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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 10:50 am 
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I have stitched up both episiotomies and natural tears and although it may be "easier" to stitch the surgical cut it just took a little more time to stitch the natural tears and the outcome (at least at 6 weeks) appeared to be about the same.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 11:08 am 
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Kelly wrote:
Yeah, honestly it wasn't the big of a deal to me in the grand scheme of things. Uncomfortable, but I was fully functional afterwards. I showered within a few hours of delivery and was up walking around and stuff. The one thing I wish I could change about my last pregnancy is that I wouldn't have worked myself up terrified of everything. Yes, labor & delivery are going to suck, but the best part is the bad stuff ends!


Yes! Actually, and I assume this is a hormone thing, I felt physically great right after both my births. Soreness didn't set in til later and really it was never a big deal for me. Some people do have really uncomfortable developments (hemorrhoids and such) but not everyone does, tearing or no.

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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 12:11 pm 
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tinglepants! wrote:
Ariann wrote:
I would think that a natural tear that is as severe as an episiotomy would hurt as much to heal from, but you would almost never have a natural tear like that. Episiotomies often go through multiple layers of flesh


I'm curious what the rate of occurrence for severe tears is...and the source(s) you have to substantiate that. I'm not saying I disagree because, honestly, I haven't done much research. I do think making the statement that something is medically rare should be accompanied by some context or source of information.

I know at least two women who tore nearly irreparably during birth and they didn't have episiotomies. In each of their cases, an episiotomy would have have resulted in a lot less trauma to their bodies. Of course, my anecdotal evidence doesn't disprove the risks of the procedure but there are reasons besides "extreme emergency" for the procedure. One of the women wasn't having what would be considered a medical emergency--her son wasn't in danger of losing air or getting stuck but she suffered months of pain because her doctor didn't believe an episiotomy was ever necessary. The force of labor wouldn't have torn her body as much had there been the extra room.

I just think it's dangerous to say anything other than it should be decided on a case-by-case basis and doctors should neither be absolutely against or absolutely for.


My source is every piece of modern research on episiotomy. Read any modern book on labor and delivery and you'll find the same. Modern obstetrics teaches that it should be an emergency-only kind of procedure. The risk of extreme tearing qualifies as an "emergency," so yes, your friend was having an emergency if the doctor saw she was tearing in a way that would be irreparable. Here's a quick summary: http://www.childbirthconnection.org/art ... p?ck=10004


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 12:52 pm 
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Ariann wrote:
tinglepants! wrote:
I just think it's dangerous to say anything other than it should be decided on a case-by-case basis and doctors should neither be absolutely against or absolutely for.


My source is every piece of modern research on episiotomy. Read any modern book on labor and delivery and you'll find the same. Modern obstetrics teaches that it should be an emergency-only kind of procedure. The risk of extreme tearing qualifies as an "emergency," so yes, your friend was having an emergency if the doctor saw she was tearing in a way that would be irreparable. Here's a quick summary: http://www.childbirthconnection.org/art ... p?ck=10004


Oh, I'm with you that it shouldn't be routine, and I wasn't doubting your knowledge--probably just being more pedantic than necessary because with medical stuff (not just birth), I think it's so easy to become either absolutely for or against without focusing on the why's--you already know the reasons but it's helpful for people like me--who lurk here because I may decide to have a child in couple years--to know where the information is coming from.

I mean, I trust my mother, a very smart woman who's skeptical of many doctors so it would be easy for me to believe her view that an episiotomy is usually necessary. But I also know that her longest labor was an hour and a half and that may have something to do with it...

Anyway, my friends' bad experiences had more to do with having an incompetent doctor/midwife who adhered to misinformation.

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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 12:53 pm 
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Another useful study: http://onlinelibrary.wiley.com/doi/10.1 ... x/abstract

Although I've seen numbers on types of tearing before, I am having a hard time finding it now. Here's one study which gives a few numbers: http://bestpractice.bmj.com/best-practi ... /1401.html

Here's another (http://www.glowm.com/resources/glowm/cd ... eacie92ve7), and a useful quote:

"When episiotomy is considered as a laceration, the researchers found that the number of patients benefiting from an episiotomy was reduced to 6%, with the nonepisiotomy patients having fewer lacerations than the episiotomy patients 78% of the time.

"Several studies have shown a significant increase in third- and fourth-degree lacerations when a midline episiotomy is made (Table 1 and Table 2). Third-degree lacerations in women who did not receive an episiotomy occurred in 0% to 6.4% of instances, compared with 0.4% to 23.9% of women with a midline episiotomy.3 Borgatta and colleagues16 found a greater than 20-fold increase in deep perineal lacerations in women with an episiotomy compared with women without an episiotomy. Limiting the use of midline episiotomy has been found to decrease significantly the incidence of third- and fourth-degree lacerations and therefore the maternal morbidity.17,18,19 Mediolateral episiotomy has not been shown to increase the incidence of deep perineal lacerations.20. . . .

"The risk of a major laceration by extension of an existing episiotomy can be in the range of 9.5%–13%.1"

There are also two kinds of episiotomy illustrated in the article, but I can't find numbers on how frequent either one is. The straight-down variety puts you more at risk of further tearing than the sideways variety.

You can see from the tables provided in this particular article how rare a 4th degree tear is according to various studies (I would assume that's what your friends had). There are other provider factors involved in the frequency of tearing, which is why you see a range in the numbers. There are a bunch of things providers and laboring women can do to decrease tearing, from relaxation techniques to positioning to coaching a slow pushing stage to supporting the perineum.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 12:59 pm 
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tinglepants! wrote:
Ariann wrote:
tinglepants! wrote:
I just think it's dangerous to say anything other than it should be decided on a case-by-case basis and doctors should neither be absolutely against or absolutely for.


My source is every piece of modern research on episiotomy. Read any modern book on labor and delivery and you'll find the same. Modern obstetrics teaches that it should be an emergency-only kind of procedure. The risk of extreme tearing qualifies as an "emergency," so yes, your friend was having an emergency if the doctor saw she was tearing in a way that would be irreparable. Here's a quick summary: http://www.childbirthconnection.org/art ... p?ck=10004


Oh, I'm with you that it shouldn't be routine, and I wasn't doubting your knowledge--probably just being more pedantic than necessary because with medical stuff (not just birth), I think it's so easy to become either absolutely for or against without focusing on the why's--you already know the reasons but it's helpful for people like me--who lurk here because I may decide to have a child in couple years--to know where the information is coming from.

I mean, I trust my mother, a very smart woman who's skeptical of many doctors so it would be easy for me to believe her view that an episiotomy is usually necessary. But I also know that her longest labor was an hour and a half and that may have something to do with it...

Anyway, my friends' bad experiences had more to do with having an incompetent doctor/midwife who adhered to misinformation.


When your mother was giving birth she was probably taught that women couldn't give birth vaginally without an episiotomy or that she'd be much happier later on with a "cleaner" cut than a ragged tear. But we shouldn't be beholden to misinformation from the past when making decisions now. The fact that her longest labor was an hour and a half means she almost definitely did not need an episiotomy, as its primary use has been to decrease the length of second stage (pushing). For comparison sake, my second stage was longer than your mother's longest labor.

I highly recommend if you're planning on having a child that you read a thorough book on pregnancy! I was a big fan of Henci Goer's "A Thinking Woman's Guide to Birth" and it seems she's put out a new book that's more geared toward birth professionals, but if you're like me, you'd probably read that, too: http://www.amazon.com/Optimal-Care-Chil ... henci+goer


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 1:00 pm 
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I had an episiotomy because the baby got stuck and was in distress (huge head, exhausted mom), and the OB gave me no choice about having a vacuum extraction. I'm fine with it; it was an emergency. We both survived, we both healed, we're fine. I tore beyond the cut (3rd degree, which means the muscles around the anus tore some, but not all the way through). The anal/rectal muscles took at least 6 weeks to heal, during which pooping was excruciating, but the muscles and skin around the vagina were no big deal at all. When we resumed sex, there was a sensation like an Indian sunburn (is there a less offensive term for this?) where I must have had scar tissue. That went away with time. 2+ years later everything's totally fine.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 1:02 pm 
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Tofulish wrote:
If it makes you feel better, I honestly felt fine right after labor. I had a very minor tear, that required one or two stitches and I felt fine enough that I wanted to walk out of the L&D room and was fine the next day.


It probably helped that you didn't have an epidural and you had a really short labor. This is speculation, but my guess is that a longer pushing stage (and a harder one - when you're being coached to push because you have an epidural and are probably pushing ineffectively) means more inflammation means more pain.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 2:24 pm 
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Ariann wrote:

When your mother was giving birth she was probably taught that women couldn't give birth vaginally without an episiotomy or that she'd be much happier later on with a "cleaner" cut than a ragged tear. But we shouldn't be beholden to misinformation from the past when making decisions now. The fact that her longest labor was an hour and a half means she almost definitely did not need an episiotomy, as its primary use has been to decrease the length of second stage (pushing). For comparison sake, my second stage was longer than your mother's longest labor.


No, she actually did need them all three times, and she didn't have them done until she started tearing. I know that. The force of such a quick labor is what did it for her (her body had very little time to acclimate--my sister took only half an hour). That's anecdotal, yes...but my point remains that it isn't helpful to use phrases like "almost definitely did not need [one]" just because most situations no longer warrant one. There are exceptions to context, and I think it's better to spread the message, "you shouldn't have one automatically, and during pregnancy, you should talk to your doctor and be satisfied in knowing that s/he won't perform an unnecessary one BUT know that, if you're an exception to the rule, you needn't be afraid."

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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 3:22 pm 
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tinglepants! wrote:
The force of such a quick labor is what did it for her


This is why I needed them both times too. Both doctors (same practice) said they don't like to do them unless it's really necessary and usually it's just with fast labors.

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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 6:45 pm 
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It's interesting though, that literally every piece I've read on episiotomy considers prolonged second stage to be the primary rationale for episiotomy and quick second stage to not be a rationale at all (although slowing down a too quick second stage is useful for preventing tears). I wonder what the research says on relationship of extensive tearing and fast second stage. Just tearing at all is not a rationale that seems to be holding up in the research.

I don't think I've said anything too strongly and I'm sorry you feel that way, tinglepants. We know that a huge proportion of obstetric interventions are unnecessary and cause greater maternal morbidity. This is a major problem in obstetrics and a huge reason that episiotomies are no longer routine - thank God we have actually done and learned from the research here, unlike so many other interventions. I think it's useful to learn from the past and not pretend everything that's been done was absolutely necessary just because it happened. Obviously some things are necessary, which is why I said in my first response to this thread that they are no longer routine and almost all practitioners only use them in emergency cases now. If you have a doctor or midwife who has a low episiotomy rate, you shouldn't have to worry about it or even talk about it with them more than a minute before your actual labor.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 6:48 pm 
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mooo, I'm curious what you've learned about this in your program.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 7:22 pm 
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I'm wondering, Ariann, if part of what tinglepants is trying to convey to you is that saying something like:

Ariann wrote:
I think it's useful to learn from the past and not pretend everything that's been done was absolutely necessary just because it happened.


in response to a story in which she explained why the episiotomy was necessary is really silencing and unkind.

At least, that's how it reads from the outside.


On another note, I learned that I do that thing that dudes do when they see someone else get hit in the nuts (the wince and protective fetal position) when I read the words "fourth degree tear".

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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 7:34 pm 
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Ariann is right, as usual. The evidence-based rationale behind episiotomy is to shorten the pushing stage once the baby is already crowning but there is still tension in the perineum, and the fetal heart rate is not looking good, so the baby needs to be born immediately. It's not controversial that the major risk of episiotomy is extension into a third or fourth degree tear. I have never heard of episiotomy for rapid births, since there would really not be time to cut one. I don't really understand how it would be done ahead of time in anticipation of a rapid birth; the perineum needs to already be stretched from the pressure of the head (or butt... hopefully not!). Any provider should be able to repair a laceration. More severe tears are more common with rapid births, so, like anything else that happens during a birth, as much as we want to be able to look back and figure out what could have been done differently, there is no way to know what the result would have been of cutting an episiotomy or not cutting one. The book Ariann mentioned is truly awesome! I use it as a reference all the time.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 7:35 pm 
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there is a lot out there about childbirth that people have been told over and over is totally necessary by an authoritative and patriarchal system (routine shaving, enemas, etc), that has turned out to be based only on convenience for the medical practitioner or misinformation. i won't get into the debate about episiotomies, as i haven't done much research or had one, but the little i have read says that they used to be very routine, in the way that you used to get shaved, enema'd, put into a twilight sleep and wake up with a baby in the nursery. my grandmother had 4 kids in the 50s, and every one of her births was like that.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 7:51 pm 
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Some docs still do it as a routine. When I was in training EVERY single one of the deliveries I attended with a particular doctor got an episiotomy. I definitely would not consider him to be in any way shape or form a doctor that I would let touch me let alone deliver my baby. I did not muster the courage to ask any questions whatsoever while under his instruction (but on a side note I got to help bring 14 babies into this world!) So talk to you doctor about when and under what circumstances they do that particular procedure.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 8:05 pm 
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Cool, annasrobbie! You're a PA? Do all PA's do births as part of their training? I didn't realize that.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 9:30 pm 
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Yeah I am a PA. I am pretty sure OB/GYN is considered a core course in all curriculum, but as far as participating in births I am sure the experiences vary widely. I was doing my clinical experience in a rural site so there was no competition from medical students so if there was a birth I was "the student" who got to attend. I unfortunately spent much of that clinical experience partly shell shocked/partly grossed out by all the body fluids/partly scared to death so I didn't get to learn as much or enjoy it as much as I would now! (I really had NO idea how much and how many body fluids were involved in birth.)


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 10:15 pm 
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Ha! Yes, the fluids. My school has medical, PA, and midwifery students, so it makes sense that there isn't really opportunity for PA's to do births.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 10:40 pm 
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Yes! The competition at some of the clinical sites was insane. My rural clinical clerkships were the best because although the patient volume was low there was lots of opportunity to participate in patient care and learn procedures.


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 Post subject: Re: episiotomy
PostPosted: Tue Jan 22, 2013 11:18 pm 
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tinglepants, I apologize if I've been unkind. It was not my intention.

I don't have conversations from the point of view that every personal experience somebody has (or their understanding of that experience) should change my theoretical viewpoint toward the universe or be equally weighed against the value of the evidence available. I stand by the opinion that medical science cannot progress without critiquing our practices and their value and I cannot even begin to comprehend how that is controversial or offensive in any way. It actually matters for the good of human health now and in the future that we say "we shouldn't have done x, y, and z because...." It also matters that we not view every experience as an exception to the rule because this is also the way practitioners justify continuing bad practices (it's amazing! 90% of my patients were exceptions to the rule!) and this is how they might justify their bad practice to you, their patient, to your detriment. I know that is psychologically difficult. I don't know how to say all of that in a way that doesn't feel "silencing."


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 Post subject: Re: episiotomy
PostPosted: Wed Jan 23, 2013 12:19 am 
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littlebird wrote:
in the way that you used to get shaved, enema'd, put into a twilight sleep and wake up with a baby in the nursery. my grandmother had 4 kids in the 50s, and every one of her births was like that.

Yeah, this was my mother's experience of her births. It was like she wasn't even conscious for them. I always remember that Ab Fab episode where there's a flashback of Edina's mother with the rubber gloved, detached birth experience (well, there is the comic suggestion of that) and I remember seeing that and thinking that that must have been what my mother's births were like with her children and that was the fashion of births of the day for, I dunno, a couple of decades...just wake me up when it's over, sort of thing.

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 Post subject: Re: episiotomy
PostPosted: Wed Jan 23, 2013 12:39 am 
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I don't know why, but I feel a deep need to understand where exactly the cutting is taking place. Cause it doesn't really seem to me like there is much of anything to cut down there without running into things you really really shouldn't be cutting into. I'll be huddled in the corner with the others, awaiting a response.

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 Post subject: Re: episiotomy
PostPosted: Wed Jan 23, 2013 12:40 am 
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Rhizopus Oligosporus wrote:
I don't know why, but I feel a deep need to understand where exactly the cutting is taking place. Cause it doesn't really seem to me like there is much of anything to cut down there without running into things you really really shouldn't be cutting into. I'll be huddled in the corner with the others, awaiting a response.


So, sometimes the baby's head is just genuinely too big to get out. If you've got time (baby isn't in distress or anything), then you wait for the vaj to expand further and/or tear naturally. If you haven't got time or there are other complicating factors (maternal fatigue, etc), then you might cut to expedite things and/or to facilitate using an additional tool (vacuum extractor).

(ETA: I'm not sure if it's a necessity or just common, but it seems like you ALWAYS hear about an episiotomy when vacuum extraction is mentioned. )

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 Post subject: Re: episiotomy
PostPosted: Wed Jan 23, 2013 1:01 am 
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Thanks coldandsleepy. My question was more where than why, but I think against my better judgement I'm going to google it.

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Last edited by Rhizopus Oligosporus on Wed Jan 23, 2013 1:03 am, edited 1 time in total.

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