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Episiotomy: Avoiding the Unkind Cut

Susan Spears figured she was on her way to a smooth delivery -- after seven hours of active labor, this first-time mom felt ready to push her baby out. But just 20 minutes later, and against her expressed wishes, her doctor decided to move things along by performing an episiotomy, an incision in the perineum -- the space between the vagina and rectum. In an instant, a healthy 7-pound, 11-ounce girl was born.

Spears was thrilled to have her daughter in her arms, but her recovery, thanks to the episiotomy, was less than thrilling. Within a day of delivery, the stitches her doctor had put in to sew up the cut dried out (she hadn't been instructed on how to care for them, such as taking frequent sitz baths -- soaking in a shallow bath of water -- to keep them moist). They pulled painfully, and some even ripped out. "It hurt whenever I moved or even laughed," she says. Even after the site had ostensibly healed, Spears "felt" the incision -- and grew skeptical about the necessity for the procedure. "I believe my doctor did an episiotomy because she was trying to hurry along the birth process," she says.

Fast-forward seven years. Pregnant with a second daughter, Spears switched to a practitioner who assured her she'd do everything possible to avoid an episiotomy. During labor, "she massaged my perineum," says Spears. "I popped out a 9-pound baby after about 20 minutes of pushing without so much as a tear." The lesson? It pays to question some birthing practices. Just because episiotomy was once routine doesn't mean it still should be. Lots of moms are left to wonder if their episiotomies were necessary. Some experts are also asking questions.

Your mom certainly had one

It wasn't until giving birth in hospitals became the norm, starting in the 1920s, that episiotomies took hold. Women frequently tore during delivery, and making a preemptive cut was considered kinder ? a way to prevent pain and protect moms from problems blamed on childbirth, such as incontinence and sexual dysfunction. Doctors were trained to do one with nearly every birth, and it became a standard of care by the 1950s.

But when researchers finally got around to scrutinizing the common wisdom by the 1970s and 1980s, study after study showed that routine episiotomies do not lessen pain or prevent urinary or anal incontinence or sexual problems and that sometimes they actually cause rectal problems and increase pain. "Episiotomy does more harm than good," says Katherine Hartmann, M.D., Ph.D., director of the Center for Women's Health Research at the University of North Carolina in Chapel Hill, which reviewed four decades' worth of data on episiotomy for the Journal of the American Medical Association.

Studies show that women who get episiotomies have the same rates of infection, healing, and pelvic pain, and they may resume sex later. They also have a greater risk for damage to the anal sphincter, which can cause lifelong bowel incontinence. An episiotomy increases a woman's risk of third- and fourth-degree lacerations by 13 percent. (A third-degree tear goes through the anal sphincter; a fourth-degree goes all the way into the rectal muscle.)

In fact, some doctors now believe that episiotomies promote further injury by providing a starting place for more serious tears. "I had an episiotomy, but I still ended up being torn from my vagina to my rectum," says Sonja Angell of Jasper, Georgia, who gave birth to an 8-pound, 9-ounce girl two years ago. "So what was the point?" Most U.S. women have a midline episiotomy, which is cut straight down and is more likely to cause a serious tear than those cut at an angle.

...but you and your daughter probably shouldn't

Thankfully, the tide is turning against episiotomy. The American College of Obstetricians and Gynecologists (ACOG) has denounced routine episiotomy, and medical schools have done a 180. The rates of episiotomy are dropping as newly minted OBs start their careers. Twenty years ago, more than 80 percent of births involved the unkind cut today it's just one in three.

Yet, as many as a million women still get unnecessary episiotomies every year. Old habits die hard especially when it comes to medical practices, says Dr. Hartmann. If you'd rather not be surprised by a scalpel, your best bet is to stay informed, and talk to your doctor or midwife. Follow these steps, from pregnancy through delivery day.

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."

Contributing editor Beth Howard is the author of Mind Your Body: A Sexual Health and Wellness Guide for Women.