• 7 Reasons Why Your Doctor Might Need To Give You An Episiotomy

    Pregnancy and childbirth can feel like uncharted terrain, even if you've done them before. They thrust you into new situations and unfamiliar, sometimes very intense, experiences.

    Learning about what we're experiencing and will experience, understanding what we can and cannot control about what may happen, and thinking in advance about what an ideal situation would look like to us, are good ways to help us stay grounded in challenging times. Making a mental map of where we are and where we're going helps us assume control over our journey.

    But the map doesn't always match the terrain.

    There are some aspects of giving birth that we can choose. But there are some aspects that we cannot choose. Sometimes, for the safety of baby and mother alike, our deliveries don't go according to plan. The top priority here is that your baby is born and that both of you are healthy and safe. In order to ensure that, sometimes our doctors need to make command decisions in our best interests.

    Episiotomies are one situation that fall into this category. This once-routine incision through the perineum toward the anus is meant to reduce tearing during vaginal delivery and create more room for the baby to come out. It was also assumed to be less infection-prone than tearing and was assumed to make for a smoother healing process.

    Your mother had one when she had you. But reality isn't always as neat as ideology. Episiotomies don't always reduce tearing, they're not necessarily less infection-prone, and they don't ensure a smoother healing process. After extensive (and ongoing) research, medical opinion has shifted away from performing them except in specific situations.

    You can help yourself prepare mentally for your big day by understanding what those specific situations are, so that if the need for an episiotomy comes up in your delivery, you'll be more ready. Depending on what country you live in and whether you have public or private insurance, your doctor may be more or less likely to opt for this procedure.

    As with every medical decision, make sure you have a doctor you trust to respect your wishes and with whom you have an open flow of communication. The more you know, the more informed choices you can make about what is best for both you and your baby.

    You can't control everything. But you can learn about what's out there and what different people think, and why they make the choices they do. This can take the scary out of intense situations and give you back a feeling of this still being your life, your experience, and your journey.

    My gynaecologists never talked to me about episiotomies. I heard about them from my mother. But you can read about them here.  

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    Prolonged labor

    There are a number of reasons your doctor may need to shorten your labor, and an episiotomy may be the most minimal medical intervention available; an effective small decision that prevents the need for bigger decisions. You may be exhausted and unable to push any more. You may be undergoing a prolonged second stage of labor. Or your baby may be experiencing fetal distress: a reduced heart rate due to oxygen deprivation.

    Fetal distress is serious business and can have permanent effects on your child, so it's best to cut it short as soon as possible. An episiotomy can speed up and ease delivery. It can also spare you the need for vacuum extraction or a forceps-assisted birth.

    A long labor is not necessarily bad for your baby. But it can be bad for you. Prolonged labor can lead to nerve and muscle damage, which in turn can lead to prolapsed pelvic organs (see #7). On the other hand, a C-section comes with its own array of significant long-term issues. A labour cut short with an episiotomy could be the gentlest of tough choices.

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    Assisted delivery

    If you do need a vacuum extraction or forceps-assisted delivery, an episiotomy can make the process easier on the baby. A bigger opening means the doctor has to apply less force to the baby's head. Also, the speed of an assisted delivery can increase tearing and lacerations, making an episiotomy the more appealing choice for the mother as well.

    As someone who had an emergency C-section, I can tell you with hard-won wisdom that it's in your best interests to go with a vaginal delivery if at all possible, however that needs to happen.

    Assisted deliveries are more likely if you've had an epidural, which can make the muscles which help turn the baby into the right position ineffective, and can also make pushing ineffective. They're also more likely if the baby is in an unusual position, if the baby is not getting enough oxygen, or if you're exhausted.  

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    Breech babies

    If your baby is in breech position, this means their bottom is going to come out first, instead of their head. In this situation, the doctor needs extra room to maneuver in the skilled task of delivering the baby's head. An episiotomy makes navigating the head out easier, and also provides room for forceps should they be used.

    On the other hand, it turns out that what labor position you choose for delivering your breech baby can make a difference. A 2014 study found that women who delivered breech babies on all fours had serious lacerations only 14.6% of the time, compared with 58.5% of the time for women who delivered breech babies with their feet up in stirrups.

    Of that 58.5%, the majority of serious lacerations were caused by the episiotomies. Breech deliveries can also benefit from a perineal sweep instead of an episiotomy. The doctor sweeps their finger between the baby and the stretched perineum, pushing the perineum back out of the way.

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    Discuss this possibility with your doctor in advance, because current medical opinion on the best approach is not uniform.

    If you have a premature baby, their soft, delicate head can't withstand as much pressure as a fully-grown baby's can, and an episiotomy can make birth a more gentle process for them. The blood vessels in the brain finish developing in the last 10 weeks of pregnancy, and before then fragile preemies risk intracranial hemorrhaging. An episiotomy eases the pressure on their head, which can lower the risk of hemorrhage.

    However, this kind of hemorrhaging may or may not be as bad as it sounds. It depends on the degree of severity. And different studies have different results. But a study at the National Institute of Child Health and Human Development's Neonatal Research Network from 2006 to 2008, observing approximately 1500 children who had had low-grade intracranial hemorrhaging as preemies, found no neurological damage in those children in those years. Find out what your doctor thinks.

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    Large babies

    Discuss this possibility with your doctor in advance too, because current medical opinion on the best approach is not uniform.

    If you have a very large baby, his shoulders can get stuck in the birth canal. This is called “shoulder dystocia” and can injure the baby. Brachial plexus injury means damage to a group of nerves that run from the baby's neck to his armpit.

    Shoulder entrapment is most common amongst diabetic mothers, but is possible with any very large baby. An episiotomy can help discover and take care of the situation promptly. The incision makes more room for the shoulders to pass through.

    Most American doctors still advocate for episiotomies in this situation. However, doctors at Brigham & Women's Hospital in Boston examined almost 95,000 births over ten years (ending in 2009), and, while the rate of shoulder dystocia episiotomies dropped from 40% to 4% over the course of the study, there was no change in the rate of brachial plexus injuries.

    If I were you I would get your doctor's opinion on this subject first, before going into labor.

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    Abnormal head position

    In a normal, ideal-situation delivery, the baby descends with her face toward her mother's tailbone. This makes the smallest diameter of her head pass through the vagina. Delivery is thus easier, faster, and less traumatic for everybody. But sometimes the baby's head is pointed somewhere else, which makes the process more difficult.

    If her head is tilted, facing her mother's hip, or facing her mother's navel (known as “occiput posterior presentation”), a bigger part of her head will have to pass through the canal. Especially in the case of occiput posterior presentation, there can be significant vaginal trauma, and an episiotomy may be indicated to enlarge the opening.

    Posterior position can be caused by a number of factors. Having an epidural increases your chances of having a posterior baby. Hypothyroidism can also be a cause.

    If your job (as, for instance, a nurse or a bodyworker) includes twisting to take care of people in bed, this can twist the lower uterus and the baby may compensate. And sometimes babies start labor in posterior position and the turn. But whatever the reason, they could use some help coming out.

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    Prior pelvic reconstructive surgery

    What if you've had work done? Childbirth is not a tidy process and it can have long-term effects on the mother's body, including the possibility of relaxation of her vaginal walls. Damage to these walls can result in the bladder or rectum bulging out of the vagina. In extreme cases, the cervix and uterus can potentially descend outside of the vagina.

    Doctors repair damaged vaginal walls with reconstructive surgery, providing necessary support to the bladder and rectum. But once this surgery is performed, it's in the woman's best interests not to have any more vaginal births. Doing so could destroy the repairs. However if a pelvic reconstructive surgery patient chooses to have another vaginal delivery anyway, despite the risks, an episiotomy could minimize the risk of destruction to the repaired areas.

    Ironically episiotomies themselves can lead to the increased lacerations and tearing that make prolapsed pelvic organs possible in the first place. But surgery is not always necessary for every organ prolapse.

    There are nonsurgical options to explore first, including placing a support device called a pessary in the vagina to support the organs. Kegels and weight loss are also options to investigate. As with any nonstandard health issue, please discuss your options with your doctor.

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