list, but some providers try it earlier, which, in my unprofessional opinion, makes sense--it's a simple position change.) The original sequence had episiotomy as the 2nd step; now it's "evaluate for episiotomy" to see if one may be necessary. The episiotomy does not resolve the SD in and of itself. It's to allow the attendant room to do internal maneuvers.

Here's the sequence:
http://www.aafp.org/afp/2004/0401/p1707.html

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#62 of 85 Old 11-07-2010, 05:15 PM
 
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AlexisT: Thanks for that! I love learning about this stuff. Had a long conversation with Mum about episiotomies yesterday... she was a midwife in Australia and the US back in the 70s and 80s. Her perspective was that they are occasionally necessary, but that hers was done because she was "15 minutes over the allowed 12 hours" and it was just routine.

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#63 of 85 Old 11-07-2010, 11:01 PM
 
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I had SD with my birth, and ds was born over an intact perineum, all 10lbs of him. Even with gaskin, he still required a few minutes of internal maneuvering to get him out. Even with both a head AND an arm between my legs, I didn't tear. Really glad my midwife didn't view my perineum as a "liability"

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#64 of 85 Old 11-08-2010, 11:54 AM
 
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One doctor I went to said that she regularly performed episiotomies because all that pushing from the baby is gonna cause the vagina to become enoromous and leave the mama with big flapping balloon for the rest of her life. So instead of letting baby keep pushing and pushing, you snip the mama and let baby slide out, thereby letting vagina retain its original size.
I think this is one of those things that is soooo variable based on the woman. I pushed out a large-ish (for my frame and relative to other babies in my family) baby, and I have an extremely tight vagina. Tight like it is difficult to get 2 fingers in. A friend of mine had a c/s long before the baby was in the vaginal canal, and she is large enough that her boyfriend can comfortably get both of his large hands into her. I think it would take hours to stretch me to that point, and it would be very painful for me, and would involve a lot of healing time after. But for her its is nothing. We are both extreme examples of natural variation among women. Vaginal birth did not make me looser, and lack of vaginal birth did not make her tighter.

I was reading a thread on a sex forum where there was talking about the use of large toys, and whether they permanently stretched the vagina. And again, a wide variety of responses. Some found that even one use of a large toy would make a permanent impact. Others found that it took repeated frequent use to make a change. And still others found that they always returned to normal.

--------

Back to epis...I was born in 1980. When my mother was shopping around for OBs, every single one of them said they do routine episiotomies. Lucky thing that she walked in the door so last-minute that they didn't have a chance.

But for my sister's birth in 1984, she found the same story about routine epis, and in that case she was there at the hospital for a few hours and they did one against her will.

--------

I've heard stories about past decades when epis were hospital policy, and if a woman gave birth too fast the OB would go back and cut her afterwards, to avoid being punished for violating the policy.

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#65 of 85 Old 11-08-2010, 02:16 PM
 
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One doctor I went to said that she regularly performed episiotomies because all that pushing from the baby is gonna cause the vagina to become enoromous and leave the mama with big flapping balloon for the rest of her life. So instead of letting baby keep pushing and pushing, you snip the mama and let baby slide out, thereby letting vagina retain its original size.

No way. How long is a baby in the vagina? For most women, less than an hour, but rarely more than a couple of hours. Episiotomy and PREGNANCY-related pelvic floor changes are much more to blame for any change in vaginal tightness than pushing a baby out.

And of course, let us not forget that 90-95% of women birth who birth vaginally do so in lithotomy with epidurals, which is more likely to lead to tearing with or without the episiotomy.

But I've heard it put this way-- why do we have no problem accepting that a penis can drastically change shape and size without permanent "damage." Why do we have such a hard time believing the same about the female equivalent organ, which is specifically designed for babies to pass through it?
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#66 of 85 Old 11-08-2010, 02:18 PM
 
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The hormones of pregnancy help the vagina stretch and recover.
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#67 of 85 Old 11-08-2010, 02:52 PM
 
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Originally Posted by mmaramba View Post
One doctor I went to said that she regularly performed episiotomies because all that pushing from the baby is gonna cause the vagina to become enoromous and leave the mama with big flapping balloon for the rest of her life. So instead of letting baby keep pushing and pushing, you snip the mama and let baby slide out, thereby letting vagina retain its original size.

No way. How long is a baby in the vagina? For most women, less than an hour, but rarely more than a couple of hours. Episiotomy and PREGNANCY-related pelvic floor changes are much more to blame for any change in vaginal tightness than pushing a baby out.

And of course, let us not forget that 90-95% of women birth who birth vaginally do so in lithotomy with epidurals, which is more likely to lead to tearing with or without the episiotomy.

But I've heard it put this way-- why do we have no problem accepting that a penis can drastically change shape and size without permanent "damage." Why do we have such a hard time believing the same about the female equivalent organ, which is specifically designed for babies to pass through it?
Good point...so true and have actually never even thought about it.

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#68 of 85 Old 11-08-2010, 03:20 PM
 
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Originally Posted by mmaramba
Episiotomy and PREGNANCY-related pelvic floor changes are much more to blame for any change in vaginal tightness than pushing a baby out.
Hmm interesting.. what role does episiotomy play in this? If it's true, the doctors that routinely perform them in an attempt to avoid enlarging the vagina are achieving the exact opposite of what they were aiming for!

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#69 of 85 Old 11-08-2010, 03:48 PM
 
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I do believe it's the current "standard of care" not to do routine epis (so, for a doc to not have a 100% epis rate.) But with the US rate being over 30%,
Do you have a link or source on the 30% rate? I wouldn't be surprised, but I'm just curious. Since the rate is so variable by provider, it must be hard to get a good sample.

What freaks me out is how much of obstetric practice is based on personal anecdote and even superstition. There are records of episiotomies being practiced in the early 1700s, but Joseph DeLee really popularized it in the 1920s. He never had any science to back the practice, but doctors just started "believing" that it would speed things up. Guess what? There's still no science to back the practice.

DeLee, by the way, was one of the loudest voices of his time in the anti-midwifery and anti-homebirth campaign.

Sorry. I'm kind of wandering with this. But my point is that routine episiotomy is a tradition and a personal belief but not a science-based practice.

(This is all detailed in Tina Cassidy's book, btw).

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#70 of 85 Old 11-08-2010, 04:08 PM
 
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--------

I've heard stories about past decades when epis were hospital policy, and if a woman gave birth too fast the OB would go back and cut her afterwards, to avoid being punished for violating the policy.
My mom told me that she gave birth to me really quickly, no tearing, but that the doctor cut her 'to let the placenta out'. Because a woman who's just given birth to a 9lb 4oz baby needs to be cut open to birth a placenta...

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#71 of 85 Old 11-08-2010, 04:09 PM
 
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[I].

And of course, let us not forget that 90-95% of women birth who birth vaginally do so in lithotomy with epidurals, which is more likely to lead to tearing with or without the episiotomy.
I do not believe that this is accurate. The epidural, sure, but not lithotomy. I hear much more c-position or semisitting now.

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#72 of 85 Old 11-08-2010, 05:52 PM
 
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OT, to 3x Mama:

The husband's knot is an extra knot to tighten the vagina during repair of an episiotomy. REVIRGINIZATION plastic surgery is to replace the hymen or build one where there never was on.

I suppose the two could be done together. I know that some women have a second repair done after child birth when the episiotomy does not heal well, is not done well, or in the case of a prolapse in which pubococcygeal muscles have the organs have fallen and are not doing their job.
Thanks for the clarification!

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#73 of 85 Old 11-08-2010, 06:10 PM
 
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I do not believe that this is accurate. The epidural, sure, but not lithotomy. I hear much more c-position or semisitting now.
But really that c-position is a lot like lithotomy. I just don't think many women would naturally take that specific position to birth. It's only because, IMO, they are confined to bed most times and many have epidurals making other positions much harder.

Marsden Wagner says the C/S rate in Brazil is sky high is due to the culture of having women retain those virginal vaginas.

Oprah's sex guru, Dr. Laura Berman has c/s because: "Why ruin a perfectly good vagina?"

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#74 of 85 Old 11-08-2010, 09:58 PM
 
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Oprah's sex guru, Dr. Laura Berman has c/s because: "Why ruin a perfectly good vagina?"
OMG...that sentiment makes me rage and cry at the same time. After I had ds2, I had no sensation in my clitoris for almost a year. Yay - I had an intact vagina...did me a whole lot of good. I still don't have normal pelvic sensation, and ds2 is five.

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#75 of 85 Old 11-11-2010, 07:41 AM - Thread Starter
 
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Do you have a link or source on the 30% rate? I wouldn't be surprised, but I'm just curious. Since the rate is so variable by provider, it must be hard to get a good sample.

What freaks me out is how much of obstetric practice is based on personal anecdote and even superstition.

(emphasis added)

 

Some of these are a little older, so it looks like it's closer to 25% now.

 

http://www.foxnews.com/story/0,2933,167196,00.html

 "One in three mothers who delivered vaginally in the U.S. from 1995 to 2003 had episiotomies" 

 

http://www.childbirthconnection.org/article.asp?ck=10004

"The episiotomy rate has been falling off for some time in the U.S. However, when Childbirth Connection carried out its national U.S. Listening to Mothers survey among women who had given birth from 2000 to 2002, 35% of mothers with a vaginal birth had experienced episiotomy."

 

http://www.ajog.org/article/S0002-9378%2808%2902241-2/abstract

"The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004."

 

http://www.webmd.com/baby/news/20050826/episiotomy-rates-too-high-say-experts

"Aug. 25, 2005 - A study looking at episiotomy rates around the world shows that a third of American women get episiotomies during childbirth. Experts tell WebMD that's too many."

 

http://www.womensenews.org/story/health/070514/women-encouraged-ask-doctors-about-episiotomy

"Monday, May 14, 2007

Two years after a landmark study called for an end to routine episiotomies, the procedure is still performed in about one-quarter of vaginal births."

 

 

SO TRUE! Yes, the book "Born in the USA" by Dr. Marsden Wagner does an excellent job of outlining such ridiculous practices of just doing something "to try it out" or "because that's how my mentor did it" - with NO REGARD FOR SCIENCE! He talks about the practice of using X-rays to asses maternal pelvis in the 1930s, then DES and Thalidomide in the '50s and '70s, and finally Cytotec in the 1990s. He calls it "vigilante obstetrics" - the practice of assuming something is safe until it's proven , otherwise, whereas what OUGHT To be done is assume any intervention or drug is dangerous until proven safe. He also points out that this sort of practice is the same as experimenting on people without obtaining informed consent. If something is in an experimental stage, only people who consent to be experimented on should be experimented on!

 

Yeah, whenever an MD says something like, "In my experience..." I have to cringe!!!!! Since generally their own experience can't possibly be enough to be statistically significant, especially if they're only in the 30s or 40s & therefore having been practicing that long! (Not to mention the whole bias that OF COURSE thinking your own actions lead to the best outcomes!)

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#76 of 85 Old 02-01-2011, 06:39 AM
 
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Can anyone recommend some good anti (routine) episiotomy articles that I could pass on to my OB? Thanks.

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#77 of 85 Old 02-01-2011, 08:04 AM - Thread Starter
 
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Can anyone recommend some good anti (routine) episiotomy articles that I could pass on to my OB? Thanks.

You could start with the book, 'Thinking woman's guide to a better birth." it summarizes LOTS of scientific studies - all of which are referenced in the back. I've heard docs will often scoff at & dismiss such books, so you could go look up the exact studies that Henci Goer sites & then share those. That book is getting a bit old now though (1999, I think?), so you could look for newer stuff here too:

http://www.ncbi.nlm.nih.gov/pubmed/

 

Although I wouldn't be too hesitant to share research from the 1980s and 1990s. Research showing that routine epis leads to WORSE perineal tears & trauma vs. risking natural tears is still good & valid decades later.

 

But most importantly, the fact that you feel the need to share anti-routine epis articles with your OB tells me you probably ought to look at getting a new HCP. :( It seems the biggest predictor of whether or not you'll have one is your HCP's practice style. The articles I quote above list the astounding variations in rates between older OBs, younger residents, and MWs. I think even still in the past decade, some older OBs were having rates near 60%. I've read on MDC that generally if an HCP thinks they are good, that HCP will find a reason to do one- so it can be hard to avoid.

 

Personally, if I had even the slightest suspicion an HCP didn't have an accurate, evidence-based view of epis, I wouldn't let him or her anywhere near my genitals. It's just a chance I'd try not to take - and if I really had no other choices, I'd have BOTH my DH and a doula hovering over his shoulder. I told DH if my HB ends in transfer and a doc is about to cut me, he is to yank the scissors out of the doc's hands & stab him in the eye with them! DH replied, "I'm not going to do that!" I said, "Ok, yeah, obviously not the stab-in-the-eye part! But I'm NOT kidding when I say I expect you to STOP IT and yank the scissors out of his hand!"

 

ETA - yeah it was the last link I posted:

 

http://www.womensenews.org/story/health/070514/women-encouraged-ask-doctors-about-episiotomy

"A study published last year in the Journal of Reproductive Medicine showed that physicians in practice 15 years or more perform episiotomies 50 percent more often than those in practice less than 15 years....

 

The JAMA article found that although episiotomy rates have consistently declined over the past 20 years, wide variation in practice indicates that its use is driven by local professional norms, training and practitioner preference rather than the needs of individual women at the time of birth. A study conducted by researchers at the University of Ottawa, Ontario, published in the April 2000 issue of Obstetrics and Gynecology, also found factors such as time pressures, malpractice concerns and lack of experience with clinical alternatives to episiotomy.

--------------------------------------------------

The article also mentioned:

"Dr. John R. Scott, a Spartanburg, S.C., obstetrician-gynecologist who advocates against routine episiotomy, thinks it's hard to retrain older doctors.

 

"You can read and understand the literature, which shows that you should let nature take its course, but it's so ingrained in you to cut a small episiotomy," Scott said in an interview."

--------------------------------------

Yes, it strikes me as a near-impossible, unrealistic goal for one patient to attempt to educate an OB & get him to change the way he practices. Much better to just find an HCP who always practices evidence-based medicine, and whose philosophy matches yours.

---------------------------
"In Listening to Mothers II, a national survey of more than 1,500 women who gave birth in 2005 conducted by Childbirth Connection, a New York-based nonprofit working to improve maternity care, 73 percent of those who had an episiotomy stated that it was done without their prior consent.I think hoping to educate an OB to get him to change his ways is an extremely unrealistic goal. So much better to just find an HCP who both practices evidence-based care in all cases, and has a philosophy that matches up with yours."

 

 

WHHOAAAAAAAA!

 

Finally, regarding the above stated, "clinical alternatives to episiotomy" I'd still worry about an HCP with a high-epis rate. Even if s/he agreed to restrict use of epis to only fetal distress for me personally, clearly this is an HCP who has no clue about physiological birth. For an HCP to sincerely believe that it is better off (or outright necessary) to CUT the perinium the majority of the time definitely proves they are severely ignorant of the normal, natural processes of birth. Therefore... they view their own actions as beneficial and/or necessary as opposed to letting the baby's head just naturally stretch out the perinium. So if they were asked NOT to do epis, I'd think they would be very likely to try to manually stretch you. :( Not good either to do that vaginal "wrenching" & yanking it apart. 

 

Just saying again, a pro-epis HCP is someone I wouldn't want near my genitals.

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#78 of 85 Old 02-01-2011, 01:41 PM
 
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Thanks a lot, MegBoz, much appreciated. Yeah my OB has definitely been in practice for a lot longer than 15 years, hence her antiqued views. I did try to discuss the issue with her before but realized right away that she wasn't one to be convinced. I am currently shopping around for another OB but I live in a part of the world where obstetricians are all pretty much of similar training and backgrounds and more natural-minded alternatives are yet nonexistent. I might just have to go your route and have someone grab the scissors out of doc's hands if they insist on snipping away.

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#79 of 85 Old 02-04-2011, 09:08 AM
 
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So is it true that once an episiotomy, always an episiotomy? (And if not an epi, then definitely a tear?) I've been hearing that a lot when asking ppl about their birth experiences.

 

In the JAMA article mentioned above, they wrote:

 

"In seeking to establish an evidence base to support or refute the use of episiotomy, randomized clinical trials in the mid and late 1980s found that routine episiotomy compared with restrictive use was associated with higher risk of anal sphincter and rectal injuries and precluded a woman from giving birth with an intact or minimally damaged perineum."

 

Is my struggle to avoid an episiotomy all in vain? Any IPAEs (in-tact perineums after episiotomy) out there?


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#80 of 85 Old 02-04-2011, 09:19 AM
 
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I wasn't cut for any of my births. I did give birth in a hospital but my CNM didn't believe in cutting women this way.

 

I do know some of my girlfriend were. One of them swears her baby needed that cut cause he "plopped out" the minute she was cut by her OB. Insert big sigh here.

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#81 of 85 Old 02-04-2011, 10:10 AM - Thread Starter
 
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Originally Posted by AlaaJ View Post

So is it true that once an episiotomy, always an episiotomy? (And if not an epi, then definitely a tear?) I've been hearing that a lot when asking ppl about their birth experiences.

 

In the JAMA article mentioned above, they wrote:

 

"In seeking to establish an evidence base to support or refute the use of episiotomy, randomized clinical trials in the mid and late 1980s found that routine episiotomy compared with restrictive use was associated with higher risk of anal sphincter and rectal injuries and precluded a woman from giving birth with an intact or minimally damaged perineum."

 

Is my struggle to avoid an episiotomy all in vain? Any IPAEs (in-tact perineums after episiotomy) out there?


The part you bolded to me just means "routine epis prevents a woman from giving birth over an intact or minimally damaged perineum." Which makes sense - I believe epis is always at least 2nd degree, so if you define "minimally damaged perineum" as 1st degree tear or less, then yes, it's impossible to do routine epis and have any women with minimally damaged perineum.


I do believe there is some truth that scar tissue is less 'stretchy' but I DON"T think that means you must always have an epis or tear if you've had past epis (or past 2nd degree tear or greater.) as a matter of fact, I'm fairly certain my MW told me she had a 4th degree tear with one of her children & thanks to perineal massage, subsequently gave birth over an in-tact perineum.

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#82 of 85 Old 02-04-2011, 10:57 AM
 
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According to Ina May Gaskin, scar tissue is stretchy and a previous epi doesn't mean a woman will always tear or need to be cut. My mother had a biggish, routine epi with her first child, and went on to have five more (four vaginally). I'm pretty sure she didn't have any more epis, and I know she didn't tear at the last birth (I was there) - not sure about the others. So it's definitely possible. 


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#83 of 85 Old 02-04-2011, 04:43 PM
 
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My friend had an epi with her first child because her OB did them routine.  When she met the OB for her second birth, he asked her what she thought of her previous birth, and she said the worst part was the healing from the epi.  That OB said "well, you don't have to have one."  She was so excited "really!?!?!?"  And she didn't have one with any of her later babies.  Poor thing didn't know it wasn't always a part of birth!


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#84 of 85 Old 02-05-2011, 12:24 AM
 
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I had a horrific epi with my first...but in fairness I had been pushing for literally hours by that point and was completely exhausted..to the point of passing out between contractions

 

 

 

but you know what? the OB rolled her %^&*($ eyes right before she did it, so I really question its need....I was so exhausted I passed out before I was stitched up..and was rather alarmed to find stitches about four days later

my oldest was also sunny side up though, so who knows

 

 

it took 3 months to heal..I hate that dr to this day,,,14 years later

 

my other two..one much smaller baby and one about the same size..not a single mark that Im aware of...felt great afterwards

and they were both epidural babies...so figure that out!

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#85 of 85 Old 02-07-2011, 01:28 PM
 
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With my first birth, I was completely unprepared and woefully naive, and just didn't question anything the doctor did because I had very strong painful contractions, and he also just surprised me with some of the interventions.  He did a pressure episiotomy that was preemptive, but I believe he does it routinely in any case.  He never talked about it or told me he was going to do it, then he didn't numb the site to stitch me up.  I took a long time to heal.

 

I don't like episiotomies, either.

 

:(


Still-learning wife to long-suffering and wonderful DH and manoula to DS #1 (8/09), an angel baby (7/10), and DD #1 due May 29!
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