I am frequently asked by clients my opinion on their birth decisions. Generally speaking my reaction is to introduce them to information from experts and then suggest that they make their decisions based on what they have gleaned from the literature along with their own intuition. Rarely do I insert my personal philosophy into these discussions because I don’t always see the decisions as black and white.
Episiotomy is one of the few topics that to me IS black and white. It may sound radical but my personal philosophy on routine (or prophylactic) episiotomy is that is is genital mutilation and I don’t feel it has a place in normal labor and delivery.
I know…“Come on Tracie, don’t tiptoe…tell us how you really feel.” I am speaking bluntly about this topic because I have seen the needless suffering it causes and I got tired of feeling helpless when hearing women’s heartbreaking stories of physical and emotional pain.
The turning point for me was when a close friend was telling me that over a year after her son’s birth she was still unable to have intercourse without intense pain at her repair site. When it came out in the conversation that she could have refused the episiotomy she said to me, “Tracie! Why didn’t you tell me this BEFORE I had one.”
Of course the reason I didn’t was that I figured it wasn’t my business and I didn’t want to be perceived as opinionated. (Can you imagine someone thinking that I am opinionated? Shocking!) After this incident I realized that I felt far more regret over my friend’s pain that I would have about possibly having an awkward moment if I were told to mind my business. I vowed to myself that I would never again let my concern for how I am perceived interfere with opportunities to educate women about protecting their bodies. So with that said, here is my take on episiotomy---take it or leave it.
One of the most common fears I hear from women is that they’ll have a big baby or at least a baby with a big head. Often that fear is heightened by practitioners who threaten that they will likely experience severe tearing if they don’t submit to an episiotomy. This is supported by well meaning friends and family who in their own experience believe this fallacy for one reason or another.
The presumption is that a) All women will need one because “there is no way something that big can fit through an opening that small” b) Episiotomy will protect the perineum from tearing.
These two presumptions are absurd on so many levels but let’s talk about why they are fallacies.
Fallacy #1: Actually has two components; “...there isn’t room for the baby to come out without an episiotomy” and “...if I don’t get one I will tear.” Allow me to interject a personal experience here. While I realize that this is anecdotal only, sometimes things make the most sense to me when I hear a real story instead of a statistic.
My first baby only weighed 7lbs. 5oz. but his head was nearly 15 in. I was told prior to delivery that I was likely carrying a baby well over 9 lbs. based on the size of his noggin. While I admit it was no picnic pushing him out, the point is, I did---and I did it without an episiotomy and without perineal tearing. (I did have a very small hymenal tear that I never felt or noticed, and lets face it--I haven’t needed that old hymen in years.) Was I able to do this because of my maternal super powers? No. I am about as average as women come. The point of the anecdote is simply that a big head does not mean a traumatic delivery. But there is more to the story.
I had discussed my passionate objection to episiotomy with my OB prior to the birth. Although for the most part he agreed that they are “usually unnecessary” he also made clear that he felt they had their place in delivery and that if it appeared that I might tear he would want to perform one. I told him I’d rather roll the dice and take my chances with tearing. We agreed to disagree and his attitude was pretty much, “Hey lady, it’s your funeral.”
Skip ahead to birth day: At the point that my son was crowning my doctor noticed "blanching” (which is where the skin is stretched so tight it appears white from lack of blood flow to that area---blanching often precedes tearing). He looked up at me and said, “I think you are going to tear. Are you sure you don’t want an episiotomy?” I politely declined. (After I told him what he could do with his @%&* scissors, I am pretty sure I offered to give him an episiotomy. I confess; I am not always my sweet self when I am in transition).
On the next contraction I gave one more push and my son practically fell out of me. After the birth; when my perineum was still intact; the doctor very sweetly said, “Good call on not getting that episiotomy.” I thought it took some humility for him to admit that.
I tell this story to illustrate how modern obstetrics is primed to believe that women can’t give birth without intervention and how that belief is passed onto the consumer because we believe that doctors always know better than us. I like to think that the conclusion of this experience was that I became empowered and my doctor learned something about women’s abilities.
Fallacy #2: An episiotomy will protect you from tearing. This is completely unreasonable. “You might tear, so lets cut you just to be safe.” This is just about as ridiculous as saying, “You might get hit by a car today, so just in case, go lay down in the driveway and I’ll run you over.”
Interestingly in obstetrical lingo a tear is called a laceration and an episiotomy is also called a laceration so what exactly does performing a laceration do to prevent a laceration. Do you see the circular logic? Let’s put it this way, if you refuse an episiotomy then the worst thing that could happen is that you might have a laceration. If you get an episiotomy then you will definitely have a laceration.
It should be noted that most women will not tear at all and of the few tears that DO occur, the majority are so insignificant as to not require suturing. When they do need suturing it is a few stitches instead of the extensive repair of several layers of fascia which is required with all episiotomies.
Here is a visual. Hold up your index finger and thumb and look at the U shaped tissue that connects the two. Imagine that is the perineum. Now with your other hand make a pair of scissors and snip the tissue there. Notice that you are not just incising the front side of that, you are also cutting the back side. This means that a 1 in. cut is really a 2 in. cut. Now imagine that you are also cutting into the muscle that is beneath that tissue.
This is how an episiotomy is performed. Unlike a tear which only occurs at the point that is stretched tightest, the episiotomy takes in all layers of skin that come in contact with the surgical scissors. This is the reason that severe tearing such as fourth degree tearing occurs almost exclusively after an episiotomy has been performed. It is extremely rare for severe tearing of any kind to occur when there has been no episiotomy.
If you have concerns about tearing even a little bit, then start researching ways to avoid it. There is really no reason to tear if certain precautions are taken. Here are a few prevention tips:
1) Completely avoid the lythotomy position. (Lying on your back with your legs in the air.) Not only is it very uncomfortable and inhibits the natural use of gravity, but the pressure on the perineum is unnatural and frequently causes tearing.
2) Talk to your doctor/midwife about providing perineal support and (if necessary) manipulation (pushing the skin back and easing the baby’s head through--kind of like putting on a tight turtle neck). If they are unwilling or unable to assist you---CHANGE PROVIDERS.
3)Absolutely do not submit to an episiotomy. There is a MUCH greater risk of 4th degree tearing when one has been performed. (Think about trying to tear a piece of fabric without cutting it and then think about how if you give it a “little snip” it can be easily torn.)
4) Learn all you can about controlled crowning through breathing and holding back for a contraction just at the point of crowning to allow that little bit of stretch that takes place right then.
5) Avoid meds especially epidural because the more in control of your muscles that you are the more able to push effectively and to hold back when needed. You are also able to adopt appropriate positions for pushing such as squatting, hands and knees, c position, etc. and your instinct will tell you what is best for you at the time. (Be open to whatever your instincts tell you)
Where did we lose sight of the fact that for thousands of years women gave birth without being rescued by a surgeon? (And that is in fact what episiotomy is---surgery.) Why is it that we believe ourselves to be so different than our predecessors when it comes to the fundamental ability to give birth?
Women’s bodies were made to give birth---that’s why we get hormones that relax our bones (relaxin), and why we get hormones to open our cervix (oxytocin) and why the uterus begins the process of expelling the baby. Babies’ bodies were made to be born---that’s why they have bones in their heads that overlap and mold to the smallest point possible, and why their shoulders pop under their shoulder blades, and why they squirm and turn instinctively in the direction opposite to where they are encountering resistance from bone (the pelvis). Have faith in the process and forget the rhetoric you may hear from negative people...it’s not worth listening to if it contradicts the facts and science of human anatomy.
