Saying No to Episiotomy: Getting through Labor and Delivery in One Piece
By Elizabeth Bruce
Issue 104, January/February 2001
Episiotomy--the cutting of perineal tissues during delivery--is not something that most women give a second thought to, at least not until they've given birth for the first time. The perineum is the delicate area between the vagina and the anus. After an episiotomy, even sitting can be painful, and sex can be unbearable. Episiotomy is the most common surgical procedure performed in the US, and, according to Sheila Kitzinger, "It is the only surgery likely to be performed without her consent on the body of a healthy woman in Western society."1 During a typical hospital birth, it's the rare woman who is not cut either "above" (in a C-section) or "below" (an episiotomy). Currently, at least 80 percent of first-time mothers delivering vaginally in the US undergo this painful procedure.2 A research review by the World Health Organization, however, indicates that evidence only supports a 5 to 20 percent episiotomy rate.3
Medical textbooks teach that episiotomies are necessary to prevent tearing and to protect the baby's head. Actually, tears are usually less severe without episiotomy, and the procedure itself can cause further tearing. Furthermore, unless the baby is premature, its head is made to withstand the pressures of delivery. For years, it was believed that an episiotomy protected a woman against future uterine prolapse, although this has since been disproved. As Penny Simkin points out, "The advantages of episiotomy have long been assumed, but never proven."4
One doctor told me that he preferred doing episiotomies because he found a straight edge easier to repair than a "jagged" tear. Christiane Northrup, MD, maintains, however, that vaginal lacerations "are trivial and very easy to repair in comparison to the damage done by episiotomies. They are also far less painful."5 In any event, should the doctor's convenience really take precedence over a woman's comfort? Another contributing factor in the hospital is the general rush to get the baby out once full cervical dilation has been reached, even though there is no evidence to suggest that faster is better. Since an OB is hired to "do something," he or she may feel pressured to do an episiotomy when things naturally slow down during transition.
Complications of Episiotomy
Although episiotomy seems like a simple operation, it carries the risk of complications, including "excessive blood loss, hematoma formation (a form of swelling or bruising), infection, or abscessing. Sometimes trauma from an episiotomy of the anal sphincter and rectal mucosa leads to a loss of rectal tone and, in severe cases, a fistula, or hole, between the vagina and rectum."6 It can also kill your sex life, at least temporarily.
Sheila Kitzinger found that episiotomy harmed women both physically and psychologically. Fifteen percent of postpartum women who had torn described their perineum as "painful or very painful" at the end of the first week, compared to 37 percent of the episiotomy group.7 Moreover, a woman "who has had an episiotomy, especially if her permission was not asked beforehand, may also feel violated. That is a word many women use when talking about their reaction to episiotomy."8 Certainly extreme pain and the feeling of being violated may help explain why some women have no interest in sex after an episiotomy.
Why Do Women Tear?
The myths that purport to explain why women tear during delivery include a)the mother is too small; b)the baby is too large; and c)pushing happened too fast. One of the most important considerations is the mother's position during second stage (pushing). The popularly used lithotomy position (flat on your back with your feet in stirrups--the standard hospital position) is the worst possible position for delivery. Putting a woman's feet into stirrups stretches her vaginal tissues in an abnormal way. The further back her legs are pushed, the more strain is involved. When a midwife notices your tissues looking "white," she will likely tell you to stop pushing, or she will apply counterpressure to the area. In contrast, a physician may figure he can repair the damage later and may continue telling you to push. In her book Gentle Birth Choices, Barbara Harper writes, "The combination of birthing in the lithotomy position and strained pushing will cause the perineum to tear."9
In 1993, I experienced the joy of my first vaginal birth (my first child had been delivered by cesarean section). My 7-pound, 11-ounce baby, born in the hospital, resulted in tears that required stitching. I now believe that the tearing occurred because I was encouraged to push before I was ready. Fortunately, I educated myself before the next birth. During the homebirths of my last two babies, I delivered in a hands-and-knees position. Although I am petite (105 pounds), both babies were birthed without any tears or cutting. My son weighed 9 pounds, 8 ounces. Total pushing time? Nine minutes and three minutes, respectively. The fact that the midwife said, "Push when you feel like it" helped immensely. I'm thankful that she urged me to slow down to allow the perineum time to stretch.
A few years ago, a woman named Gail came to me with a serious concern. During the birth of her first baby, she had received an episiotomy that resulted in a fourth-degree tear into the anus. Now pregnant again, Gail was worried that the resulting scar tissue might not stretch and that she would be cut again. Since the original incision had caused her considerable discomfort, she was anxious to do anything possible to avoid repeating the experience.
We discussed upright positions and the importance of expressing her wishes in a birth plan, and she and her husband used perineal massage at home. Gail birthed a 10-pound baby girl in the side-lying position and was elated at the fact that her perineum remained intact. She was also thrilled with her relatively easy recovery.
How to Avoid Episiotomy
If possible, have a midwife deliver your baby instead of a physician. Although midwives are skilled at performing episiotomies, they rarely find them necessary. Typically, midwives "place warm compresses on the perineum to relax the tissue and make it more flexible, or massage and stretch it out with warm oil."10
Hiring a doula is another way to keep your perineum intact. A doula stays with the mother during her labor and helps the mother and her partner to be comfortable. She helps make sure that the parents' birth plan is followed, and provides physical and emotional support during labor. In one study, the presence of a doula resulted in a 60 percent reduction in epidural requests and a 40 percent reduction in forceps deliveries;11 both procedures are major contributors to high episiotomy rates.
There are situations when an episiotomy may be necessary, but these are rare. A breech birth is the classic example, when time is of the essence to birth the baby's head. Other unusual fetal positions, such as face first or a compound presentation, may necessitate an episiotomy. Premature births sometimes also require an episiotomy to take pressure off the baby's delicate skull.
Women's bodies are designed to give birth without surgical intervention. Episiotomy was invented to facilitate forceps deliveries and has continued mainly out of habit not necessity. If you eat well during pregnancy, move around during labor and delivery, and deliver in a supportive environment, chances are that you won't require an episiotomy or even tear. If you do tear, recovery is almost always easier than with an episiotomy. As with most concerns about labor, often the best advice is to trust the process and to follow your instincts.
How To Prevent Tearing
There are several steps you can take before and during birth to prevent tearing:
Good nutrition. It's important for keeping all of your tissues supple.
Kegel exercises. In the weeks leading up to birth, Kegels are helpful in maintaining tone and blood flow, although it is possible to do too many; between 20 and 30 a day is probably about the right number.
Perineal massage. Before the birth, some women use massage to stretch the perineal area, although this is not necessary. Practicing relaxing the area can be helpful, however, as you will need to do this during delivery.
Squat and shout. In her book Active Birth, Janet Balaskas lists several ways to avoid tearing during birth, including giving birth in a darkened, private place, using an upright or squatting position, following your body's cues about when and how to push, applying hot compresses (if it appears necessary), and feeling free to shout as the baby emerges.1
Rest on all fours. The importance of being able to move around during labor cannot be overstated. Upright positions, including squatting, standing (supported), and all fours are ideal for taking pressure off the perineum, as is a side-lying position. Unfortunately, the semi-propped position that most hospitals now advocate is not a good one for keeping the perineum intact. Not only is the pelvic outlet smaller in this position, but the perineal tissues are stretched unnaturally.
Water birth. Giving birth in the water may also help prevent tears, as water distributes the pressure evenly and slows the birth.
Go slow. Whether in or out of the water, both Balaskas and Harper suggest that the birthing woman place her own hand on the perineum during crowning, so that she "can work with the contractions and slowly ease the baby out without tearing the perineum."2
Pant. When possible, panting can be encouraged instead of all-out pushing, to slow the birth; a woman feeling the baby emerge may do this instinctively.