When would you do an episiotomy?
What do the midwives and student midwives think ought to be the reasons why an episiotomy is performed?
I made an episiotomy in 1992 and another one in 1999 so am not a terribly experience episiotomiser. Having had two episiotomies personally, I do need to have compelling reasons for inflicting this on women. But here are my reasons for performing the procedure not necessarily in order of importance.
1 A primip breech birth where the perineum is very tight and rigid. If this was a cephalic birth I would likely get a tear but in a breech the buttocks are unlikely to tear the perinuem and there might be a problem with the head and it is difficult to cut just before the aftercoming head.
2. A shoulder dystocia where the perinuem was rigid and tight and I needed to have access to perform a maneuvre.
3 A Cephalic presentation where the head had been sitting there for ages, there is masses of caput, and the perinuem is rigid, threatening to buttonhole, and the FH is causing concern; or any combination of the foregoing. Often once one has made an epis in such cases, and the head is born, all is revealed as one realises one has missed a face to pubes!!
We have only done 1 episiotomy in over 10 years and we hardly ever suture. If there is a large tear we use herbal sitz baths for the woman.
Elaine, independent midwife
Because without the baby just won’t get out (rigid perineum) or if it appears to be obvious that the alternative is an ‘explosion’ of the perineum, leaving it shattered.
Very descriptive, but I know exactly what you mean. 1000 piece jigsaws aren’t THAT daunting sometimes.
Reminds me of a primip I cared for some years back – student midwife was attending – momentarily had about half of the peri covered with a pad – asked her to move (reasons given at the time) to my absolute shock and horror – huge buttonhole about to, as you say, do the explosion thingy !!!
Whilst grabbing the scissors, buttonhole went – exposing the spincter, as this was only about 2cm above the anal verge with head not quite fully crowned yet – have had quite a few potential buttonholes or small ones, but much further up the peri – and this happened sooo quickly –
So – reasons I cut epis:-
- the exploding peri thing/ buttonhole
- tight/rigid peri holding up birth forever with no further progess of the head despite chinning, position change or maternal effort
I have only been qualified for 3 years and I think I have only performed the 1 episiotomy, which was for a delay in 2nd stage and an extremely rigid perineum. I have found both personally and by listening to other midwives that sometimes just infiltrating (injecting local anaesthetic into) the perineum gives some women enough to push baby out themselves, without the need for episiotomy. I feel this is due to the fact that they cannot feel the terrible ‘burning perineum’ which has previously stopped them from pushing further.
I have been qualified 1 year, and cut my first episiotomy last week – after 70 odd catches. Woman was a primip, and had laboured quickly and ‘2nd stage’ around an hour, with the head just sitting behind the perineum. However, the perineum was white & rigid & there was no sign of it stretching up. FH was fine, & the woman was pushing nice & gently.
2nd midwife & I knew there was only 1 way, & with reluctance, I cut a small episiotomy, following which, the head shot out!!! Turned out she was a horsewoman!! (Wish I had asked in the history taking!!!)
When I sewed it up, the tissue was really friable. Am going to contact the woman later to see how the repair is, and whether there have been any problems. She is happy for me to do so, and will let me know too if she needs to chat or debrief.
When I qualified in 1988 about 80% of women had episiotomies and I had plenty of experience of doing them in my training! I marvel at the change today when some students complain that they have never had to do one in their training – how far we have travelled! I read a wonderful book called ‘Episiotomy and the second stage of labour’, (ed. Sheila Kitzinger) and my whole outlook changed and my episiotomy rate fell to about 5-10%. Personally had one in 1976 – thought I’d never walk again! Second time round in 1983 just a small tear and the difference in recovery was incomparable – so much better! I find it amazing to watch the perineum stretch if you just let the birth proceed slowly and don’t direct the pushing (i.e. the cheerleading approach!). Often if it isn’t stretching a change of position helps.
One statement that I always feel is important is that a tear heels much better than an episiotomy as it has always thinned out first. Also one of the few episiotomies I did was on a horse rider as the perineum was like leather. Not so for other sportswomen.
Can I ask about the (fewer) episiotomies you do now? I suppose the question is what indications for episiotomy do you use….but I’m curious about the details of your decision-making in practice.
Specifically, when do you start thinking an episiotomy might be needed, do you get consent then, in the second stage not knowing if you’ll cut one, do you usually infiltrate with local anaesthetic first or can you really make an epis. on very thinned out tissue with no pain to the mother…. and if the concern is “fetal distress” then does an episiotomy really speed things up enough to matter (esp. with a multip.) ? All opinions welcome!
I ask all these detailed questions because I’ve only done episiotomies at someone else’s request, as a student midwife. Now qualified, I’ve gotten consent for episiotomies a few times, and even infiltrated once (simple lack of progress) but the baby always arrived first or fears of fetal compromise were relieved before the cut. I’ve found that encouraging changes of position really helps with progress when contractions are poor, etc., but in practice I then can’t access the perineum to do an epis…..back to the bed and semirecumbent the way I try to avoid.
I only get consent for an episiotomy just before I feel I need to do one after trying change of position several times and it also depends on the womans state ie: is she too tired, scared, distressed etc. Sometimes discussing it is enough to give her second wind and get on with things but I don’t use it to frighten her, eg “if you don’t push I will cut you and you don’t want that do you..”
I have never done an episiotomy for fetal distress so I can’t comment personally. however I have seen them done and sometimes the baby shoots out immediately and sometimes it takes a few contractions, which suggests to me that the epis was not neccessary.
On occasions I have seen midwives infiltrate the area and simply taking some of the pain away enables the woman to carry on and push the baby out. Whether there is some deep-seated fear around birth I don’t know.
The two I have done have both been when the second stage had been over 3 hours and the baby’s head had been sat there half in/half out for 15 mins or more. In a way they both had reasons for the long 2nd stage.
One was a woman who had had several shots of pethidine early in labour (induction for PROM). When I took over she was very tired and ‘out of it’. Second stage was very long and despite everything I couldn’t get her mobile or upright. We compromised on left-lateral for a while but she was only comfortable semi-recumbent. Head appeared and just sat there. Perineum went white and sister popped her head round the door to see what was going on (ie taking too long…GRRR). She asked me how long the head had been there, 15mins, and then informed the parents that it wasn’t going to come out without help and that an epis was needed. I was newly qualified and so went with her experience and baby did come out quickly so maybe she was right.
The other was only 2 weeks ago; the woman had been very mobile and we had tried every position possible. On the bed, on the floor, standing, squatting, kneeling, lying on side again. The head appeared early on, but just stayed half in, half out and didn’t seem to come any further. There seemed to me to be no more stretch left?? Eventually after 3 hours mum was tired, her legs ached, she wanted to sit down. We discussed episiotomy, waited a while longer, infiltrated, waited, no change so I did a small epis but the baby took 2 more contractions to come out. He turned out to have his hand alongside his head.
I personally found when I had my children having the stitches worse than having the baby. Especially as with my first two you were taken to a different room for your stitches and it often wasn’t done for a couple of hours. The man who sutured me after my first child I assume was a doctor, but as he arrived already gowned and masked and didn’t introduce himself he could have been anyone. It was so much better when midwives did the stitches – no problems there and healed just the same with my last one with no stitches.
Indications for episiotomy – very few. Those I’ve done in the last year or two have been in primigravidas who have been pushing for a long time (2 hours + ) and the only thing stopping the birth appears to be the perineum. This would be after all other options have been tried, i.e definitely not forced pushing, change of position.
The term ‘fetal distress’ should not really be used – it is fetal compromise due to bradycardia or whatever. I remember attending a study day on fetal monitoring fairly early on in my midwifery practice where it was stated that the fetal heart will be bradycardic when the head is on the perineum due to the ‘diving seal reflex’. i.e. the fetus is conserving its oxygen stores by lowering its heart rate due to head compression. If all has been normal until then and no other problems then is ok. How many episiotomies are done for this reason and then the baby comes out with apgars of 9 & 10?!!!
I can’t remember the last time I infiltrated a perineum. On the rare occasions that I do an epis it is when the perineum is stretched so thinly that it would be extremely difficult to infiltrate and the head should be born with the next contraction. If done at the height of the contraction when the woman is pushing this seams to numb the perineum so that the pain felt is minimal. Obviously I would get consent again prior to this.
I would discuss the woman’s birth plan during the labour whenever possible, it should also have been discussed and documented in the natenatal period. I would inform the woman that I would only perform an episiotomy if absolutely necessary and discuss ways that she can prevent a tear/epis i.e. remaining upright, trying different positions for birth, involuntary pushing, not pushing too soon – I often say that the best time to push is when even if I offered you a million pounds not to, you would still have to push! Hopefully by this time the vaginal tissue has been ‘taken up’ and thinned sufficiently to allow the baby to descend easily.
The last time I did an episiotomy, it was on a para 2 (new partner) who had been pushing for over 2 hours. There was no apparent reason, but once the baby was born, it had the most moulding I had ever seen – it still looked newly born at discharge two weeks later. My only regret was not giving vit K by intra-muscular injection – I worried for weeks, but never heard about any subsequent problems from the health visitor – apparently normal development.
I think I did about 8 episiotomies in training, and only one small one (so far) in the past 15 months! I was told to do one not long ago on a woman who came in unannounced and fully (P1) who I discovered (from glancing at her handheld notes) had a previous 4th degree tear and episiotomy in the USA. As she was beyond reasonable discussion at this point (had epidural last time and had not experienced labour as such)….her husband asked me not to do one, as he felt it would upset her more. Unable to coordinate controlled birthing of the baby (woman yelling louder than me!).
The result was a 3rd degree tear, which she kindly said (after returning to planet earth) was an improvement on last time!!….I still felt bad….she chose to birth half kneeling half squatting on the bed whilst rocking back and forth….normally a great position, but under those circumstances I wonder. I have tried to reflect a lot since that night, (with the student I was with as well), but the whole thing was over in 40 minutes from meeting the couple to the birth of their baby!
…I’m sure there’s more to it than fast delivery/position etc….on suturing the lady in question, the reg. found it difficult as her tissue/muscle was very friable…?nutrition/general make-up? I do remember…having gone back through my ‘little red book’, that her little chap came out with one hand waving at me!
I wonder if I would have done things any differently if I had been more experienced…and what could I have done….Any advice welcome please…this was my first experience with previous bad tears.
Didn’t you do well in the circs. Had you made an epis she might have had another 4th degree which was what happened after the previous episiotomy. I am more and more of the opinion that major perineal damage is prevented more by what we do antenatally, in practicing with the woman and discussing the baby s-l-i-d-i-n-g out s-l-o-w-l-y, and maybe a bit of perineal massage with Vit E oil, than by whatever we try to do at the birth, and of course you had absolutely no opportunity to do any preventative work in 40 minutes. More ammunition for caseload practice!
I also had a woman deliver with a third degree tear last week, and I felt really bad about it, although on reflection I’m not sure what I could have done. The head came out fine, then immediately the shoulders and at least one hand all came out in a rush. So an epis probably wouldn’t have helped. This woman was a primip, so her perineum wasn’t scarred.
I would like to let you know of an American anamoly that took me awhile to figure out. It has to do with perineal tears in birth. It was my experience working in the UK that third degree tears were rare things and something to be professionally embarrassed over. Not here.
Here there are not 3 degrees of tearing but 4. Why 4? I couldn’t figure it out for awhile. But eventually the penny dropped. What we would call third degree tears are so common here that they have divided them into 2 categories. And a very high percentage of these tears are following episiotomy. It is midline, not medio-lateral but I doubt the placement of the episiotomy is the culprit. OBs deliver most of the babies here and they did not have the benefit of being taught by midwives. The medical school adage here is: see one, do one, teach one. And that often isn’t far off from the truth.
So second stage is an uncontrolled explosion, as far as the perineum is concerned. All women are in lithotomy with feet in stirrups. Episiotomy is not uncommon, the mother is told to “Push hard!”. The best part is that the training on the mechanism of birth does NOT include the concept of internal rotation of head or shoulders. Therefore once the head is born, the body should come out IMMEDIATELY. And we know (here) how dangerous second stage is for the baby, so the doctor starts pulling on the head when that doesn’t happen. Which we know is most of the time. So what happens next? Well, America has the most phenomenally high incidence of shoulder dystocia accompanied by serious tears.
So as bad as things are in the UK, and I don’t minimise that for a second, just remember you could be practising in amerika.
Melody – midwife in the USA
I have attended about 40 births so far as a midwife and a student, and touch wood never had to do an epis. Came close once, V. low FRH with a Reg telling me to ‘cut her and get it out’. I thought the woman could do it if left alone, so I made several trips to the drawers to get various equipment, then …..oops… dropped the scissors as the babe crowned 😉 fab as the woman only had a small 1st deg tear.
I agree with Mary and would consider one with very dodgy fetal hearts, a perineum that looked as if it was going to ‘explode’ and possibly a tiny one if a woman was almost there, but was being threatened with an instrumental (but only after I’d done everything else first eg position changes, coached pushing etc). I know they can be necessary, but I hate the sound they make when cut. I used to feel like crying as a student when the doctors would do one.
My reasons for performing an episiotomy are:-
- If I suspect fetal distress
- Shoulder Dystocia – if manoeuvres other than MacRoberts are necessary.
Thankfully I’ve only performed 2.
The other night, for the first time, I was considering ‘doing’ an episiotomy since the head seemed to be ‘sitting’ on the perineum for a while AND it really did look like it was going to EXPLODE (FH remained brilliant, so I just couldn’t justify this. Instead, I (for the first time) continued to apply warm compresses and finally babe appeared – intact perineum on PRIMIP for once – I was so glad that i didn’t ‘do’ an episiotomy in this case :-))).
When would you do an episiotomy?
This has always caused me problems. When I trained in 1982, there were episiotomies on all primips. Obviously things got better and when I was teaching in the late 80’s, the only indications were fetal – i.e. fetal distress. But … now I’m ‘experienced’ I’m tempted to disagree with a lot of this.
Firstly, I do feel ‘fetal distress’ is extremely difficult to diagnose and if the episiotomy is performed at the right time, the length labour will only be reduced by 2 – 3 minutes, so probably a waste of time and increased trauma for the Mum.
I agree with many of the postings – i.e. limiting the ‘exploding perineum’ theory. It’s a gut feeling (probably down to ‘experience’) when you just know that the perineum looks as though things aren’t going right. I’ve 3 examples of this …
Home birth, previous 3 degree tear – Mum requested an episiotomy this time, despite my efforts in disuading her. It was extremely tricky because she was kneeling for the birth. I though I wouldn’t have to do one but as the birth progressed, it was clear that the perineum was not stretching (? due to scar tissue), so I did the deed. Mum was really pleased with the outcome.
Another woman I supported – 5′ 0″, very big partner – as the head descended, the perineum went completely white and translucent – I did do an epis. Baby was ‘bonny’ – 9 lbs. There was no other trauma, so I’ll never know if I made the right decision.
The most peculiar experience was looking after a Mum postnatally, who’s baby had been born through the perinuem, leaving the ‘introitus’ intact. At the time I tried to find others that this had happened to, in order to offer some support for her (she was pretty traumatised) but couldn’t find anyone.
The whole issue is difficult – there are no right or wrongs, just experience and judgement. This doesn’t help students I know!
Enkin et al (2000) writes in his conclusion:
“There is some evidence to support the practices of guarding the perineum, but none to support claims that liberal use of episiotomy reduces the risk of seve perineal trauma, improves perineal healing, prevents fetal trauma, or reduces the risk of urinary stress incontinence after delivery. Episiotomy should be used only to releive fetal or maternal distress (???? maybe we should be performing episiotomy at 7cm ???!! ps Enkin et al didn’t write this ‘bit’!) or to achieve adequate progress when it is the perineum that is responsible for lack of progress” (careful! another subjective statement – they didn’t write this ‘bit’ either!!!).
Enkin, M Keirse, M J N C Neilson, J Crowther, C Duley, L Hodnett, E and Hofmeyr, J (2000) The second stage of labor IN Enkin et al eds. (2000) A guide to effective care in pregnancy and childbirth 3rd ed. Oxford: Oxford University Press
I was on a night shift with a midwife (three years since she qualified); I had never worked with her before. We took over the care of a woman at 8pm – a primip who came in with irregular contractions at 5pm and ruptured membranes. Fetal head was high and position was OP at 6pm VE.
When we talked with her, she mentioned wanting to use the birthing pool (to possibly alleviate the back pain) but was told by the midwife that there aren’t enough staff for it. She discussed pain relief with the woman and the woman stated that she wants to avoide epidural but might consider pethidine but worried about the possible effects it might have on the baby and bf. The midwife explained that the pethidine would not take away the pain and that put the woman off the idea. We tried a change of position but just moving caused her pain and this prompted her decision for an epidural. At 9pm she had a epidural in situ. At 10.25 pm she was VEd again (by me!! ) and I found that her cervix was 8, max 9, head -1 above spines, and what felt like still OP. The midwife increased the epidural.
By 11pm the woman was experiencing pain in the lower back. I felt it was due to her being immobile and sitting on her bum. By 12 midnight, it was recorded by the midwife that there was involuntary pushing but the woman did say to me that she couldn’t tell if it was pushing that she felt or just pain from her back. What happened at 12.35 am was ANOTHER VE, again by me, this time the midwife saying that if I were to find her cervix fully we were to encourage pushing. I wasn’t happy about this but felt that it was not the place to argue this in front of the woman, and the midwife seemed to be making decisions without discussing with me beforehand, or explaining the reasons behind her decisions.
When I did the VE, I felt that her cervix was fully but was not happy with the idea of her pushing. The head was still high and she could be pushing for hours if she started then. During this VE, whilst I still had my fingers in the woman’s vagina, the midwife caught sight of the fetal head, got rather excited and shouted “I can see the head, I can see the head, start pushing!!”. She also recorded in the notes that ‘vertex was visible when labia parted’. Now excuse me, I know I am still a student, but I did not just have to PART the woman’s labia to see the fetal head, I had my fingers in her, and the fetal head was about two thirds the length of my middle finger away. I DID NOT THINK SHE WAS READY TO PUSH.
So the midwife got her pushing, chin on chest, you know the routine, hands behind knees, into your bottom, (!!!) at just before 1am. Shortly after, we noticed a rising fetal heart baseline (Surprise surprise). She pushed and pushed, cheered on by the overpaid cheerleader who also doubles as the midwife ( sorry for being rude) who at times took on this guttural tone in her voice….it was scary. In between she also had the audacity to tell this woman that it’s going to be hard work and it’ll be a while before the baby is born.
At 2pm , she muttered something and left the room, and came back with the Registrar without asking prior consent from the woman. The doc didn’t even introduce himself, looked at her bits and saw the slowly advancing vertex and decided that she needed Syntocinon up. The midwife runs out for syntocinon (again without consulting the woman) and during her absence, the doc told me to to do an episiotomy to which I said no. At 2.05am the midwife put synto up and was told to do the episiotomy and she did, TWICE. Then she prised the baby’s head out of the woman’s vagina with her fingers and left me to do the rest. I allowed the rest of the baby’s body to come pout slowly, bearing in mind the cut. The baby was born at 2.10am.
I didn’t see the midwife for much more of the shift, she left me to clean up after she sutured the woman, oh, I think one of the last things she said to me was when she got pissed off with me for not knowing what ST is. (Sanitary Towels).
In my mind I was trying to justify the episiotomy, but I can’t. I don’t believe that the baby had been given enough time to descend (especially OP) and I don’t believe that the woman was treated fairly. I have problems with the notion that some people excuse others who act so incompetently just because they were nice. I know a lot of nice people, but very few of those people I would have faith in to help me or anyone I love birth a baby (be it mine or not). I hope I don’t come across as too harsh but that experience actually traumatised me, and for the first time for a very long time then, I felt quite bad about myself.
Please don’t feel that way about yourself. It is so very hard to be assertive as a student – essentially you feel powerless. But it is experiences like this which will stick with you forever – that you will remember, and in future, when faced with similar clinical situations will be able to draw on to ensure no such repeat. Also, it may spur you on to other things – like it did for me. It was witnessing such abuse that made me train as a supervisor of midwives. You can be proud that you will be a caring midwife, a good midwife and a radical one!
It’s awful feeling bad and guilty about things we’ve done/pressured into doing. To be honest, if you didn’t feel so awful about that situation, you wouldn’t be the potentially excellent midwife you’re going to be – or contribute to this email group; that’s what the Association of Radical Midwives is all about.
I read your account with interest – in my day as delivery suite sister, we didn’t ‘allow’ epidurals if we were short-staffed. It’s obviously gone the other way. I agree, it probably doesn’t need one-to-one care when an epidural is doing all the work – but surely there is a safety aspect to this. I think its really sad that the midwife was so short-sighted about the value of the pool – it could have changed that whole scenario for both the Mum and you.
I did a three year course (caught 43 babies in that time) and have been qualified for 8 months – I have just done my first ever Episiotomy, 1st baby, done for fetal bradycardia – head was sitting on a thin perineum which just seemed to stop stretching, no further advancement over two contractions so did an epis (talked through it by senior midwife having never done one before) and head was born with next contraction. It was one of the things I have dreaded having to do and it is was about as bad as I expected. I have had two extremely painful episiotonmies myself and I’m sure this has an impact on my feelings about making that cut. I do think practise varies enormously between individual midwives – would be interested in your conclusions.
Would anyone count prematurity of baby as a reason for an episiotomy?
In my experience if the babe is prem. then it is usually quite small and almost slips out. Certainly haven’t seen a case that would require an epis. Although perhaps others may have different experience?
No not really – the very prem babies I’ve delivered; (including a few 700- 800 gramers) by the time you cut the epis to me the head is more likely to deliver too quickly with it than without and thus increasing the risk of cerebral haemorrhage which is what you’re are trying to prevent – prem breech may be a different story – haven’t seen any current research on that one
I didn’t have an episiotomy with my preemie (32 weeks) – she shot out without me even needing to push – was so quick that there wouldn’t have been time for them to do one in any case – one minute I said I thought I might need to push soon, the next she was there!
I have never attended a woman at the birth of a prem, but all the doctors I have seen, seem to do liberal episiotomies saying the babies heads can’t stand up to birth. Have no idea if this is research based though?
My youngest brother was born almost 20 yrs ago at 28wks and breech. He apparently just slipped out vaginally with no episiotomy or stitches and his head was fine (though this was often the subject of family debate during his teen years!! lol). He arrived in the back of an ambulance while mum was being transferred from one hospital where she was in with pre-eclampsia to our other hospital where the special baby unit is, so whether she would have had an episiotomy or even a c/s had she been in hospital at the time I dont know. Also he was her 3rd so this may have made a difference perhaps? Would this be different to if he had been her 1st?
Where can I find relevant, readable evidence showing that elective, prophylactic episiotomies are not necessary? I’m thinking in the context of somebody who had a first baby overseas where they are still commonplace and who feels they are necessary. Also evidence of the benefits of perineal massage and any good articles on the procedure of perineal massage.
Off the top of my head ‘Episiotomy – challenging Obstetric Interventions’ by Ian Graham 1997. May be too involved actually, but the chapters are also referenced, although it is an American book.
“A Guide to Effective Care in Pregnancy and Childbirth” by Enkin, Keirse et al, 3rd Edition, (OUP, 2000) says:
“There is no evidence to supposrt the postulated benefits of liberal use of episiotomy. Controlled trials show that restricted use of episiotomy results in less risk of posterior perineal trauma, less need for suturing perineal trauma, fewer healing complications, and no differences in the risk of severe vaginal or perineal trauma, postpartum perineal pain, dyspareunia, or urinary incontinence. The only disadvantage shown in the restrictive use of episiotomy is an increased risk of anterior peineal trauma. These results are similar for both mediolateral and midline episiotomy.”
“There is no evidence to support the suggestion that liberal use of episiotomy minimizes trauma to the fetal head. Data from the randomized trials show similar distributions of Apgar scores and rates of admission to the special care nursery.” (p295)
“CONCLUSIONS…Episiotomy should be used only to relieve fetal or maternal distress, or to achieve adequate progress when it is the perineum that is responsible for lack of progress” (p298)
I have twice come across women having second babies who had their first in other countries where epis is apparently the norm with the rationale of minimising perineal trauma (I know – bizarre isn’t it!). They both had torn – one small superficial tear but very sore and stingy (previous babe in Italy), the other quite a long 2nd degree tear (previous babe in Korea) – they both felt that care had been sub-standard because that had been allowed to tear. I took over care of the Korean woman in advanced labour and only met the other woman postnatally so I don’t know what discussions went on about perineal damage/episiotomy antenatally. The woman I looked after spoke very little English. Her birth partner was her husband, whose English was very good but he seemed to be selective about what bits he was translating for her – the language barrier made it very difficult to help her to have a gentle, controlled birth and baby shot out all in one go which maybe accounts for the tear.
Obstetric Myths Versus Research Realities, by Henci Goer – chapter on episiotomy, summarising the literature, with full refs
Reviewing Thorp JM and Bowes WA. Episiotomy: Can its routine use be defended? Am J Obstet Gynecol 1989;160(5 Pt 1):1027-1030 she notes that “No study found that midline or mediolateral episiotomy reduced the incidence of third- or fourth-degree tears. ” 
See this Article on midline versus mediolateral episiotomy in the BMJ (http://www.bmj.com/cgi/content/full/320/7250/1615)
Correspondence arising from it is perhaps a more entertaining read. It includes a wonderful letter from Rachel Myr, who was on this list, saying that the importance of the midwife makes a difference to perineal outcomes too – on postnatal wards, “we learn to recognize our colleagues’ ‘signatures’ by watching mothers sit down on chairs”. There is also a letter from Sheila Kitzinger, and then one from an Argentinian obstetrician which left me staggered – they are considering changing their policy of “routine” episiotomy, applied to 80% of women, to one of “selective” use, estimated appropriate for … wait for it… a mere 30% !!!!!
I am in a bit of a difficult situation over the question of whether or not to have a routine episiotomy during the birth of my second child and wonder if you could please offer any advice?
I gave birth to my son 10 years ago and all went well except that I was given a routine episiotomy. Unfortunately, I also tore. I put up with much discomfort and pain for 2 years after the birth, only to be told I required a Phentons operation to sort out the problem. I went ahead with the op and all was much improved after.
I am unsure weather to go with my widwife’s advice and have another cut to avoid the same happening again as I feel I am now a different shape and have been doing massage with oils to help the area stretch.
I have stage 4 endometriosis and have had several lots of surgery etc. over the last 2 years and so want to avoid further surgery if possible, Please help me if you can – any advise or thoughts on the matter would be greatly appreciated.
I’m glad the op did help to make you more comfortable. There are individual stories that perineal massage has helped but no conclusive evidence that this will prevent all tears. What also may help is that you are in control of the birthing of the head and just ease or pant out the baby as you wish to. Find the position that suits you.
Some women who have had perineal problems in a previous birth find this last part very scary as they don’t wish to have any more interference and actually will close their legs together involuntarily. I hope whoever attends you will be very sensitive to this possible reaction and encourage you to take the time to adjust if it happens.
All I can offer you is a few anectdotal experiences where the doctor’s advice was to do a routine episiotomy due to previous extended torn episiotomy wound repairs. In both situations it was not necessary. There was one small tear that didn’t need suturing and the other no tear at all. Both times the women eased out their babies under there own control as they were keen not to be cut.
The other information that may be of use comes from Anne Frye, author of “Holistic Home Birth Midwifery” textbook, and that is that oil of evening primrose is a useful oil for helping scarred tissue to be more flexible. There may be some homeopathy that may help but that is not my area of expertise.
I suppose my other thoughts is questioning why an episiotomy would be better than a tear. It is hardly likely to prevent damage to the Fenton’s repair as there is evidence that episiotomies extend to a 3rd or 4th degree more often than a spontaneous 1st or 2nd degree tear does. Also you may get away with no damage or a little tear whereas an episiotomy is definately equal to a large tear.
Have you considered a waterbirth? The relaxation value around the perineum may help a lot.
You might not make your mind up until the last possible moment. You sound very keen to birth your baby normally and I hope all goes well for you.
With my first baby I had a large episiotomy. I remember being told “we’re just going to give you a wee cut now” then I felt the needle (anaesthetic) go in then immediately after I felt immense pain which was them cutting me without giving the anaesthetic a chance to take effect. After a couple more pushes they said they needed to cut me a bit more!
After my baby was born I was scared to move and was given no help to sit up. The midwife said she needed to get a doctor to stitch me as it looked a bit “complicated” (!) so i was left half sitting, half lying, not able to hold my baby properly as I was scared if I moved I would fall to bits, for TWO HOURS until a doctor came. I had no pain relief during labour but needed gas and air while being stitched and even that didn’t really help.
I was in agony for weeks afterwards. I had been stitched very badly, in fact my midwife said she couldn’t figure out exactly what the doc had done. I had to call her out several times during the first fortnight to snip off great big knots which were causing me pain. I also got an infection and ended up on antibiotics.
The whole experience was the most horrendous thing that has ever happened to me. It completely ruined the first two months with my baby. The pain was so bad I felt it hadn’t been worth it and then spent months worrying that I didn’t love my son. I had a very small tear with my second baby and nothing at all with my third and the difference was immense. I know not everyone has such a bad experience of episiotomy, but thank goodness they seem to be done less and less as I wouldn’t wish what I went through on anyone.
Sorry to ramble on for so long, but I actually feel better for getting this off my chest. I thought I was completely ‘over it’ too, obviously not!
They are *extremely* painful! I had one with my first baby. She only weighed 6 lbs. 14 oz. (With my next 3, I had even larger incisions on my belly and my uterus because of breech presentation and physician distress.) The hard part is that you even have to sit on it afterwards. Very painful indeed. I have heard of incisions even becoming infected. The thing is, I was never told it would be done to me; they just did it. With my home births I had very minor tearing which did not even come close to an episiotomy.
I cannot express with words what it means to be to have an independent midwife who helped me have natural births. Bless you all, wise women!
Graphic picture of a mediolateral episiotomy being cut
Obstetric Myths Versus Research Realities, by Henci Goer – chapter on episiotomy, summarising the literature, with full refs
AH updated 29 October 2002