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Episiotomy and Alternatives

Posted on January 23rd, 2013 by | 4 views

By Joan-e Rapine
www.MohalaBirth.com

 

An episiotomy is a medical technology added to the hospital birthing scene. It is a surgical incision made in the perineum to enlarge the vaginal opening. Many myths exist about episiotomies, and despite recent research that proves this surgical cut unnecessary and unsafe, episiotomies are still extremely common in the United States (90% in the U.S. (Larson) compared to 16% in England (Maduma-Butshe)). Like any other surgery, episiotomy carries with it some risks along with benefits.

There are two types of incisions: A midline, from the vagina toward the anus, and a mediolateral, on the diagonal toward one side (Griffin). The midline incision heals better and is more easily repaired, but some doctors are afraid of harming the anal sphincter muscles and prefer a cut to the side (mediolateral). The mediolateral cut results in greater blood loss, causes more pain, and is harder to heal, because muscle tissue heals better when severed in a straight line rather than diagonally (Noble1 66). The size of the cut depends on when it is cut during labor and therefor, on the birth attendant. Some attendants rush labor and cut it early in the second stage. This cut is usually large and painful. Other attendants wait until the last minute and cut a “pressure episiotomy,” when the baby’s head is crowning. This cut is smaller, less painful and generally safer (Griffin). Reasons for performing an episiotomy vary from fetal distress to an impatient birth attendant. Many hospital births result in a birthing woman trying to “obey her attendant’s instructions to push…”(Kitzinger) If the woman begins pushing before her body is ready, the baby’s head may push against the transcervical ligaments before they have time to completely soften. This is when major tears happen and an episiotomy may be ‘required’ (Kitzinger, Noble2 204).

Benefits of an Episiotomy

In some cases an episiotomy may actually benefit the mother and/or baby. In case of true fetal distress (usually marked by a decrease in fetal heart rate that does not increase after the contraction has ended), the baby may need to be born immediately. Enlarging the vaginal opening may help the baby come out quicker or be delivered by the use of forceps inserted high into the pelvis. In addition, if the baby is truly a large one and the mother has tired of laboring, an episiotomy may help ease the baby out. An episiotomy is usually done when forceps are needed to allow more space for “maneuvering the blades.”(Kitzinger) And finally, an episiotomy is usually helpful for a breech birth to yield more room for rotation as the baby is being born (Kitzinger).


Common Myths about Episiotomies

  1. Episiotomy can prevent tears- not only is this not true, but an episiotomy may extend into a large tear, as Dr. Michael Klein said, “Episiotomies seem to cause the very problems they’re supposed to prevent.”(Larson) Dr. Klein compares it to tearing a piece of cloth: “It’s much easier to tear a piece of cloth that’s already been cut than to tear one that’s intact.”(Larson) He concluded from his studies that there were more chances of tears running through the rectum with an episiotomy than with natural tears (no episiotomy) (Larson).
  2. A straight cut made by scissors heals better than a natural tear with jagged edges- Research has shown that natural tears usually involve only the skin layer and therefor heal faster and better than an incision made by scissors that cut through other layers of skin and muscle. “What nature cuts, nature heals.”(Sears 364)
  3. An episiotomy shortens the second stage of labor and therefor is healthier for the baby- This one is partially true- an episiotomy can shorten the second stage of labor and in case of an emergency this can benefit the baby (Sears 364). However, in a non-emergency birth there is no need to speed up labor. Labor benefits the baby by preparing it for life outside of the uterus thus babies need their mothers to go through a period of labor for their health. Speeding labor may in fact deprive them of an important step in their preparedness (Sears 366).
  4. Episiotomies prevent uterine prolapse (a condition where the vaginal muscles cannot support the uterus due to injury or strain during birth)- There is no scientific evidence to support this belief. Michel Odent, a leading obstetrician in the field of natural childbirth, found from his own experience that this condition is much more apt to happen when doctors speed up labor artificially and put more strain on those muscles than nature has intended. In his opinion forceps (and usually when forceps are used there is an episiotomy) also damage those muscles and contribute to uterine prolapse (Odent 101).

  5. A woman is less likely to suffer from long term pelvic- floor muscle problems if she has an episiotomy- Research suggests just the opposite- women tend to have more pelvic floor muscle problems after an episiotomy (sears 364). Furthermore, the incision itself and the repair cause problems and “lead to poor results later.”(Noble1 67) Dr.Klein’s study shows that those women, who had no episiotomies, including those who tore naturally, had less pelvic floor weakness and other related problems (Larson).
  6. An episiotomy keeps the vagina from stretching out of shape and adds to vaginal ‘stiffness’- By the time the episiotomy would have been cut the vagina has already been completely stretched. Furthermore, studies show that women who do not have an episiotomy (including those who tear naturally) resume their sexual activity sooner than those who were cut (Larson, Marble, Sears 364).  Unfortunately, despite the available research and study results, many women (and even worsemany obstetricians) still believe in these myths. In addition to the mentioned dangers, other dangers include excessive blood loss, infection, hematoma (a form of swelling or bruising) or abscessing (Harper 75), urinary and fecal incontinence, and poor future sexual function (Marble).  In rare cases a fistula (hole) may occur in the perineum (Harper 75).

 

Avoiding an episiotomy

An episiotomy can easily be avoided (unless medically needed, as in an emergency), but can just as easily happen without proper preparation. Here are some suggestions for avoiding an episiotomy:

  • Carefully choose your healthcare provider/birth attendant- this is probably the most important step in avoiding an episiotomy, because no matter how well you may prepare your mind and body, if your attendant ‘chooses’ to cut, than you will probably get cut.It is never too early in the pregnancy to discuss this topic and labor management in general. Find out what that person believes about medical intervention and labor management. Does that practitioner ‘deliver’ babies, or do his/her patients give birth? The practitioner’s view of labor management or nonmanagement is very important. If your doctor tells you “I don’t do them (epis.) routinely, but you’ll probably need one,” (Griffin) than you should probably seek a different practitioner.
  • Good Nutrition is essential for proper body and muscle work. Important nutrients to consume duringpregnancy, and especially later in pregnancy, include proteins, vitamin E, ‘good’ fat, omega-3 and omega-6 essential fatty acids (found in nuts, seeds, legumes and fish) (Griffin).
  • Exercise- specific exercises can prepare the pelvic floor (PF) muscles for birth and also help you become more aware of them, which is important during birth (Noble1 68-9). PF exercises include pelvic rock, squatting, and ‘kegal’ exercises (Griffin). For detailed exercises see Elizabeth Noble’s book Essential Exercises for the Childbearing Year.
  • Perineal massage- massage the perineum daily with regular massage oil, vitamin E oil, or withessential oil blends. Use two lubricated fingers, one inserted into the lower part of the vagina, and gently massage and stretch the perineum. This can be done during labor as well, between contractions. In addition to massage, as the baby’s head is crowning, perineal support can be provided by placing a warm pressure-compress against the perineum (Griffin).
  • Mental and emotional preparation- Multisensory visualizations can be done in a state of “relaxation and openness,”(Kitzinger) to help prepare for the birth. Use images of your body opening to your baby, and images of the baby coming down. This may help you relax about labor and birth. It may also help you during labor, if you have already ‘practiced’ it before (Kitzinger, Crawford 176).
  • Changing positions during labor- Some positions, such as lying flat on your back, are contraindicated to the process of labor and therefore should be avoided. An upright position, such as squatting, is much more conducive to the process and healthier for the baby (does not cut off circulation and oxygen supply) (Griffin). If labor progresses rapidly, assume a position on all fours or lie on your side. In these positions there is less pressure on the perineum and therefore, less chances of ‘needing’ an episiotomy. These positions are good for an artificially induced labor (usually comes on faster and harder) and provide the extra time needed for the vaginal muscles to “fan out.”(Kitzinger) Conclusion It is indeed a sad fact that in light of all the research that shows the danger of episiotomies, and despite the fact that even the World Health Organization is against routine episiotomies (Maduma-Butshe), they are still so common. Fortunately there are practitioners who question this routine practice and will help women birth in a more gentle, natural way. Among those practitioners are midwives who “simply don’t like to perform them (epis.),”(Odent 101). If a woman truly wants to avoid being cut, she should seek the help of a midwife, when possible.

Midwives are also trained to work “with the birth process, not doing surgery.”(Crawford 69) An article in the British Medical Journal calls for us to “rapidly compare episiotomy rates between facilities and countries.”(Maduma-Butshe) That will help us reevaluate our obstetrical practices and whom they benefit. What puzzles me most about the routine of it all, is that if we know that each woman is different (isn’t that what every obstetrician tells his/her patients?), how can we have a routine? Michel Odent figured it out a long time ago: “…each labor will be different. We accept this. We do not plan particular strategies, nor do we adopt hard-and-fast rules.”(Odent 39) How can we have a routine that involves all (90%) women?  Isn’t that like saying they are all the same and therefore we can anticipate their labor outcome? I feel that as childbirth educators it may be our task to open the eyes not only of the women who attend our classes, but of the doctors who attend their births, as well.

 

Joan-e Rapine is a certified childbirth education (BWI), doula (BWI), and lactation counselor. She is faculty at CAPPA in the CLE program and the Chair of the BirthWorks International Trainee Review Committee. Joan-e joined BirthWorks because it was the only childbirth organization that shared her belief that the knowledge of how to give birth and parent already exists within each mother. She dedicates her work to helping women tap into that knowledge and feel empowered by who they are as women and as mothers. She lives with her husband, Tom, and daughters, Mia and Shani, in Hawaii. She has been helping pregnant and breastfeeding families since 1999. She can be reached through www.MohalaBirth.com

 

Resources
1. Crawford, K., PhD, and Walters, J. C., M.D. (1996). Natural Childbirth After Cesarean.  Massachusetts: Blackwell Science.
2. Griffin, N., MA, AAHCC. (1995). Avoiding An Episiotomy”, Mothering, summer 1995, issue 75, Pg. 57.
3. Harper, Barbara, R.N. Gentle Birth Choices. Healing Arts Press: Vermont, 1994.
4. Kitzinger, Sheila, “Episiotomy”, Mothering, spring 1990, issue 55, Pg. 62.
5. Larson, Beverly, and Linda Rao, “Childbirth In The ‘90s”, Prevention, April 1995, Vol. 47, issue 4, Pg. 86.
6. Maduma-Butshe, A., and Adele Dyall; et al, “Routine episiotomy in Developing Countries- Time to Change a Harmful Practice”, British Medical Journal, 1998, Vol. 316, issue 7139, Pg.1179.
7. Marble, Michelle, “Study Suggests Episiotomy Not Beneficial”, Woman’s Health Weekly, July 96, Pg. 13.
8. Noble1, Elizabeth. Having Twins. Houghton Miffilin: Massachusetts, 1991.
9. Noble2, Elizabeth, Essential Exercises for the Childbearing Year. New Life Images: Massachusetts, 1995.
10. Odent, Michel, M.D. Birth Reborn. Birth Works Press: New Jersey, 1994.
11. Sears, William, M.D. and Martha Sears, R.N. The Pregnancy Book. Little, Brown and company: New York, 1997.

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