Man, doctors love those episiotomies, don't they?

punkrockabye

Interesting appointment today! I wanted to get a feel for the attitude the hospital has on episiotomies. The doc I saw today did say that they don't like to do them, and in the end clarified that it's not done unless something goes wrong and the baby has to be out immediately and mom isn't tearing enough for it (which, yeah, I do understand that true emergencies do occur). But what we discussed in between was interesting. 

She was very adamant about the "fact" that tearing naturally is very bad. "Opens you up to a tear through the rectum, prolapse, and infection." She just shook her head when I mentioned the "cutting a sheet before tearing it" example. I think there was some slight miscommunication when I mentioned tearing naturally because I believe it aids in better healing, because she said leaving it unrepaired would be like asking them to not close a c/s incision, which was absolutely not what I meant.  But she drew a diagram and pointed out the jagged tear, which I guess she wanted me to think is bad, but it only makes sense that a natural tear won't be pretty!

In the end though it was very clear that they won't want to cut me just for convenience. Another plus was that she was totally unfazed when I mentioned taking my placenta; she's seen it quite a bit. She also encouraged all the standard perenium preparation techniques, which was nice to hear. I really need to stop slacking on that!

sschwege

Sounds like a good conversation!

RockyMtnMama

I've only talked to midwives (CNMs) about this and our Bradley instructor, so I thought most of the healthcare world thought episiotomies were worse than natural tearing. 

I'd love to hear more about why a clean cut with a length determined by the careprovider heals better than a ridged tear that is only as long as your body needed.  I thought the visual paper test made a lot of sense.  Plus, I had a natural tear with #1 (very minor - 2 stiches) and then an episiotomy + tear with #2 (layers of stiches) and the repair for the second was much worse, but the doctor was good to recovery was similar. 

 

Jcrab

RockyMtnMama:

I've only talked to midwives (CNMs) about this and our Bradley instructor, so I thought most of the healthcare world thought episiotomies were worse than natural tearing. 

I'd love to hear more about why a clean cut with a length determined by the careprovider heals better than a ridged tear that is only as long as your body needed.  I thought the visual paper test made a lot of sense.  Plus, I had a natural tear with #1 (very minor - 2 stiches) and then an episiotomy + tear with #2 (layers of stiches) and the repair for the second was much worse, but the doctor was good to recovery was similar. 

 

 

Interesting. With my HBAC, DD's heart rate was very low and while I was pushing effectively my perineum wasn't stretching fast enough to let her out so the MW had to help stretch (and to a degree tear) the tissue to allow her to be born in a timely manner. I only had 6 stitches and it was sore but not all that bad. To me this shows tearing, even with help is far less traumatic than an actual incision. My MW had mentioned she might have to do an episiotomy (which would have been her first ever) but we just barely avoided it. 

runrinserepeat

I *think* the argument for a clean cut is that it's easier for the doctor to stitch up. I still don't understand how people think that a straight cut will heal better than a tear, though, even with this argument.

Not all doctors are on board with epis, though. My doctor was totally on board when I told her I'd only want an episiotomy as a last resort. 

punkrockabye

I still have no idea why she thought I'd believe that being cut is safer in terms of severity of tearing. I mean, I do understand that sometimes it's just necessary to get the baby out asap and if mom's not tearing, you have to do what you have to do. But my focus was on general tearing during birth and how I feel that doing it naturally will result in a smaller wound than starting a cut that will then allow itself to tear drastically. Yes, it'll be jagged, and the doctor will have to put a little more effort into repairing it. Uh, sorry for making you work a bit? haha.

The way I see it, if someone tears naturally and it's ALL the way through, that would have happened with or without being cut! My body will only tear as far as it needs to--so, if at all--to let the baby pass. It's not gonna say "welp, already started, might as well go all the way!" like it can if the process is started for it. 

But, what I mainly wanted to hear was that nobody will tell me "you look like you're going to tear, let's just cut you now" which I now know is not likely to happen. 

stever

Hmmmm... I got a 3rd degree tear when I delivered DS and DH has never mentioned since then that he thinks I look deformed.

caralck

These days the training is to cut only when absolutely necessary (ie need to get the baby out 1 minute ago).  At least that was my training in my FP residency.  I cut 2 in the 3 yrs and it was for those moments only.  Even when I used a vacuum, I didn't have to cut every time.  Cutting increases the chances of a more severe tear...which takes longer to repair so anytime you can limit a tear to 1st or 2nd degree, the happier you are...especially when it happens in the middle of the night.

dosafyre

She can be as adamant as she wants...but I believe the reason they don't cut routinely anymore, is because the studies and data doesn't support that it is better...and in fact leads to more tearing and infection.

I like to think that Santa Claus is real too...but that doesn't make it so. Plus, I'd be offended if a doc felt she had to draw me a diagram for this (but then again, I work in graphics, so maybe that's just me)  :P

punkrockabye

ICarriedAWatermelon:

caralck:

These days the training is to cut only when absolutely necessary (ie need to get the baby out 1 minute ago).  At least that was my training in my FP residency.  I cut 2 in the 3 yrs and it was for those moments only.  Even when I used a vacuum, I didn't have to cut every time.  Cutting increases the chances of a more severe tear...which takes longer to repair so anytime you can limit a tear to 1st or 2nd degree, the happier you are...especially when it happens in the middle of the night.

Thank you for sharing your real-life experience. I am also in medicine and have trained on L&D for several weeks, and I don't think I ever saw or performed an episiotomy.

I found the title of this thread to be obnoxious.

I found the doctor's reaction and insistence that it is SO much better to be cut because "it would just be a small cut and wound, but when you tear it can rip through the rectum completely" to be not only obnoxious, but also misleading and insulting. 

caralck

Just like with anything, you'll find a wide range of what doctors will do and want to do.  So it can be insulting to be lumped into a group when you don't necessarily share that opinion.  Some are definitely more cut happy and actually think they make it better by cutting automatically (let's call them the dumb ones.  Okay, that's not nice of me.  LOL!).  I think it depends on where they trained and who trained them.  I personally observed that philosophy more commonly with older physicians and those in busy places because it makes it faster for them.  I guess I'm glad that my training was more in line with evidence based medicine, which OB, of all fields, lacks the most adherence to.  I never did get around to telling my doctor that he is to only cut if my baby will die.  I guess I can tell him that when I'm in labor since he is unlikely to remember it before hand.  Too many patients to think about but when he's with me at the moment of truth, at least then I know his focus is on me alone.  I did write it down in my birth preference sheet but didn't give him a copy.  Just discussed stuff along the way.  Considering he has been great about other things I've requested this pregnancy (such as no cervix checks until today's 40 wk visit), I can't imagine this will be any different.  

It is ethically wrong to lie to patients to serve your own preferences and I think for women who don't feel empowered to question their doctors, it's a shame that such a thing happens frequently.  I'm glad you were able to get her to be more honest because of your ability to have that conversation.  Good luck on your delivery!

IgnatusDem

MY Dr. doesn't routinely do them.  She even told me she wouldn't do one.  But then as I was pushing I was beginning to tear up towards my urethra.  So she cut a tiny one just to direct the tearing down.  Out of the two options, I'd prefer the episiotomy.  However, I still had a third degree tear on top of it.  DS has a monster head :S

But, I'm 5 weeks out and feeling pretty normal down there as long as I eat enough fiber and drink plenty of water. 

chicagojackie

When you are trying to get two layers of tissue to heal, you have to line them up and stitch them together as evenly as possible so that the edges are even. It is very, very difficult to get the layers of a jagged tear to line up nicely (so they can heal well, not a "time factor or convenience factor") with sutures.

This translates into a longer, more difficult healing process as well as more sutures for the patient.

Sewing people up is not a problem--and doesn't hurt the provider a bit. It is however awful to have to do a big repair on someone that takes more time, causes them more pain and will take longer to heal then if you had a controlled tear to allow the baby's head to deliver, especially in a fetal distress situation.

Episiotomy is a last resort, really, but if it is needed to spare mom's important structures (urethra, rectal sphincter) or to spare baby from distress and deliver quickly, it must be considered. 

Remember that most doctors and high level providers went into it because they want to take care of people, and low-intervention is best practice. Sometimes though intervention is needed and that is based on the provider's experience and judgment. If you don't trust the judgment of the person delivering you, switch.