February 27, 2008
Volume 10, Issue 5
Midwifery Today E-News
“Episiotomy”
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Quote of the Week

"It will certainly come as news to the Amish and other groups in this country who have long chosen homebirth that they're simply being 'trendy' or 'fashionable.'"

Katie Prown, PhD
Campaign Manager of The Big Push for Midwives 2008
Responding to the ACOG February 6, 2008, Statement on Homebirth


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The Art of Midwifery

Avoiding an epidural is also helpful in preventing perineal damage. In one study, women with no anesthesia had the highest rate of intact perinea (34.1 percent), while women with epidurals had the highest episiotomy rate (65.2 percent). Another study shows that women who got an epidural were more than three times as likely to suffer third- or fourth-degree tears. Why would this be?

For one thing, women with epidurals often end up getting cut because they don't have enough sensation to push the baby out. The effects of epidurals are notoriously variable, and even the best anesthesiologist in the world can't predict when delivery will occur, or how different women may be affected by the same dosage of medication. Furthermore, an epidural prevents the mother from assuming optimal positions during delivery. She is also denied the natural sensations of an urge to push and has to rely on external sources to tell her when it is appropriate, instead of listening to the wisdom of her body.

Not surprisingly, oxytocin (or Pitocin) also increases a woman's chances of serious tearing: 47 percent with Pitocin vs. 29 percent of those without Pitocin tore deeply.

Elizabeth Bruce
From the article "Everything You Need to Know to Prevent Perineal Tearing," which was excerpted from the book Get Through Childbirth in One Piece? How to Prevent Episiotomies and Tearing and published in Midwifery Today, Issue 65
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Research to Remember

A retrospective review was performed of the medical literature on outcomes for routine episiotomy between 1950 and 2004. Although long term outcomes could not be determined, the study showed not only no benefit from the episiotomy, but negative effects. Pain with intercourse was more common, and fecal and urinary incontinence were not prevented.

JAMA 293(17): 2141–48, May 2005


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Preventing Episiotomies

In the ten years I apprenticed with lay midwives, we expended tremendous energy on "preventing" episiotomies. We massaged. We oiled. We had the couple do perineal massage months before delivery. We applied hot packs and cold packs. We used our hands to support the perineum and hold everything together. Preventing this surgical incision was a huge focus of our energy.

Ironically, none of us ever cut episiotomies.... What we were really doing, of course, was trying to prevent lacerations that would result in a transport to the hospital for a significant repair.

While in midwifery school I actually cut episiotomies to learn how to cut and repair them.... Once I was practicing as a certified nurse-midwife, I cut episiotomies fairly regularly—certainly every time the skin blanched. I'd been taught that blanching was an indication the tissue was about to tear and the repair would be a nightmare. The surgical incision of an episiotomy was touted as better for the mother and the practitioner. The mother was supposed to experience less pain, heal faster and have better perineal tone if an episiotomy was performed. Tears, I was taught, were difficult to repair, painful for the mother and risked perineal integrity for the woman's lifetime.

One day, going over my birth log and comparing episiotomy rates and laceration rates, I suddenly realized that all the hoopla I'd been doing to "prevent" episiotomies was absurd. The way to prevent episiotomies was not to do them. Period. It was that simple. My practice changed. I did episiotomies only when I was concerned for fetal well-being and thought it might speed up the very end of second stage.

I then looked at all the work I did to "prevent" lacerations. This really came to my attention when I precepted two former lay midwives who had been "preventing" lacerations all the years they'd practiced as homebirth midwives. They massaged throughout second stage, they placed hot packs on the perineum and poured mineral oil into the vault to help with the descent.

I had another "epiphany." Women's bodies are meant to give birth. Our vaginas and our perineums are meant to stretch open to accommodate the heads and bodies of our offspring. Our labia actually exist to unfold into that crowning bulge that fills the entire space between our legs as we give birth. Why on earth were we doing all this messing around with Mother Nature? Why did we think we had to improve on an already perfect system?

This was, I must admit, the most challenging of old habits to give up. I stopped doing anything to the perineum. I didn't even support it. I just sat back and watched with my usual wonder as woman after woman unfolded and opened up for the birth of her child. Did my laceration rate increase? Not at all. In fact, in reviewing my birth log, I found that I went from 33% repaired lacerations to 5% repaired lacerations. What had changed, besides my attitude?

As I watched my two students go through their processes, I realized that much of what I was trained to do to prevent episiotomies and lacerations actually caused swelling and underlying trauma to the tissue. When I left that tissue alone to do what it does best—stretch for birth—my episiotomy rate dropped to almost zero (I still occasionally get unnerved by a persistently low fetal heart rate) and my laceration rate to 5%. My students really struggled when I asked them to keep their hands away. What a challenge it is to let go of old habits!

Katherine Jensen
Excerpted from "Preventing Episiotomies," Midwifery Today, Issue 75
View table of contents / Order the back issue
For another article on episiotomy, don't miss Issue 85 of Midwifery Today—Technology: Stemming the Tide—out in March 2008.


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On March 31, 2006, the American College of Obstetricians and Gynecologists (ACOG) changed their stance on the use of episiotomy, although they stopped short of completely discouraging it, stating that "[T]he use of episiotomy during labor should be restricted, with physicians encouraged to use clinical judgment to decide when the procedure is necessary."


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Question of the Week

Q: I am looking for some feedback about menstrual cycles while breastfeeding. I understand that exclusive breastfeeding generally stops the ovulation process. Several moms that I know of experienced this, but they seem to be feeding through the night. One in particular, however, is exclusively breastfeeding, but baby sleeps for 5–8 hours at night.

The periods have returned but only a fraction of what they normally are. The baby is 15 weeks old, so I am assuming that the lochia are complete. These periods are coming about every 3-1/2 weeks.

Does anyone have info on this?

— D.C.
Michigan


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Question of the Week Responses

Q: What is your experience with tearing during homebirths when the woman has had a prior episiotomy? Do you handle primips differently than women who had a prior episiotomy or tore, or who had a prior birth or births with an intact perineum?

— Anonymous

A: I am a labor doula and midwife's assistant and will be (hopefully) starting my path to midwifery soon. I had an episiotomy with my son in the hospital which was pretty uncomfortable afterwards and we had a homebirth with my daughter 2.5 years later. I did NOT tear down the old scar (thank heavens!) but I did have a little skid mark on the right inner labia from her little hand being up next to her head/ear. If she hadn't had her hand there, I think I would have remained completely intact. So, I was pretty happy with not tearing down the bottom, but did find that the healing on the side took longer only because any little movement at all pulls the area and I had to be down for a while to just be still.

I also saw a VBAC homebirth where a mom didn't tear on her old scar with a 12 lb 4 oz big baby! It was truly amazing and wonderful for mom and she was so happy. I have seen quite a few times moms with previous tears or episiotomies don't tear, and the few that do tear, don't tear as deeply or badly.

— Shaana Keller

A: The chances of a woman having a perineal tear when she has had an episiotomy with a previous birth are no greater in the home environment than with a hospital birth. I have cared for plenty of women who have had intact perineums after an episiotomy the first time. One woman I remember had been told by another midwife that she would "rip like a paper bag" the next time she gave birth, and was so terrified she was almost in tears when I met her in labour. With gentle encouragement, kind words and a willingness to let the perineum stretch gradually during the birth she ended up without any tears; she was so pleased!

I think the important thing is to find out why the episiotomy was performed, and then reassure women that a tear is not necessarily going to happen. Encourage her to massage the area with olive or almond oil in the weeks up to the birth and most of all be patient with the birth of the head (as long as there are no signs of fetal distress) to allow the tissues to stretch—upright or all fours allows this to happen much better. Finally, have faith that the woman can do it—if you believe it, so will she!

— Alison Andrews, Midwife,
Wales, UK


Q: I am a 28-year-old woman and I've just been told that I have uterine didelphys—with two of everything (cervix, uterus and vaginal canal). According to the gynecologist I saw, I can become pregnant but she said there is a higher risk of premature birth and of a caesarean. Other than this I am perfectly healthy and have had no illnesses or anything.

While I am not planning to get pregnant in the next two years, I would really like to think about my options, to prepare myself when the time is right. I have always planned on having a homebirth with a midwife to assist. I really want the opinion of someone who is not solely from the medical side of things. I know the doctors tell me what they think is the right thing to do but I have always felt that birth is a more natural occurrence than what the majority of the medical society seems to believe.

— Deborah

A: A friend of mine had the same thing. Her mother took DES and that's how she got two uteruses, two vaginas, and two cervices. When she became pregnant, she really wanted a homebirth and was told that she was high-risk, which is why she decided not to put me on the spot. She found a wonderful nurse-midwife with a birth center, who decided she could have a homebirth.

She did and everything went smoothly. However, she tore the septum and had reconstructive surgery after weaning her baby from breastfeeding.

Then she became pregnant with her second child and decided I would be her midwife this time around, and she would have a homebirth. I don't know how, but the medical community heard about it and threatened me and my midwife partner, that if something "bad" happened, we would lose our licenses.

She went overdue and we did everything to induce: breast pump, cottonroot bark, castor oil. By 10 pm we decided to leave her for a rest and come back the next morning. An hour later, her sister called: "The head is out, what do we do?" My partner and I arrived just on time to deliver the placenta. The mother went on hands and knees and directed her husband to catch the baby. No tear, no bleeding. It was a birth from heaven.

— Chinmayo Forro, CDM
Anchorage, AK


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Think about It

ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, homebirths. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).

— Excerpted from the ACOG February 6, 2008, Statement on Homebirth,
www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm


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Feedback

I was just sitting here at my computer and I was thinking how much I've learned from all of you (in the Midwifery Today Forums) in the past couple of months. I'm an RN and am getting ready to begin a CNM program soon. I have always had a very "medical" view of many things and that, for the most part, won't change too much. I have to say, however, that this forum has given me so much information and respect for other types of midwives.

If you had suggested to me a few months ago that having a "homebirth" was a viable and safe choice for a woman, I would have laughed and checked you for a high fever. But after reading the posts on this board (and reading Ina May, someone I had never heard of before I found you all), I have new respect for homebirths (though I probably still wouldn't choose one for myself) and especially for the skill and knowledge of traditional midwives. Reading stories about these brave and talented women (including many of you!) makes me realize that I would trust my care to a CPM in a HEARTBEAT!

So, I will continue to read and continue to learn so much, and will always defend and promote the skills and contributions of CNMs AND CPMs. The holistic view taken by many CPMs is so wonderful and I hope to incorporate much of that in my future practice as a CNM. Thank you!!

Jennifer Wolfe


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