Why are episiotomies so bad? - Mothering Forums

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Old 03-29-2006, 09:45 PM - Thread Starter
 
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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!

Mom to Liz (14) and Dillon (3) and Mitchell FINALLY born 7/11/10!
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Old 03-29-2006, 09:55 PM
 
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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.
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Old 03-29-2006, 09:56 PM
 
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Old 03-29-2006, 10:00 PM
 
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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.

Michelle -mom to Katlyn 4/00 , Jake 3/02, and Seth 5/04
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Old 03-29-2006, 10:09 PM
 
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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.
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Old 03-29-2006, 10:11 PM - Thread Starter
 
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Quote:
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!

Mom to Liz (14) and Dillon (3) and Mitchell FINALLY born 7/11/10!
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Old 03-29-2006, 10:13 PM
 
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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.
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Old 03-29-2006, 10:14 PM
 
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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.
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Old 03-29-2006, 10:23 PM
 
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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.

Jami (25) Roland (27) & Caleb (5), Jacob (3.5) , Kaitlyn (2)
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Old 03-29-2006, 10:26 PM
 
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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.
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Old 03-29-2006, 10:30 PM
 
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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.
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Old 03-29-2006, 10:30 PM
 
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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.

Kristina in Kitsap County, WA
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Old 03-29-2006, 10:39 PM
 
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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

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Old 03-29-2006, 10:55 PM
 
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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!
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Old 03-30-2006, 12:22 AM
 
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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.
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Old 03-30-2006, 12:45 AM
 
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Quote:
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.

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Old 03-30-2006, 12:47 AM
 
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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

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Old 03-30-2006, 12:49 AM - Thread Starter
 
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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.

Mom to Liz (14) and Dillon (3) and Mitchell FINALLY born 7/11/10!
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Old 03-30-2006, 01:51 AM
 
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Quote:
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.
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Old 03-30-2006, 01:57 AM
 
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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.
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Old 03-30-2006, 02:25 AM
 
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Originally Posted by tie-dyed
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.
It's your body, you get to say where people's hands are. Push squatting or standing, or completely underwater and folks are less likely to figure out a way to put their hands where you don't want them.

This is one of my pet peeves as well. Listening to Pam and some other folks around here has changed how I view my role at a birth. It turns out that babies come out if I never touch the perineum (which is a radical concept in allopathic medicine.) And I see fewer tears since I have given up trying to prevent them.

Episiotomy is one of the interventions that has been best studied in modern times. No maternal benefits have ever been found - episiotomies cause more pain, more infection, slower healing, and a much higher chance of extension to 3rd or 4th degree tearing. And, like cesarean sections increasing the risk of uterine rupture in a subsequent pregnancy, episiotomy scars increase the risk of tearing in a subsequent birth (but fortunately, still most women will birth subsequent babies with much less perineal trauma than their original episiotomy caused.)
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Old 03-30-2006, 02:42 AM
 
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I never did bother doing perineal massage, and had TWO stiches put in for a little skid mark after DS was born. Two. And the midwife who saw me later said she wouldn't have bothered with the stitches at all.

And this was flat-on-my-back, cheerleader-style directed pushing, during an induced labor, not a gentle natural birth at all.

If I'd let that idiot OB cut like he wanted to (he had the scissors on my butt while I was yelling "F*ck NO, DUDE!", I guarantee I'd have wound up with a heckuva lot more than TWO wholly unnecessary stitches.
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Old 03-30-2006, 03:13 AM
 
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My second degree episitomy took months to heal from. Months. It was bad.

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Old 03-30-2006, 03:58 AM
 
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I've had experiences with both. My first birth was with an sOB that was in the delivery room 20 minutes total. If I had been a little more educated, I would have known that when he said that almost all of his first time moms required epis that he was an old school, scissor happy, assembly line practicing Dr. He cut me without asking or telling me, and then left right after stitching. I still to this day get angry about it- and it was 4 1/2 years ago. I mean, he was in the room 20 minutes at most-would it have killed him to wait another 2 or 3 minutes to help my tissues stretch? I still feel violated and am bothered every time I think about it. Recovery from that was long and hard. The first two weeks were brutal.

It was the dissatisfaction with my first birth that led me down the AP/NFL path. My second birth was a planned natural birth, and labor lasted 45 minutes start to finish and ended with me delivering dd in the front seat of our van. I tore horribly- a third degree tear down, and then tore up straight through my urethra and clitoris. I didn't really know how bad it was until after they stitched me up- it was more painful than labor and delivery- and one of the nurses told me that the paramedics who brought me in said it looked like I had sat on a hand grenade. : (And in a cruel twist of fate, the SOB from my first delivery was the Dr on call who did the stitching. He was mumbling and cursing under his breath the whole time about how miserable the repair was...) Recovery from that was difficult too, but when all was said and done, it wasn't any more difficult than recoering from the monster epis from my first birth, and my tearing was considered very severe.

One of my major goals for my nexxt birth is to brith over an intact perineum. Or, if I do tear, to have it be less severe! But after experiencing both, I would take a tear, especially a minor tear, any day.

Violin teaching, doula-ing Mom to Abby, (8) Ashlynn, (6) : and Max (11/13/08) Diagnosed with Metopic Craniosynostosis. First surgery 5/1/09, Second surgery March 2010.
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Old 03-30-2006, 05:09 AM
 
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I had an episiotomy that tore to a 4th degree tear with my first baby who was persistently posterior and born via vacuum extraction. It took me MONTHS to heal from it.
I had a tiny skid mark with my second baby and it took me a week to heal.
I had no perineal trauma with my third baby and I was itching to get out of bed 12 hours after he was born, despite my midwife's suggestion to stay in bed for 3 days.
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Old 03-30-2006, 05:26 AM
 
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I don't think anyone has mentioned this yet: my friends who have had epis have said they just never pee the same way again. It's uncomfortable and doesn't feel right and "sprays" differently.

I had "skid marks" with my twins, one regular and one feet-first breech, who I birthed on my back with several obs, and nothing with #3 who I birthed on my side with my dh, my doula, and a midwife.
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Old 03-30-2006, 05:34 AM
 
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With ds1 (9# 5oz, 14" head) I had an epi. that either was cut huge, or tore after the cut. It was straight down at 6'oclock. It was huuuge, and lots of stitches, and took months to heal. Even after it was healed, I had occasional stiffness/discomfort in the scar tissue.

Ds2 (11# 1oz, 14 1/2" head) I had a waterbirth. My MW had me support my own perineum if/when I felt I needed to. I had a tiny little tear at around 11'oclock, no stitch, and it was healed in a couple weeks.
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Old 03-30-2006, 09:59 AM
 
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Quote:
Originally Posted by rebeccalizzie
Heck, even most doctors I know of don't perform them routinely anymore.
Then *why* don't you have your location posted Rebecca? Come on, you've found an area where there's less than a 50% slice rate and you aren't sharing .

The other problem is that when an episiotomy goes badly it can cause maternal death. 3rd and 4th degree tears (the ones to and through the anal sphincter) only happen with episiotomies and those are the ones that get the worst infections.
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Old 03-30-2006, 10:05 AM
 
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Quote:
Originally Posted by 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.
Just curious here, did he put in a monitor that let you change positions and did he encourage you to try changing positions to see if the heartrate would come back up?
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Old 03-30-2006, 12:14 PM - Thread Starter
 
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Originally Posted by sapphire_chan
Then *why* don't you have your location posted Rebecca? Come on, you've found an area where there's less than a 50% slice rate and you aren't sharing .

The other problem is that when an episiotomy goes badly it can cause maternal death. 3rd and 4th degree tears (the ones to and through the anal sphincter) only happen with episiotomies and those are the ones that get the worst infections.
Um...ouch. Ouch ouch ouch.

I'm in Ohio, so I somehow doubt the rate is less than 50%. I just go to an awesome *very* natural ob, and my friends' ob's (except one horrible one) don't cut routinely either. It's not my location...it's the people I happen to know!

Mom to Liz (14) and Dillon (3) and Mitchell FINALLY born 7/11/10!
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