Just say no to needless cutting

Educate yourself. Know when episiotomy is necessary. An incision is the right course when the fetus is in trouble and a quick delivery is critical, or when instruments such as forceps or a vacuum will be used. Your provider may also tell you she'll consider an episiotomy if your baby is very premature. "A preemie's skull is softer than that of a full-term baby, and the pressure of the mother's perineum on the baby's head can trigger bleeding in the brain," says Michelle Collins, a certified nurse-midwife at Vanderbilt University in Nashville, Tennessee.

Bring up the subject. Ask your provider what his episiotomy rate is and under what circumstances he generally performs one. The rate should ideally be less than the target rate of 15 percent, Hartmann says.

Don't think it's too early to ask. You certainly don't want to wait until you're on the delivery table to bring it up. If your doc hasn't kept up on the latest info about episiotomies, he may be routinely performing them –– unless his patients pipe up. "Right from the beginning we told my OB that I didn't want an episiotomy if at all possible," says new mom Lindsey Coffman of Springfield, Missouri. "When she came in the room to deliver my daughter, she remembered. I didn't tear or get cut." Coffman was lucky; about two-thirds of first-timers do have some tearing.

Pay attention to good pregnancy nutrition. Eating healthfully may actually help you avoid an episiotomy. "Proper nutrition aids in the formation of healthy skin and peri- neal tissue, and that helps the perineum's ability to be more flexible and stretch well," says Collins.
A good diet also helps keep a mom's weight gain to a normal limit, which in turn helps to keep the baby's weight within a healthy range. That increases the chances that labor will progress normally and hopefully not require an incision.

Take matters into your own hands. Perineal massage, or "working" the skin of the perineum to make it more supple and elastic in late pregnancy, may help decrease both tears and the need for an episiotomy, says Vani Dandolu, M.D., director of urogynecology and pelvic reconstructive surgery at Temple University School of Medicine in Philadelphia. One study found that 24 percent of women in first pregnancies who performed prenatal perineal massage had no tears, compared with just 15 percent of those who didn't practice the technique.
The key is to do it regularly in the final months of pregnancy. Here's how: Apply a lubricant (K-Y Jelly, vitamin E, cocoa butter) around the perineum. Then place your thumbs about 1½ inches inside your vagina, pressing downward and to the sides at the same time. Gently stretch for several minutes, until you feel a slight burning or stinging sensation. Hold the pressure for about two minutes or until the tissue begins to feel slightly numb. Massage the lower vagina with your thumbs for several more minutes, remembering to avoid the urinary opening. This technique should take between five and ten minutes, and be performed once or twice a day starting at about the 34th week of pregnancy. Perineal massage may not be advisable for some women, such as those with active herpes lesions, so talk to your provider first.
"My husband massaged my perineum with vitamin E for many a night during pregnancy," says Dawn Opie of Alexandria, Virginia. "I'm pretty certain that was the clincher in my avoiding an episiotomy."

Reiterate your wishes. You've discussed and agreed on it before, but at the time of delivery, be sure to remind your doctor that you want to avoid an episiotomy. "It can also help to let the labor nurse know, too," says Jay Goldberg, M.D., clinical associate professor in the department of obstetrics and gynecology at Jefferson Medical College in Philadelphia.
Deena Taylor, a New York City mother of three, is glad her nurse was on board at her first delivery. "We had talked to the doctor ahead of time. He didn't seem to think episiotomy was a big deal," she says. But her labor nurse made the difference: "She kept urging me to push, did perineal massage, and challenged me to prove my doctor wrong; he was sure I'd need an episiotomy because of the baby's size. He was shocked when the nurse called him to deliver."

Be willing to take it slow. If you are giving birth with the help of a midwife, she may know this by training and instinct: Carefully controlling (as best you can!) your pushing in the second stage of labor gives the perineum time to stretch naturally. Dr. Goldberg promotes a technique he calls "super crowning." "At the time of crowning, rather than let the baby's head burst through uncontrollably, you hold it steady or even push it in slightly for a couple of contractions to allow the tissues to stretch slowly and naturally," Dr. Goldberg says. He believes this approach significantly reduces the incidence of vaginal lacerations  -- especially third- and fourth-degree tears.Of course, no woman can rule out the possibility that interventions like episiotomy may become necessary, and complications do happen, despite good intentions. But by knowing the facts and discussing them with your provider, you might be able to avoid an episiotomy. "When I got pregnant the second time, I knew the questions to ask: 'What percentage of your births involve episiotomy?' and 'What do you do to avoid it?'" Spears says. "As a result, it was a great experience. Having done it both ways, there was no question what was best for me."

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