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Episiotomies: The Dreaded Snip

Of all the squeamish discussions about birth experiences, probably nothing makes a woman cringe and cross her legs quicker than when talk about labor turns to the big E. No, it is not the epidural, but the episiotomy. Many women are questioning this once-routine procedure. In it, the doctor snips the stretching skin of the perineum (area of skin between the vagina and the anus) downward towards the anus (median episiotomy) or downwards and sideways (mediolateral episiotomy), to enlarge the vaginal opening to make it easier for the baby's head to emerge.

Many hospitals continue this outdated procedure despite significant studies that show routine episiotomies, performed during the birthing process, cause more harm than good. Imagine the following: If you hold a piece of cloth at two corners and attempt to tear it by pulling at the two ends, it's very difficult to rip. However, if you make a small snip in the centre and pull the corners, the cloth rips easily.

Episiotomies Are Said To Have The Following Benefits

  • Speed up birth
  • Prevent tearing
  • Protect against incontinence
  • Protect against pelvic-floor relaxation
  • Heal easier than tears

The Following, However, Have Also Been Reported As Side Effects Of The Episiotomy

  • Infection
  • Increased pain
  • Longer healing times
  • Increase in third- and fourth-degree vaginal lacerations
  • Increased discomfort when intercourse is resumed

Episiotomies Myths

The following are some of the myths surrounding episiotomies

A Nice Clean Cut Is Better Than A Jagged Tear

"Like any surgical procedure, episiotomy carries a number of risks: Excessive blood loss, haematoma formation, and infection. There is no evidence ...that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents foetal trauma or reduces the risk of urinary stress incontinence." -Sleep, Roberts, and Chalmers 1989.

Routine episiotomy (as opposed to episiotomy for an emergency situation such as foetal distress) is a typical example of an obstetrical procedure that still exists despite a lack of evidence for it and a considerable body of evidence against it.

Episiotomies Help Prevent Brain Damage As The Baby's Head "Pounds" Against The Tissues

Perhaps the most absurd rationale of all is brain damage from the baby's head "pounding on the perineum". A woman's perineum is soft, elastic tissue, not concrete. No-one has ever shown that an episiotomy protects foetal neurologic well-being, not even in the tiniest, most vulnerable pre-term infants, let alone a healthy, term newborn. - Lobb, Duthie, and Cooke, 1986 and 1990.

Episiotomies Help Protect The Mother's Pelvic Floor And Reduces Her Chances Of Incontinence

What are pelvic-floor problems? Many women experience pelvic-floor dysfunction around the time of birth and/or later in life. Pelvic-floor problems include leaking urine (urinary incontinence), leaking gas or - more rarely - faeces (bowel incontinence), sexual dissatisfaction, and a sagging of the inner organs (uterine and other pelvic organ prolapse). It is important for every woman to understand what she can do to keep her pelvic floor strong and protect it from injury.

These days, there is a lot of conflicting and confusing information about the cause of pelvic-floor problems. Vaginal birth has been blamed, and some suggest that episiotomy or even a surgical birth, (elective C-section) when there is no medical complication, will prevent weakened pelvic floor muscles and injury. Unfortunately, there is a lot of false, unproven, and incomplete information on this topic. - Muscle Function After Childbirth, Gordon H and Logue M Perineal. Lancet 1985; 2-123-125

Asian Women Need Episiotomies Because Their Vaginas Cannot "Stretch" As Much As A Caucasian's

Another absurd example of non-research-based practice. There is no medical evidence to support this. Episiotomies are rarely necessary and you can lessen your chances of having this surgical incision. Some preventative measures that may help:

  • Choose a doctor who doesn't do routine episiotomies. (Ask your doctor how often he finds it necessary to do episiotomies).
  • Have good nutrition (healthy skin stretches more easily).
  • Do your Kegels (exercise for your pelvic floor muscles) often and regularly.
  • Have prenatal perinea/massages
  • Execute slow, controlled pushing instead of directed pushing by doctors and midwives, ie, only push when you feel the urge
  • Give birth off the bed - not on your back
  • Remember, as with any medical procedure, there is always a time and a place where it is a valid option.

Being knowledgeable about your body and any proposed procedures during labor will take you a long way to having a more satisfying birth. - Outcomes of Routine Episiotomy: A Systematic Review. Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KM,. JAMA 2005; 293:2141-8.

A Cut Too Deep?

Dr Paul, a O&G consultant shares his view on the issue:

Why Do Doctors Perform Episiotomies? Can A Mother Opt Not To Have One?

The episiotomy was intended to prevent tearing of the vagina at places other than the midline. Such tears could extend up into the urethra, the clitoris and vulva] flaps. With episiotomy, one can redirect the tear to only the midline. Some eplsiotomies can be overdone. They may be performed too early so that the perineum has not thinned out enough and the "cut" would incorporate not only the skin (as in a properly timed episiotomy) but may cut across fat, and sometimes even the perineal muscles.

This may then cause a very painful post-delivery period. I do not generally do an episiotomy unless 1 foresee a tear in an area other than the midline. If so, I would make a small nick at the midline. This would be much less painful than a whopping big perineal cut. Rather than the mother blindly asking not to have one, it would be best to discuss it with her obstetrician. There are indications (or a judicious episiotomy and the doctor's hands must not be tied down by her demands.

What Happens If An Episiotomy Goes Wrong?

An episiotomy seldom goes wrong. The worst that could happen would probably be a very painful post delivery period. The reasons for doing it have changed. It used to be done to prevent a fourth-degree tear, which is a tear into the anal canal or worse, into the lower portion of the rectum.

But this has been challenged as it would seem that you have effectively removed the natural harriers that would prevent the tearing into the rectum and anus. The more important factors in preventing a bad tear are the controlled delivery of the head and effective guarding of the perineum.

In Countries Where Medical Intervention Is Not Routine, How Do Women Cope?

The natural tears of the vagina would heal on their own, but the vaginal entrance becomes much larger - useful for future child bearing, but gives little sexual pleasure during intercourse.

What Can Women Do?

Talk to their obstetricians about their philosophy on episiotomy; when and why it is done. There is no such thing as a routine episiotomy.


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