So, the Dr that may be delivering my baby does not under any circumstances perform episiotomies. I mentioned this today to a friend of mine at home in [name_f]England[/name_f] (I live, and will be having my baby in the states) and she was horrified and said I should change Drs and that it is much worse to tear than it is to be cut.
I am already considering changing my Dr for various reasons, but I don’t have any reason to disbelieve what she is saying regarding episiotomies.
I have just begun doing a little research and I can’t seem to find anything to back up what my friend is saying. I don’t suppose there are any medical professionals here that can enlighten me to some FACTS? The medical field is definitely not an area of expertise for me and the only friends I have in the field are a brain surgeon and a radiologist…
Also, any personal experiences with tearing/being cut are welcome.
I’ve heard just the opposite - that’s it’s better to tear than to be cut. Something about the way the layers of fascia heal… I’ve heard that with episiotomies you can lose some sensation in the area, because the clitoral tissue extends down into the labia and an episiotomy can cause nerve damage… This is all anecdotal though. I have also heard that there are times when it may be necessary - if a baby is really stuck or if you’re already tearing quite a lot. They say that little pushes (panting/grunting), rather than long ones (the old-school “hold your breath and count to ten” Lamaze type) can keep things going at a manageable pace, and help your pelvic floor adjust to the idea of allowing a baby through. In any event, it sounds like a good sign if your doc isn’t scissors-happy!
natural tears heal easier. But as long as baby comes out slowly and the doctor and or partner does some perineum massage and it appears that you will be ok then Dr should not just cut to cut. I was a neonatal nurse before moving to [name_f]Canada[/name_f] 7 years ago.
I’m no expert, but from what I’ve found out through some research and some heresay, is that tearing definitely heals faster and less painfully, and that episiotomies are become a fairly outdated and uncommon practice.
Thankfully, episiotomies are outdated in the US. Everything I’d heard prior to birth indicated they were a bad idea. I had natural tearing when I had my son. Everything healed up just fine and I had no complications due to the tearing.
[name_f]My[/name_f] midwives prefer a tear, they say it heals much better than a cut. However, when giving birth to my daughter I had to have a forceps assisted birth because she was posterior, so an episiotomy was the only option. I’m curious what your Dr. would do in that situation if he wouldn’t do an episiotomy? For what its worth, my episiotomy did heal very nicely and quickly.
[name_m]Hi[/name_m], MD here though not an obstetrician (general surgery resident). It was previously thought that a controlled surgical incision was better than an uncontrolled tear, but the question was pretty rigorously studied in the 80s-90s and the opposite was deemed to be true. The armchair reason behind this is that tears occur along the weakest points, whereas an incision is indiscriminate in terms of weak v strong tissue. Since scar tissue is much weaker than the surrounding tissue, it did not make sense to weaken strong tissue via an episiotomy (does that make sense?) Therefore no obstetrician in practice now routinely cuts episiotomies.
That being said, I find a complete and total refusal to perform an episiotomy under any circumstances very baffling. There are situations in which they are absolutely medically indicated. The obstetrical profession only turned away from routine, preventive, proactive episiotomies, not ones where the delivery of the baby seems seriously impaired by obstructive soft tissue. Episiotomies in the right circumstances prevent horrible, disfiguring, function-impeding serious tears, not to mention relieve an obstructed labor which of course has serious consequences for the baby. So I wonder what your doctor meant.
[name_m]Blade[/name_m], thank you in particular for such an informative post. Maybe she mean that she under no circumstances performs an episiotomy routinely? I’m not sure I will have to clarify with her on Thursday.
You know, I have a few concerns about my Dr already and although she is pleasant enough she has given me a cause for concern with a few of the things she has said. Firstly, she made the assumption I would be having an epidural and talked about it like it was a certainty - I am a ftm and have no idea whether I am going to need pain relief, and if I do I don’t know what method of pain relief I will want. So I found her presumption concerning and a little rude if i’m honest.
She also said that she prefers if her patients lay on their backs when delivering. I thought this was a strange thing to say, as I imagine I will do it in whatever position my body tells me to be in at the time?? The final concern was that she avoided answering my question about her c section rate. She is very young and has not been doing all this for long so maybe she is just shy about revealing her statistics, I don’t know.
I have never been afraid of birth - It is something I am looking forward to. I know it is manageable and people do it every day - I feel calm about it… until I think about her being there trying to force me into acting out HER rigid birth plan that I don’t seem to be getting much of a say in. I though that a birth plan was supposed to be flexible and drawn up by me? [name_m]How[/name_m] I would like things to play out in an ideal world?
I am always polite, and although I am probably an extremely annoying patient asking so many questions, I want to feel like we are on the same page. It is difficult because she’s a nice person and I feel comfortable around her - I don’t want to offend her or start questioning her expertise.
Sorry for the rant. I even spent around 60 seconds considering giving birth at home! - which I actually think is really quite reckless.
Your doctor has given you clues that you might not like her during labor. I am sure she meant no routine episiotomies. You need one if she uses a vacuum, for example. However, assuming you will get an epidural and insisting on lying on your back are not good signs. If you have an epidural, you pretty much have to lie down, especially if the dose is high enough to make you totally numb. I have had one epidural, and I was very annoyed when I discovered that though it numbed the contractions, I still felt every inch of the baby descending through my vagina! I thought I was getting a numb vagina! I never had another epidural after that disappointment.
However, if you are not medicated, lying on your back is pretty painful and very inefficient. In my unmedicated births, I vastly preferred hands and knees.
There are usually options between standard OB and home birth. Have you tried to find a CNM practice?
Thank you [name_f]Galatea[/name_f]! I didn’t realise that after having an epidural you have to lay down, I guess that explains why she said it to me. She seems to prefer that her patients do it this way, and that is going to be a problem for me. I mean maybe that is the route I will go down, but I’m not going to be making assumptions.
A midwife has been ruled out - although this would be my ideal way of doing things - my Husband is completely and utterly terrified of something going wrong and wants a surgeon doing the delivery. I have never seen him afraid of anything before, and I don’t want him to be afraid. I am happy to stick with an OB/GYN… just maybe not this particular one. I’m from [name_f]England[/name_f] and a midwife delivery is standard unless there are any complications. People seem to have much nicer experiences doing it this way. Hopefully if all goes well with my first, my husband will feel more comfortable using a midwife the second time around.
At my appointment on Thursday I am going to explain that I am considering switching to someone else because of my concerns. I will see how she responds. I think the biggest problem for me is that she doesn’t explain her reasoning for anything.
Would your husband consider you seeing a midwife that practices with OBs? The practice I used with my children there were midwives and OBs in the same practice and overall they had some lower C-section rates compared to other practices in my area. I delivered in a hospital with a midwife but if something had gone wrong they would have had an OB there immediately to take over and I could have even met with an OB while having prenatal visits.
The not sharing C-section rates (for whatever reason she should be honest with you), assuming an epidural and position seem red flags to me. I did have both my children laying down since my son descended too quickly to move (I asked while pushing if that was the best position and the midwife told me it was too late to move) and I had leg pain with every contraction with my daughter. [name_m]Both[/name_m] babies were born very quickly without any issues from me being on my back.
I have heard lots of moms say the same thing: “I will use a doctor with my first, and then a midwife with my second,” but the problem with that reasoning is that the first one sets the tone for the rest, and it is in the first delivery that so many interventions can happen that might lead to a section and then it will be harder to have that second birth be more natural. The first birth is the most important, as in many communities, VBACs are not the standard of care. To give you an example, my first was induced because of very low fluid. It took 20 hours just to get to 3 cm, and then I got an epidural (not really sure why) and I fell asleep for two hours and woke up at 10 cm. Then it took 3 hours to push him out, but because I had a CNM, she was patient and let me do my work, despite the OB who was their attending specialist out in the hall pushing for a section. There were no disturbing signs with my baby; it was just taking a “long” time. It was only long by OB standards; I think it was pretty darn quick for being pretty numb and stuck on my back! In fact, my midwife covered the clock and kept encouraging me, and she was the only reason I did not have a section.
[name_f]My[/name_f] husband was also weird about midwives when we were pregnant the first time, so I bought this book (http://www.amazon.com/Thinking-Womans-Guide-Better-Birth/dp/0399525173), and he only needed to read the intro before he agreed to see a CNM. We had #1 and #2 in a hospital with a CNM and thus had all the safety of the hospital (quick surgery times, etc.) with the humane treatment of a midwife. I would highly recommend seeking out a CNM group and using them in a hospital.
In my training, I’ve only performed one episiotomy in 45 deliveries. I don’t like doing them personally but there are certain circumstances where they are appropriate. Anecdotally, I feel that tears tend to heal better but episiotomies are more controllable and less likely to go through something they shouldn’t. Also, I wouldn’t trust any practitioner who does midline episiotomies as they can cause more damage than a third degree tear in the long run.
To weigh in on the last part of your post, I had a second degree tear and it was fine. I was overall sore of course, from the birth itself, and sitting in one position was uncomfortable, but within a week I felt normal again.
I’m sorry to hear about the troubles with your doctor. Mine doesn’t have the greatest bedside manner, but he’s excellent at what he does. It was also never assumed I would get an epidural, although I ended choosing one anyway.
Thank you for this. I think it is what I need to hear right now. [name_f]My[/name_f] husband has said he will support whatever choice I make from the beginning, but I so badly want him to feel comfortable and like me and the baby are in safe hands. Maybe I should stop thinking about my husband and just go with my gut. I looked into it and there are OB’s on the delivery ward, so if there were to be a problem there wouldn’t be a delay in receiving help.
I believe what you’re saying about the first birth setting precedence too. I honestly want to thank you for your posts, I really think that your words have been the push that I have needed to make the switch to a midwife.
Good. I am really glad to hear that. I was worried that I had offended you. There are plenty of stats to show that hospital CNMs have just as healthy outcomes with lower costs and interventions. In many other developed countries, most women deliver with midwives, not doctors; doctors are only for high-risk moms.
an epidural (or spinal, or Combined Spinal-Epidural) in the United States is essentially the only method of pharmacologic pain relief offered. In Europe it is common to offer shots of narcotic medication and/or nitrous oxide (“laughing gas,” as at the dentist). This are not preferred here since narcotic pain medication is quickly absorbed, acts systemically, and is 100% passed onto the baby. If given too close to delivery the baby is essentially drugged and can have more respiratory distress than otherwise. Nitrous oxide caused psychological dissociation, where you the mother no longer are fully aware of your surrounding and the events taking place. Since it removes the mother as an active participant in her own labor, and of course potentially erases all of the wonderful memories of the birth and meeting the baby for the first time, it is extremely rarely used in the US. Epidural/spinal anesthesia, on the other hand, provides focused local pain relief with zero effects on the baby. The mother is psychologically aware, a full participant, and will remember the birth well.
Ideally an epidural provides a sensory block rather than a motor one, but there is nearly always a degree of motor impairment. A person with an epidural will be unable to safely bear weight on their legs and as such, once it’s placed, you will not be able to stand, walk or squat. You can lay to one side or another, curl your legs up to your chest, and lay supine, but that’s it. However, pushing on your back is not the horror show you might think. IN addition to providing the optimal view for your birth attendant, who can safely assess baby’s position, guide baby out of the birth canal, apply appropriate perineal pressure to prevent a precipitous birth & tearing… it is the position which requires the least amount of energy for you, the mother, to maintain. Childbirth takes a tremendous amount of energy (estimates average around 4000 calories burned for a labor & delivery). You will be expending a great deal of effort in the pushing stage. Having to maintain your own weight in addition to that (whether squatting, sitting, hands & knees, whatever) really can tire you out.
In the US, around 80% of births are medicated. Frankly, the majority of women simply say “it’s not so much that I can’t do this unmedicated, it’s that I don’t have to.” It is in NO way required that a woman be medicated for a hospital birth. A substantial number of women have unmedicated births in hospitals daily across the US, with OBs. However, the only caveat is that if things go south very fast, and you need an emergency c-section without an epidural already in place, you will have to be intubated and go under general anesthesia for the birth (thus being unconscious and missing the whole thing). If you simply need an urgent c-section, not an emergent one, then there will be time to place a spinal (not an epidural, which takes ~30min to achieve full effect, but a spinal, which acts immediately). The chance of needing a true emergency c-section is very slim, but it is non-zero.
For low-risk women, seeing a Nurse-Midwife who is in practice with an obstetrics group and delivers in a hospital is the absolute best of all worlds. Midwives tend to have a smaller panel of patients, spend more time with their healthy patients, and many women find them more reassuring. Since they risk out to OBs both antenatally and during labor if significant complications arise, they take care of only healthy women and healthy babies. Their outcomes data are superb.
C-section rate is both useful and not useful. In order to interpret it, you need to know what kind of patients she takes care of. If she sees many high-risk women and/or high-risk babies; if she practices in an urban setting where many patients have multiple comorbidities and poor primary care; if she’s in an area with a high percentage of multiples due to [name_m]ART[/name_m], etc, her c-section rate will naturally be much higher. If you’re in an area of the US where many women are obese, have gestational diabetes, and have macrosomic fetuses, her c-section rate will be higher. [name_m]Even[/name_m] then, the only statistic that really matters is YOU. In your labor, if you experience any of the indications for section (obstructed labor, malpositioned/breech baby, fetal distress, disorders of placentation, etc) who cares if 15-40% of her other patients experienced the same thing or not? Conversely, if your labor is a breeze, your pelvic outlet is lovely, your baby’s placenta continues to function, her cord doesn’t get in the way, etc-- who cares? I think you might feel that if [name_m]Doctor[/name_m] A sections 24%, but [name_m]Doctor[/name_m] B sections 40%, it’s apples and apples and you should go with [name_m]Doctor[/name_m] A. Maybe so. But honestly the medical community has a great deal of difficulty in determining who has an “unnecessary” c-section. Unless you can pore over the charts, labor curves and fetal tracings of each of these patients, you can’t ever really know.
Episiotomies are not routinely indicated with vacuum deliveries, only if the baby is asynclitic or otherwise malpositioned.
Thank you, [name_m]Blade[/name_m]! Your posts are so informative. I am low risk, and the midwives work in a hospital with the obstetrics group. There will be OB on the labour ward in case of any emergency.
I’ve arranged a “meet and greet” with the midwife team on monday and am hoping my husband will come away from it feeling reassured that they are professionals and not a bunch of hippies who are against interventions at all costs… he works in nuclear science so this whole process of childbirth is very scary to him, and he feels out of control. If it were up to him I think he would have a team of 20 surgeons delivering this baby.
I have been told that there are 2 OBs in particular who work very closely with the midwives, so if my husband is still overly anxious after the meet and greet, we still have that option.
Thanks again everyone! I’m on the right track and feeling great about labour. Only 11 more weeks to go!